BJA Education, 17 (3): 79–83 (2017)
doi: 10.1093/bjaed/mkw046
Matrix reference 1A02,
2A09, 2B02, 3B00
The future of general anaesthesia in obstetrics
RS Chaggar BMedSci (Hons) MBBS FRCA1 and JP Campbell MBChB (Hons)
MRCS FRCA2,*
1
ST7 in Anaesthesia, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane
Road, London W12 0HS, UK and 2Consultant Anaesthetist, Queen Charlotte’s and Chelsea Hospital, Imperial
College Healthcare NHS Trust, Du Cane Road, London W12 0HS, UK
*To whom correspondence should be addressed. Tel: +44 20 3313 3991; Fax: +44 203313 5373; E-mail: jeremy.campbell@imperial.nhs.uk
Key points
• Accidental awareness during general anaesthesia is
a particular risk in obstetrics.
• Propofol may have advantages over thiopental as an
i.v. induction agent in obstetrics.
• Rocuronium and sugammadex may be used instead
of succinylcholine for neuromuscular block in
obstetrics.
• Guidelines for the management of difficult and
failed tracheal intubation in obstetrics have recent-
ly been published.
• Skills in obstetric general anaesthesia should be
maintained by regular simulation training.
Until the 1950s, anaesthesia for Caesarean section was per-
formed using an open breathing system with gauze and ether
or chloroform. By the mid-1950s, the use of tubocurarine to facili-
tate tracheal intubation had become common practice. Succinyl-
choline then became popular because its rapid onset of action
avoided some of the dangers associated with the delay in intub-
ating the trachea when tubocurarine was used alone.1 In 1959,
thiopental was used for induction of general anaesthesia in ob-
stetrics as part of a technique based only on thiopental, succinyl-
choline, nitrous oxide, and oxygen (i.e. without the addition of a
volatile agent). Cricoid pressure was introduced in 1961, and in
1970, the traditional rapid sequence induction (RSI) was de-
scribed and halothane was used for maintenance of anaesthesia,
alongside nitrous oxide. Apart from the introduction of new vola-
tile agents, there has been almost no change in the practice of
general anaesthesia in obstetrics since this time.2
© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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Advance Access Publication Date: 13 July 2016
It is well established that central neuraxial block is the gold
standard technique for obstetric anaesthesia and understand-
ably this has been the focus of research into improvements in
quality and safety. However, in 2014, two major reports were pub-
lished that call into question certain aspects of modern practice
of general anaesthesia in obstetrics: the Fifth National Audit
Project (NAP5) which investigated accidental awareness during
general anaesthesia (AAGA),3 and the Report on Confidential
Enquiries into Maternal Deaths (MBRRACE-UK report).4 General
anaesthesia for Caesarean section has been discussed in this
journal by Levy5 and subsequently by McGlennan and Mustafa.6
The purpose of this article is to consider the current controversies
in techniques for general anaesthesia in obstetrics, and how
these may influence practice in the future.
Accidental awareness during general
anaesthesia
AAGA is well known to be a particular problem in obstetrics. Con-
cerns about harmful effects of anaesthetics on the fetus (both dir-
ectly and by the effect on uteroplacental blood flow) have led
anaesthetists in the past to administer ‘light’ anaesthesia. Until
the 1970s, it was standard practice to use doses of thiopental in
the region of 200–250 mg for induction, and to maintain anaes-
thesia using nitrous oxide and oxygen alone (i.e. without the
use of a volatile agent) to try to avoid neonatal sedation and
blood loss through reduction in uterine tone.3 Using this tech-
nique, nearly one-fifth of women had ‘unpleasant recall’.7 In
1970, it was shown that addition of halothane to the gas mixture
could reduce the incidence of awareness to <1%.8
The recent national audit into AAGA (NAP5) has again high-
lighted the issue of awareness in the obstetric population. Obstet-
ric cases comprised only 0.8% of all general anaesthetics, but
accounted for 10% of reported cases of AAGA. The rate of AAGA
79
The future of general anaesthesia in obstetrics
for all obstetric procedures in NAP5 was 1:1200 (compared with
an overall incidence of ∼1:19 000), increasing to 1:670 for Caesar-
ean section. Several risk factors for AAGA were identified in the
NAP5 report, most of which are present in obstetric patients
and procedures, creating a ‘perfect storm’ for AAGA (Table 1).3,9
All episodes of awareness were thought to be of short duration
(in most cases only a few seconds) and most occurred at, or short-
ly after, induction of anaesthesia. This is likely to coincide with
the period of time when the i.v. induction agent is wearing off
and the partial pressure of the volatile agent is increasing: the
i.v.–inhalation interval (Fig. 1). This interval is a particular con-
cern in obstetrics for several reasons:3,9
(i) Thiopental is usually used for induction, often in low doses
(see later).
(ii) Opioids are usually omitted at induction.
(iii) Any difficulty with airway management will result in a delay
in delivery of volatile agent.
(iv) The increased cardiac output in late pregnancy reduces the
duration of action of an i.v. bolus of induction agent, and
also prolongs the time taken to achieve an effective partial
pressure of volatile agent.
(v) In a Category 1 Caesarean section, there is a short duration of
time between induction of anaesthesia and the initial surgical
incision. Consequently, maximal surgical stimulation may
occur at a time when the depth of anaesthesia is inadequate.
Women’s anxiety levels before undergoing Caesarean section
are often high and this may predispose to AAGA. Also, certain
Table 1 The ‘perfect storm’: risk factors for AAGA in the obstetric
patient3,6
Patient Organizational Technical factors
factors factors
Female sex Trainee Use of thiopental (sometimes in
anaesthetist inappropriately low doses)
Young age Out-of-hours Rapid sequence induction
surgery
Obesity Urgent/immediate Use of neuromuscular block
surgery
Difficult Omission of opioids at induction
airway
Fig 1 Diagrammatic representation of a ‘gap’ in delivery of anaesthetic as the
effect of the i.v. bolus of induction agent is in decline, and the volatile agent has
been turned on too late, is interrupted or the fresh gas flow rate is insufficient to
achieve overpressure. Reproduced here with permission from The Royal College of
Anaesthetists. Originally published in Accidental Awareness during General
Anaesthesia in the United Kingdom and Ireland. Report and findings of the 5th
National Audit Project, September 2014.
80 BJA Education | Volume 17, Number 3, 2017
physiological changes of pregnancy (e.g. tachycardia) may
make it more difficult to identify the clinical signs of inadequate
anaesthesia.3
The findings of NAP5 have given rise to several considerations
when giving a general anaesthetic in obstetrics.
Consent
Anaesthetists should regard obstetric patients as being at in-
creased risk of AAGA and this should be discussed during the
consenting process. Since general anaesthesia in obstetrics is
often performed in emergency, time-critical situations, a de-
tailed discussion of AAGA is clearly not practical. However, it
has been suggested that before a Category 1 Caesarean section,
a woman could be given a brief description of cricoid pressure
with a comment that she may be aware of sensations during in-
duction of anaesthesia.9
Choice of induction agent
Thiopental is still the most popular induction agent for general
anaesthesia in obstetrics in the UK,10 although its use is increas-
ingly rare for non-obstetric cases. Doses of thiopental were re-
ported as being low (<4 mg kg−1) in half of the NAP5 obstetric
cases and it was recommended that a dose of at least 5 mg kg−1
should be used for the healthy parturient.3 Concerns about thio-
pental have been compounded by the recent maternal mortality
report which found that in some cases, the dose of thiopental
used for induction of anaesthesia in severely ill women (e.g.
with hypovolaemic shock) was probably too high and may have
contributed to haemodynamic instability.4 Although this might
represent poor recognition of the critically ill mother, it may
also be the result of increasing unfamiliarity with thiopental,
particularly among junior anaesthetists. This has led to the sug-
gestion that thiopental should be replaced with propofol in obste-
trics. Rucklidge11 and Lucas and colleagues2 have summarized
the advantages and disadvantages of propofol and thiopental
for induction of general anaesthesia in obstetrics (Table 2).
Use of volatile agents and nitrous oxide
An end-tidal minimum alveolar concentration (MAC) of volatile
anaesthetic agent of 0.5 has previously been advocated for Cae-
sarean section under general anaesthesia in order to minimize
neonatal sedation and blood loss through reduced uterine tone.
However, the use of a higher MAC is not necessarily associated
with increased neonatal sedation.12 Therefore, in order to min-
imize the i.v.–inhalation gap, adequate end-tidal volatile levels
should be achieved as soon as possible, for example, by using a
high initial concentration of volatile agent (‘overpressure’) com-
bined with high fresh gas flows.9 When high concentrations of
volatile agents are used, uterotonic agents should be used to
maintain uterine tone.3
The additional use of nitrous oxide in adequate concentration
as a carrier gas during Caesarean section can reduce the amount
of volatile agent required and it does not decrease uterine tone. In
order to clarify the safe maximum concentration of nitrous oxide,
research is needed to investigate the safe minimum inspired oxy-
gen concentration during general anaesthesia for Caesarean sec-
tion, especially when the fetus is compromised.3
Use of opioids
Opioids have traditionally been avoided as part of a standard RSI
for Caesarean section because these drugs cross the placenta and
 The future of general anaesthesia in obstetrics

Table 2 Factors favouring the use of thiopental and propofol for minimizes delay in intubating the trachea, and it has a shorter
induction of general anaesthesia in obstetrics2,8 duration of action than alternative agents. In theory, this short
duration of action enables the early return of spontaneous venti-
Favouring thiopental Favouring propofol
lation in the event of a failed intubation, allowing the woman to
Well known, especially to New generation of anaesthetists be woken. However, it has been shown that in the majority of pa-
older anaesthetists may be unfamiliar with thiopental tients who have received succinylcholine, life-threatening desat-
Propofol is commonly used for non- uration will have occurred before recovery of neuromuscular
obstetric cases function.14
Relatively cardiostable Evidence of overdosage with Since the recommended dose of succinylcholine is 1.5 mg
thiopental in MBRRACE-UK report, kg−1, a single 100 mg ampoule contains a sufficient dose for a
contributing to haemodynamic woman weighing up to 70 kg. For women weighing more than
instability this, administration of a single ampoule will result in underdos-
Evidence of underdosage with ing with succinylcholine, and this could produce suboptimal in-
thiopental in NAP5 report, tubating conditions (and consequently increase the risk of
contributing to AAGA AAGA). With the increasing prevalence of obesity in the pregnant
More known about its No evidence that propofol has more population, it is prudent to have a second ampoule of succinyl-
neonatal effects than adverse effects on the neonate choline available in order to increase the dose when necessary.3
other agents compared with thiopental
Succinylcholine is well known to be associated with import-
Risk of syringe swap between
ant side-effects, especially muscle pains and anaphylaxis. It
thiopental and antibiotic
has also been observed that if tracheal intubation is difficult
Propofol does not require pre-mixing
with succinylcholine, neuromuscular block may have started to
before administration
wear off by the time subsequent attempts at laryngoscopy
Propofol cheaper than thiopental
Thiopental in short supply
occur, with consequent deterioration in the quality of the intub-
ating conditions. There is therefore growing interest in the use of
rocuronium instead of succinylcholine for RSI in obstetrics.
may cause neonatal respiratory depression, and also potentially When rocuronium is administered at a dose of 1.2 mg kg−1, it
delay the return of spontaneous ventilation in the mother in the has a similar onset time to succinylcholine in the obstetric popu-
event of a failed intubation and discontinuation of anaesthesia. lation, with comparable intubating conditions.15 If there is a
However, these concerns are not evidence-based. The use of an failed intubation and a decision is made to wake the mother, a
opioid before induction may help to reduce the duration of the 1.2 mg kg−1 dose of rocuronium may be reversed using sugamma-
i.v.–inhalation gap, and also provides analgesia for airway instru- dex (at a dose of 16 mg kg−1). This produces a return of neuromus-
mentation and skin incision, two of the most stimulating parts cular function in a mean 2.9 (standard deviation 1.7) min, faster
of anaesthesia and surgery. Research is needed to define the than the spontaneous offset of succinylcholine.16 It should be
ideal dose and timing of opioids during general anaesthesia for noted that a 16 mg kg−1 dose of sugammadex may require mul-
Caesarean section.3 tiple vials of the drug to be drawn up into a syringe, and the
time taken to do this should be considered as part of a plan for
Maintenance of anaesthesia during difficult airway a failed intubation.
management When succinylcholine is administered for RSI in the non-ob-
stetric population, it has been shown to be associated with a sig-
Two-thirds of NAP5 obstetric cases were associated with diffi-
nificantly faster onset of desaturation during the subsequent
culty in managing the woman’s airway, with consequent delays
period of apnoea compared with rocuronium.17 This is probably
in delivery of volatile agent. It is recommended that before induc-
due to muscle fasciculations which occur after administration
tion, the anaesthetist must decide what action to take if airway
of succinylcholine, and the consequent increase in total body
management is difficult; if it is decided that general anaesthesia
oxygen consumption.
should be maintained, a second syringe of i.v. induction agent,
prepared before induction, should be used to maintain anaesthe-
sia during airway management.3 Difficult and failed intubation in obstetrics
The incidence of failed tracheal intubation is one in 390 for ob-
Depth of anaesthesia monitoring
stetric general anaesthesia and one in 443 for general anaesthe-
Depth of anaesthesia monitoring during obstetric general anaes- sia for Caesarean section.18 A number of developments in airway
thesia is uncommon in the UK, although it may be more common management have taken place in the last few years which have
in other countries.3 The time taken to establish this monitoring been considered in the recently published OAA/DAS guidelines
means it is probably not practical for a Category 1 Caesarean sec- for the management of difficult and failed tracheal intubation
tion, although it is likely to have a more useful role in elective/less in obstetrics.19 These provide algorithms for the safe provision
urgent obstetric cases under general anaesthesia. Interpretation of general anaesthesia in obstetrics, failed tracheal intubation,
of depth of anaesthesia monitoring is controversial and it has and the ‘can’t intubate, can’t oxygenate’ situation. They also in-
been suggested that the gold standard for determining the level clude criteria which the anaesthetist should use when deciding
of consciousness remains clinical assessment.13 whether to wake a woman or proceed with surgery after failed
tracheal intubation.
Other considerations
Positioning
Neuromuscular block
It is essential that the woman is in the optimal position before in-
Succinylcholine continues to be the neuromuscular blocking duction of general anaesthesia in obstetrics. Airway manage-
agent of choice for RSI in obstetrics. Its rapid onset of action ment (including application of cricoid pressure, insertion of

BJA Education | Volume 17, Number 3, 2017 81

The future of general anaesthesia in obstetrics
laryngoscope, view at intubation, ease of ventilation, safe apnoea
time, and front of neck access) may be improved by the woman
being in the head elevated (ramped) position (in which the exter-
nal auditory meatus is in the same horizontal line as the supras-
ternal notch). This position may also increase functional residual
capacity in parturients, which may increase the time to desatur-
ation after the onset of apnoea. The ramped position can be
achieved with the use of pillows or specific devices [e.g. Oxford
Head Elevating Laryngoscopy Pillow (HELP) System®].
Pre-oxygenation
Administration of 100% oxygen before induction of anaesthesia
increases the oxygen reserve in the woman’s lungs and thus in-
creases time to hypoxaemia during the subsequent period of ap-
noea. Once the woman is apnoeic but before laryngoscopy is
performed, 100% oxygen should continue to be administered
using a tight-fitting face mask while maintaining a patent airway.
This enables oxygenation to continue by bulk flow to the alveoli
(apnoeic oxygenation). In addition to pre-oxygenation using a
face mask, the anaesthetist should consider using nasal cannu-
lae attached to 5 litre min−1 oxygen flow. This will maintain
bulk flow of oxygen during airway manipulation, and may further
increase the time to hypoxaemia.19
Cricoid pressure
If cricoid pressure is incorrectly performed, it can lead to a poor
view at laryngoscopy by distorting laryngeal anatomy or flexing
the neck. It can also hinder insertion of a tracheal tube or supra-
glottic airway device (SAD) and may make mask ventilation more
difficult. Therefore, if there is difficulty with intubation or mask
ventilation, the anaesthetist should consider reducing or remov-
ing cricoid pressure, and it should be removed for insertion of an
SAD. If cricoid pressure is reduced or removed, the anaesthetist
should be aware that regurgitation may occur and should be
ready to reapply cricoid pressure, apply head-down tilt, and suc-
tion the orophyarynx.19
Videolaryngoscopy
Over the last few years, several indirect rigid laryngoscopes (often
called videolaryngoscopes) have been introduced. These devices
produce a view of the glottis from the end of the laryngoscope
blade using a camera (whereas a conventional laryngoscope
requires a direct view of the glottis). A videolaryngoscope can im-
prove the view of the glottis compared with direct laryngoscopy,
and the device should be immediately available for all obstetric
general anaesthetics. Several designs of videolaryngoscope are
available and there is little evidence to recommend any one de-
vice over another.20
Use of SADs
Anaesthetists in the UK are now very familiar with anaesthesia
using the laryngeal mask airway (LMA), and their use in the man-
agement of the obstetric airway after a failed intubation is well
established.19 A range of LMAs is now available, with newer
‘second generation’ devices designed to improve the airway
seal and decrease the risk of regurgitation of gastric contents.
The LMA Supreme™, LMA ProSeal™, and i-gel® all provide an
improved airway seal compared with the classic LMA, and also
allowing a gastric tube to be inserted in order to aspirate air
and/or to drain stomach contents.
Training
Over the last 30 yr, there has been a large reduction in the propor-
tion of Caesarean sections performed under general anaesthesia.
In 2013, only 8% of all Caesarean sections were performed under
82 BJA Education | Volume 17, Number 3, 2017
general anaesthesia, most of which were emergency cases.3 In
some delivery units, there may now be less than one general an-
aesthetic performed per week. The Confidential Enquiry into Ma-
ternal Deaths continues to record a small number of deaths from
hypoventilation in association with general anaesthesia.4 Be-
cause of infrequent practice in obstetric general anaesthesia, it
is essential that all obstetric anaesthetists maintain their skills
by regularly practising drills, including perioperative airway cri-
ses such as difficult/failed intubation and bronchospasm.
Consultant presence during out-of-hours periods
Although general anaesthetics in obstetrics are relatively uncom-
mon, most are performed by trainees, usually outside the hospi-
tal’s main operating theatre area and during out-of-hours
periods with distant supervision.3 The considerable decrease in
the use of general anaesthesia in obstetrics, together with reduc-
tions in junior doctors’ working hours, means that trainees have
much less experience of general anaesthesia than in the past.
The potential dangers associated with obstetric general anaes-
thesia are likely to strengthen the argument for increased pres-
ence of consultant anaesthetists on delivery units during out-
of-hours periods.
Declaration of interest
None declared.
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