International Journal of Obstetric Anesthesia (2019) xxx, xxx–xxx

0959-289X/$ - see front matter Ó 2019 Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.ijoa.2019.08.005

ORIGINAL ARTICLE
www.obstetanesthesia.com

Surgical conditions with rocuronium versus suxamethonium

in cesarean section: a randomized trial
J. Bláha,a,† P. Nosková,a,† K. Hlinecká,b V. Krakovská,c V. Fundová,a T. Bartošová,a
P. Michálek,a M. Střı́teskýa
a
Department of Anesthesiology, Resuscitation and Intensive Medicine, 1st Faculty of Medicine, Charles University and
General University Hospital in Prague, Czech Republic
b
Department of Gynecology and Obstetrics, 1st Faculty of Medicine, Charles University and General University
Hospital in Prague, Czech Republic
c
Neonatology, Department of Gynecology and Obstetrics, 1st Faculty of Medicine, Charles University and General
University Hospital in Prague, Czech Republic

ABSTRACT
Background: Onset times and conditions for intubation after rocuronium versus suxamethonium at cesarean section have been
evaluated, but no study thus far has examined the influence of these neuromuscular blocking drugs on the surgical conditions
or their effect on the duration of surgery and the ease of fetal delivery. We aimed to compare the surgical conditions for delivery
in parturients who received deep neuromuscular block with rocuronium with those who had induction with suxamethonium.
Methods: Ninety patients undergoing cesarean section under general anesthesia were randomized to receive either rocuronium
0.6 mg/kg or suxamethonium 1 mg/kg for tracheal intubation and delivery. Times to delivery and the quality of surgical condi-
tions, using a five-point Surgical Rating Scale for Delivery (SRSD) ranging from 1 (poor) to 5 (excellent), were evaluated.
Results: The median SRSD (range) was found to be significantly better in the rocuronium group [4 (3–5) points vs 3 (2–4) points
with suxamethonium (P <0.001)]. Whereas the mean (SD) induction-to-intubation interval was longer with rocuronium [106 (34) s
vs 68 (32) s with suxamethonium (95% CI of the difference 24 to 52 s, P <0.001)], the incision-to-delivery interval was shorter in the
rocuronium group [147 (68) s vs 196 (51) s with suxamethonium (95% CI of the difference 75 to 24 s, P <0.001)]. The mean
induction-to-delivery intervals were similar [268 (73) s vs 276 (63) s, respectively].
Conclusions: Whereas the induction-to-delivery intervals were comparable, we found rocuronium superior to suxamethonium in
allowing better surgical conditions for fetal delivery, which enabled an easier delivery and a shorter incision-to-delivery interval.
Ó 2019 Elsevier Ltd. All rights reserved.

Keywords: Cesarean section; Neuromuscular block; Muscle relaxation; Operative time; Surgical conditions

Introduction of drug crossing the placenta from the maternal to the

While onset time and conditions for intubation with
rocuronium versus suxamethonium have been repeat-
edly evaluated,1–3 none of these studies focused on sur-
gical conditions for cesarean section and their effect
on the duration of surgery and ease of delivery. New-
born adaptation depends partly on the time between
induction of anesthesia (and administration of anesthet-
ics) and umbilical cord ligation,4–6 because the amount
Accepted August 2019
Correspondence to: M. Střı́teský, Department of Anesthesiology,
Resuscitation and Intensive Medicine, 1st Faculty of Medicine,
Charles University, General University Hospital in Prague, U
Nemocnice 2, 128 08 Prague 2, Czech Republic.
E-mail address: martin.stritesky@vfn.cz
†
Drs Bláha and Nosková contributed equally to this manuscript.
fetal circulation is determined not only by the drug’s
physicochemical and structural properties, but also by
the dose and duration of transplacental transfer. The
time interval for this transfer is determined by the time
from onset of anesthesia and the time needed for intuba-
tion (induction-to-intubation interval) and by the time
from the start of surgery to fetal delivery (incision-to-
delivery interval).
Several factors influence the total time needed for
delivery (induction-to-delivery interval), but the level
of neuromuscular blockade is among the most impor-
tant for both intubation and surgical delivery. Common
practice in cesarean section is that, after induction of
anesthesia and initial muscle paralysis with suxametho-
nium, a non-depolarizing neuromuscular blocking drug

Please cite this article in press as: Bláha J et al. Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized
trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005
2 Surgical conditions with rocuronium versus suxamethonium in cesarean section
is administered after the delivery of the fetus.7 If the sur-
gery is not straightforward, the effect of suxamethonium
may already be starting to fade by the time of delivery
and thus the conditions for delivery may begin to dete-
riorate. Due to its longer effect, this problem does not
arise after rocuronium. Therefore, in our study, we
focused primarily on a comparison of the surgical condi-
tions for fetal delivery in parturients receiving rocuro-
nium versus those having a more traditional induction
sequence with suxamethonium.
Methods
This prospective randomized double-blind controlled
trial was conducted at a tertiary care university hospital
which has an average of 4600 births per year, in the per-
iod between August 2014 and September 2016. The
study was approved by the Ethics Committee of the
General University Hospital in Prague (ref: 1216/13 S-
IV) and by the Czech State Institute for Drug Control
(ref: KH 76113/14-I) and was registered at the European
Clinical Trials Database (EudraCT 2013-003077-97) and
the Clinical Trials Database (ClinicalTrials.gov:
NCT01941628). The study was conducted in accordance
with the Helsinki Declaration principles and is reported
according to the Consolidated Standards of Reporting
Trials Statement.8 Signed informed consent was
obtained from each participant.
The primary objective of the study was to compare
the surgical conditions for fetal delivery during cesarean
section under general anesthesia after deep neuromuscu-
lar block (defined as a train-of-four (TOF) count=0)
from rocuronium versus induction with suxametho-
nium. The total time to delivery (induction-to-delivery
interval), the time from the initial skin incision to fetal
delivery (incision-to-delivery interval) and a five-point
Surgical Rating Scale for Delivery (SRSD), evaluated
by the surgeon, were used as primary endpoints for
assessment of surgical conditions. Newborn post-natal
adaptation, particularly muscle tone and breathing,
were the primary safety measures. Secondary outcomes
were comparison of time to intubation (induction-to-
intubation interval, defined as the time between admin-
istration of the neuromuscular blocking drug and inser-
tion of the tracheal tube between the vocal cords), blood
loss, postoperative muscle pain, and surgical/anesthetic
complications.
The eligible patients were women undergoing cate-
gory 3 or 4 cesarean section9 under general anesthesia.
Patients were screened and enrolled in the study by an
anesthesiologist during the pre-anesthesia visit. The
inclusion criteria were as follows: age 18–45 years, good
physical status (American Society of Anesthesiologists
(ASA) physical classification II) and written informed
consent. The exclusion criteria included multiple preg-
Please cite this article in press as: Bláha J et al. Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized
trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005
nancy, urgent cesarean surgery, abnormal placentation,
prematurity (<34 weeks), severe fetal hypoxia, history of
severe pre-existing disease, hypersensitivity or allergy to
rocuronium, suxamethonium or sugammadex, con-
traindication to the use of neuromuscular blocking
drugs, and other serious fetal or maternal conditions.
The discontinuation criterion was extremely difficult
fetal delivery (uterotomy-to-delivery interval >180 s).
The participants were randomly assigned into one of
two study groups: rocuronium (ROC) or suxametho-
nium (SUX). The treatment allocation was performed
using an online randomization generator of randomly
permuted blocks (www.randomization.com, seed
8192). Each patient was allocated before entering the
operating room. The randomization was kept blinded
for the patient, surgeon and surgical team, neonatolo-
gist, and investigator. For safety reasons and to avoid
possible malpractice and risk of poorly maintained anes-
thesia throughout the surgery, the choice of muscle
relaxation was not blinded to the attending obstetric
anesthesiologist.
A dose of neuromuscular drug was prepared and
labeled by the anesthesiologist in a 10-mL syringe (or
10 + 5 mL syringes if the patient weighed more than
100 kg) so that 0.1 mL of study solution was equivalent
to a dose of neuromuscular drug per 1 kg of maternal
weight (i.e., 10 mL of study solution contained either
suxamethonium 100 mg or rocuronium 60 mg). To
determine an appropriate dose, an actual maternal
weight minus 6 kg (fetus + placenta + amniotic fluid)
was used.
The standard departmental protocol for cesarean sec-
tion under general anesthesia was used, with metoclo-
pramide and ranitidine administered orally for
aspiration prevention at least one hour before surgery.
After pre-oxygenation, general anesthesia was induced
using intravenous thiopentone 5 mg/kg followed by
the study drug of 0.1 mL/kg, and until delivery was
maintained with sevoflurane at an expired concentration
of 0.7% in a 50% gas mixture of nitrous oxide and oxy-
gen. Intubation in all patients was performed based on
monitoring (at the time of TOF count of 0), without cri-
coid pressure and using the McCoy laryngoscope and
cuffed tracheal tube size 7.0. If the time to TOF count=0
exceeded 60 s, bag-valve-mask ventilation was allowed
to be used regardless of maternal oxygen (O2) satura-
tion. After ligation of the umbilical cord, sufentanil
0.5 lg/kg was administered for analgesia and sevoflu-
rane concentration was increased to 1.2%.
In the ROC group, rocuronium 0.6 mg/kg (Esmeron,
Merck Sharp & Dohme V.B., Nederland) was used to
aid intubation post induction and to induce deep neuro-
muscular block for surgery. Deep neuromuscular block
was maintained by additional doses until suturing of the
rectus abdominis muscle fascia. Sugammadex (Bridion,
J. Bláha et al.
Merck Sharp & Dohme Limited, Great Britain) at a
dose of 4 mg/kg was administered at the end of the pro-
cedure to reverse neuromuscular block.
In the SUX group, suxamethonium (Succinylcholin-
jodid Valeant, Valeant Czech Pharma s.r.o., Czech
Republic) at a dose of 1 mg/kg was used after induction
of general anesthesia. Atracurium 0.25 mg/kg was given
after fetal delivery to maintain stable anesthesia or at the
surgeon’s request. Neostigmine 0.5–1 mg with atropine
was administered at the end of surgery, if required, to
reverse neuromuscular block.
A Pfannenstiel supra cervical laparotomy and semilu-
nar lower segment uterotomy were used in all cases. All
cesarean deliveries were performed by the same group of
obstetricians who evaluated the surgical conditions in
both study groups. The intra-operative monitoring was
performed using a Datex Ohmeda S/5 TM Compact
Anesthesia Monitor (Datex Ohmeda Inc., USA),
according to national general standards for patient
monitoring during general anesthesia. The neuromuscu-
lar block depth was measured using a TOF Watch SX
device (Organon) stimulating the ulnar nerve on the
right distal forearm; the response of the adductor polli-
cis muscle was evaluated using accelerometry. The TOF
stimulation was recorded in 15-s cycles throughout the
surgery in both study groups. For evaluation of surgical
conditions, the Surgical Rating Scale for Delivery
(SRSD), a modification of the Leiden surgical rating
scale10 was used. The SRSD is a five-point scale evalua-
tion (1-poor, 2-below average, 3-average, 4-above aver-
age, 5-excellent) based on the following parameters:
relaxation of the rectus abdominis muscle, accessibility
to the abdominal cavity, organ visualization, and ease
of fetal delivery. The surgical conditions were rated by
the surgeon immediately after the delivery.
A visual analogue scale (VAS) was used to evaluate
postoperative pain at the end of surgery (time 0), and
at 3, 6, 9, 12, 18, and 24 h after the surgery. The end
of surgery was defined as the time of transfer from the
operating room to the post-anesthesia care unit
(PACU). The evaluation of newborn adaptation was
performed by an experienced neonatologist using Apgar
scores at 1, 5, and 10 min and by clinical assessment of
muscle tone (physiological: reduced, significantly
reduced, none) and breathing [1-physiological; 2-need
for tactile stimulation; 3-continuous positive airway
pressure; and 4-intubation]. Arterial and venous umbil-
ical cord blood gas analyses were performed in the deliv-
ery room with an ABL 90 Flex (Radiometer Medical,
Denmark) blood gas analyzer.
The sample size of 90 was calculated to detect a 20%
difference between the groups in the duration from
induction to delivery, with 80% power. This calculation
was based on data from our previous study
(NCT01550640) and on a between-subject standard
deviation of change of 1.6 min for time of delivery.
Please cite this article in press as: Bláha J et al. Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized
trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005
3
The sample size needed to detect a 20% difference
between the groups in the duration from incision to
delivery in a post hoc analysis was estimated to be 56.
The statistical analysis was performed with the STATIS-
TICA 10 software (StatSoft, Czech Republic) or Graph-
Pad software. All data were tested for normality using
the Kolmogorov-Smirnov test before the final analysis.
Numerical data from both groups were compared using
the Student t-test or the Mann–Whitney rank-sum test,
as appropriate. For categorical variables, the Fisher
exact test and the Pearson chi-square test were used.
All statistical tests were performed as two-tailed and val-
ues of P <0.05 were considered statistically significant.
Results
A total of 90 women were included, with 45 patients
allocated to the ROC group and the other 45 to the
SUX group. All participants were of ASA physical sta-
tus class II. Fig. 1 shows the study patient flow diagram.
The most common reason for cesarean section in this
study was previous cesarean section (22 vs 21 patients),
breech position (8 vs 10 patients), and neurological dis-
ease (7 vs 4 patients). In all but seven cases, the reason
for the choice of general anesthesia was refusal of regio-
nal anesthesia by the patient. The characteristics of the
patients are presented in Table 1. No intra- or postoper-
ative major complications and no severe maternal
hypoxia (oxygen saturation below 85%) were recorded
throughout the study. No postoperative myalgia was
observed in any parturient after rocuronium and in only
two patients (4.4%) after suxamethonium (at 6–9 h post-
surgery).
Anesthesia, and surgical times and conditions for
fetal delivery are shown in Table 2 and Fig. 2. Of 90 sur-
gical condition evaluations, 30 (33%) were evaluated by
surgeons with clinical obstetric practice experience of 3–
5 years, 6 (7%) with experience of 5–10 years and 54
(60%) by surgeons with experience of more than
10 years. The TOF-ratio at the time of delivery was 0
in all patients, but the TOF-count differed between the
groups. While in the ROC group the TOF-count at
delivery was 0 in all patients, in the SUX group it was
0 in 55.3% of patients only (count 1, 7.9%; count 2,
7.9%; count 3, 10.5%; and count 4, 18.4%).
The total time from induction to delivery was not sig-
nificantly different between the ROC and SUX groups,
but the time from induction of general anesthesia to
intubation was significantly longer after rocuronium
(P <0.001), whereas the time from incision to delivery
was significantly longer after suxamethonium
(P=0.0002). There was no significant difference between
groups for the time taken to check the correct position
of the tracheal tube (time between intubation and inci-
sion). We found a significant correlation (P <0.001)
between the incision-to-delivery intervals and surgical
4 Surgical conditions with rocuronium versus suxamethonium in cesarean section

Fig. 1 Assessment, randomization, and follow-up of the study’s patients. ROC=rocuronium, SUX=suxamethonium

Table 1 Characteristics of parturients undergoing cesarean section under general anesthesia.

Rocuronium group Suxamethonium group
Range Range
Age (y) 32.5 (2.2) 22.1–43 34.0 (5.5) 21.7–42.9
Actual weight (kg) 79.2 (13.2) 59–121 83.0 (15.8) 59–146
Height (cm) 168.3 (6.4) 153–182 166.6 (7.9) 150–182
Body mass index (kg/m2) 28.0 (4.6) 19.8–40.4 29.9 (4.8) 20.9–41.5
Mallampati class III or IV 8 (8.9) 9 (10)
Breech presentation 8 (17.8) 10 (22.2)
Previous cesarean section 22 (48.9) 21 (46.7)
Values are mean (SD) or number (%).; Data are presented as mean (SD) or number (proportion). BMI=body mass index.

conditions (SRSD) for fetal delivery (Pearson correla- Discussion

tion coefficient 0.50; P <0.001, Fig. 3). The latter condi-
tions were one point better after rocuronium compared
with suxamethonium [median 4 (3–5) points vs 3 (2–4)
points, P <0.001]. When comparing average/below aver-
age with above average/excellent surgical conditions, the
SRSD difference between the ROC and SUX groups
was also significant (33.3% and 66.7% in the ROC group
vs 93.3% and 6.7% in the SUX group, P <0.0001).
No differences in newborn post-natal adaptation
were found between the ROC and SUX groups. Apgar
scores at 1, 5, and 10 min, muscle tone, breathing assess-
ments, and arterial and venous umbilical cord blood gas
analyses, were all not significantly different between the
ROC and SUX groups (Table 3).
The use of rocuronium for intubation in cesarean sec-
tion is still somewhat controversial. The dose of
0.6 mg/kg is considered insufficient to ensure fast intu-
bation during apnea, whereas a dose of 1 mg/kg is not
approved for use in cesarean section.2,3,11,12 This is the
one reason why suxamethonium has been the preferred
neuromuscular blocking drug for rapid sequence induc-
tion and intubation in cesarean section for almost
50 years.13–15 However, for non-obstetric rapid sequence
induction, rocuronium is now recommended. In a recent
survey, only 14% of responding anesthesiologists in the
UK used rocuronium for rapid sequence induction at
cesarean section, but 52% supported a change to the

Please cite this article in press as: Bláha J et al. Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized
trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005
 Table 2 Times from induction of anesthesia to end of surgery; and induction characteristics.
Rocuronium group Suxamethonium group Difference in means P-value
J. Bláha et al.

Mean Median mean median

Induction – delivery interval (s) 268.4 (72.9) 265 (223–330) 275.6 (63.4) 267 (239–400) 7.2 ( 39.5 to 19.3) 0.62
Induction – intubation interval (s) 105.8 (33.7) 108 (77–134) 67.6 (32.1) 63 (50–123) 38.2 (24.4 to 52.0) <0.001
Incision – delivery interval (s) 146.6 (68.3) 130 (99–179) 196.2 (50.7) 201 (167–277) 49.7 ( 74.8 to 24.4) 0.0002
Intubation – incision interval (min) 15.8 (6.9) 15 (4–43) 11.7 (6.4) 10 (3–29) 4.1 (0.4 to 7.8) 0.061
Length of surgery (min) 39.3 (8.9) 39 (27–53) 39.4 (9.6) 38 (26–54) 0.1 ( 4.0 to 3.8) 0.976
End of surgery to extubation (min) 5.2 (4.6) 4 (0–13) 8.8 (5.8) 8 (2–19) 3.5 ( 5.8 to 1.4) 0.002
SRSD (points) 3.73 (0.53) 4 (3–5) 2.77 (0.55) 3 (2–4) 1.0 ( 0.01 to 0.20) <0.001
Blood loss (mL) 533 (76) 500 (500–600) 538 (98) 500 (500–650) 5 ( 38 to 28) 0.859
Thiopental (mg/kg) 4.7 (0.16) 4.7 (4.5–5.1) 4.7 (0.21) 4.7 (4.5–5.3) 0.471
Muscle relaxant dose (mL/kg) 0.092 (0.01) 0.093 (0.090–0.106) 0.095 (0.00) 0.094 (0.09–0.106) 0.072
Muscle relaxant dose (mg/kg) 0.55 (0.05) 0.56 (0.54–0.65) 0.95 (0.04) 0.94 (0.9–0.11) 0.177
Data are presented as mean (SD) or median (range). Difference between the groups is expressed as median (95% confidence interval). SRSD: Surgical rating scale for delivery.

trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005

during surgery. Circles are the mean (SD)

reader is referred to the web version of this article)

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2-below average, 3-average, 4-above average, 5-excellent).

Surgical Rating Scale for Delivery (SRSD; 1-poor, 2-below

Incision-to-delivery interval is presented as time in seconds,
surgical conditions (Pearson correlation r=0.50; p <0.001).
Squares denote the proportions of individual ratings obtained
the five-point Surgical Rating Scale for Delivery score (1-poor,

pretation of the references to colour in this figure legend, the

surgical conditions evaluated by surgeon are presented as
5

cles=rocuronium; green triangles=suxamethonium. (For inter-

average, 3-average, 4-above average, 5-excellent). Blue cir-
delivery rated by the surgeon during cesarean section using
Fig. 2 Distribution of the surgical conditions for fetal

Fig. 3 Correlation between incision-to-delivery interval and

6 Surgical conditions with rocuronium versus suxamethonium in cesarean section

Table 3 Characteristics of newborns, adaptation evaluation, and umbilical arterial blood gas analysis.
Newborns Rocuronium group Suxamethonium group P-value
Range Range
Weight (g) 3277 (479) 1310–3980 3311 (561) 1650–4510 0.76
Gestational age (weeks) 38.6 (0.8) 37–41 38.1 (1.5) 34–40 0.06
Apgar 1-min 8.6 (1.9) 3–10 8.7 (1.5) 3–10 0.71
Apgar 5-min 9.5 (0.7) 8–10 9.5 (1.0) 5–10 0.81
Apgar 10-min 9.8 (0.5) 9–10 9.8 (0.5) 7–10 0.84
Muscle tonus (grade 1–4) 1.2 (0.4) 1–3 1.3 (0.4) 1–3 0.32
Breathing (grade 1–4) 1.1 (0.4) 1–2 1.2 (0.5) 1–2 0.47
Hb (g L 1) 150 (15) 121–201 151 (16) 125–186 0.70
pH 7.32 (0.03) 7.24–7.38 7.31 (0.03) 7.27–7.38 0.24
pCO2 (kPa) 6.4 (0.8) 3.25–7.56 6.7 (0.7) 4.34–8.18 0.10
Actual HCO3 (mmol/L) 24.0 (2.4) 13.5–28.7 24.6 (2.0) 17–28.1 0.20
Standard HCO3 (mmol/L) 21.6 (1.7) 16.5–26.1 21.6 (1.3) 17.5–24.9 0.95
BE (mmol/L) 2.1 (2.1) 10–2.4 1.8 (1.7) 7–2.2 0.47
pO2 (kPa) 3.4 (2.6) 0.8–18.8 2.8 (0.8) 1.2–5.4 0.13
Sat O2 (%) 45.3 (19.1) 6.9–95.8 41.2 (15.9) 11.5–83.3 0.29
Total CO2 (mmol/L) 21.6 (2.1) 12.2–25.2 22.3 (1.8) 15.4–25.6 0.13
Data are presented as mean (SD) or range. Assessment of muscle tonus: 1-physiological, 2-reduced, 3-significantly reduced, 4-none; assessment of
breathing: 1-physiological, 2-need of tactile stimulation, 4-CPAP, 4-intubation. CPAP=continuous positive airway pressure.

administration of rocuronium as the neuromuscular
blocker of choice in this setting.16 There are obvious rea-
sons favoring rocuronium instead of suxamethonium in
cesarean section. Suxamethonium-induced fasciculation
increases oxygen consumption during apnea, which may
become relevant in the event of airway obstruction or
difficult intubation.17,18 Unlike suxamethonium, rocuro-
nium is not associated with the risk of malignant hyper-
thermia, hyperkalemia or vagal arrest, and it does not
increase intragastric or intracranial pressure.19 More
importantly, deeper and more sustained neuromuscular
block from rocuronium may allow more efficient imple-
mentation of difficult airway management in the case of
failed intubation, including the possibility of an immedi-
ate reversal of block.20,21 Nevertheless, this purported
advantage of rocuronium is unproven. The reversal of
paralysis does not guarantee restoration of a patent air-
way in an unconscious patient,22 and the total time
needed to prepare and administer sugammadex, from
the time of the initial decision to use it, may not prevent
a patient from suffering significant arterial oxygen
desaturation.23
An important aspect of our study is that it supports a
rocuronium dose of 0.6 mg/kg, which is only approved
for cesarean section. While the induction-to-intubation
interval was, in accordance with previous studies, longer
after rocuronium compared with suxamethonium (mean
difference 38 s, P <0.001), the subsequent incision-to-
delivery interval was conversely significantly shorter
(mean difference 50 s, P <0.001). Summing these inter-
vals, the induction-to-delivery intervals were compara-
ble in each group, so the duration of transplacental
transfer of the anesthetics was likely to have been simi-
lar. This is supported by the fact that we did not observe
any difference in Apgar scores, muscle tone, breathing
or umbilical cord blood gas analyses. Nevertheless, the
study was not powered to detect differences in neonatal
outcomes. These results are in contrast to the study by
Kosinova et al., in which the use of rocuronium was
associated with lower Apgar scores at 1-min compared
with those after suxamethonium.24
Although there was no difference between rocuro-
nium and suxamethonium for the time to delivery, we
found demonstrably better surgical conditions for deliv-
ery associated with rocuronium. This corresponded with
a significantly faster surgical time for fetal delivery in
patients receiving rocuronium. The mutual relationship
of these two variables was also confirmed by the moder-
ate positive correlation between surgical conditions and
fetal delivery time. The reason why rocuronium pro-
duced better surgical delivery conditions, allowing a
shorter surgical time to delivery, is most likely because
the effect of suxamethonium was already wearing off
at the time of delivery (with atracurium not yet given).
Nearly half the patients given suxamethonium had at
least one detectable TOF-stimulated twitch at the time
of delivery, compared with deep neuromuscular block
from rocuronium. The question is whether the more
rapid onset of action of suxamethonium compared to
rocuronium at a dose of 0.6 mg/kg,25 and thus faster
intubation, but then only moderate neuromuscular
block during surgery, is a key reason for choosing sux-
amethonium. It can be argued that good neuromuscular
block throughout the surgery, as is usual for other sur-
gical abdominal procedures, will allow optimal surgical
conditions at cesarean section as well. However, the like-
lihood of deep neuromuscular block at the end of sur-
gery necessitates use of sugammadex to ensure safe
and effective reversal, so the availability and cost of sug-
ammadex must be considered. Based on the results of

Please cite this article in press as: Bláha J et al. Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized
trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005
J. Bláha et al.
previous studies, an intubation dose of rocuronium of
1 mg/kg would provide a shorter time to intubation than
a dose of 0.6 mg/kg. Thus, the total time of delivery
might be shortened compared with suxamethonium
and thus provide even better conditions for newborn
adaptation.
There are several limitations to our study. The first is
that a global assessment of the surgical conditions,
which is primarily subjective, might be influenced by
the subjective opinion of the individual surgeon. There-
fore, an integral part of the evaluation of the surgical
conditions was an objective comparison of the time
intervals before fetal delivery. These were consistent
with the subjective evaluation of the conditions. More-
over, the scale used to describe the surgical conditions
was subjective and the clinical relevance of differences
found is uncertain. Secondly, the blinding of the surgeon
may have been compromised in this study because the
time to intubation after rocuronium was longer and sux-
amethonium causes fasciculations. However, the range
of values was wide and similar between groups (ROC
group 77–134 s and SUX group 50–123 s), which likely
minimized this risk of bias. Thirdly, we did not record
the number of intubations that required bag-valve-
mask ventilation due to maternal hypoxia as this proce-
dure was permitted regardless of maternal oxygen satu-
ration. This information is primarily relevant in high-
risk patients and patients of high body mass index, so
a finding of no severe maternal hypoxia in either group
should be interpreted cautiously. Fourthly, the compar-
ison of rocuronium with suxamethonium at a dose of
1 mg/kg might not reflect clinical practice elsewhere; in
acute settings in particular the dose of suxamethonium
may not be based on maternal weight, with many
women being given one standard vial containing
100 mg. The actual dose administered to women weigh-
ing 75–100 kg is then 1–1.3 mg/kg, although at cesarean
section excellent intubating conditions occur after doses
up to 1.6 mg/kg.26 Further, it is not clear whether the
dosing of rocuronium and suxamethonium should be
based on current, ideal, corrected or lean body weight.
While it is recommended that rocuronium dosing uses
lean or ideal body weight,27,28 suxamethonium dosing
based on the ideal or lean body weight does not create
good intubating conditions and dosing based on actual
body weight is recommended.29,30
Finally, especially in the case of rocuronium, the
onset, duration and recovery from rocuronium also var-
ies widely within different geographic populations, so in
practice neuromuscular block monitoring should be
used to guide times to intubation. For example, its
potency appears to be significantly higher in American
patients compared with similar European patients,31
and the recovery time longer in Chinese compared with
Caucasian patients or in adults compared with
children.32
Please cite this article in press as: Bláha J et al. Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized
trial. Int J Obstet Anesth (2019), https://doi.org/10.1016/j.ijoa.2019.08.005
7
In conclusion, while the induction-to-delivery inter-
vals in cesarean section were comparable for rocuro-
nium 0.6 mg/kg and suxamethonium 1 mg/kg, in this
study rocuronium was found to provide better surgical
conditions for fetal delivery and faster surgical access.
This might be of value for safe delivery and postnatal
neonatal adaptation, especially in technically more com-
plicated cesarean section surgery, although the findings
are not generalizable to high-risk pregnancies or difficult
airway management scenarios.
Declaration of interests
J. Blaha has received consultancy fees from Merck
Sharp & Dohme Corp. The authors declare no other
potential conflicts of interest relevant to this article.
Funding
The study was supported in part by a research grant
from Investigator-Initiated Studies Program of Merck
Sharp & Dohme Corp. (Protocol No. 8616-094) and
by MH CZ – DRO VFN-64165.
Acknowledgments
The authors thank all anesthesiologists and obstetric
team personnel for extending their workload during
the study period. The opinions expressed in this paper
are those of the authors and do not necessarily represent
those of Merck Sharp & Dohme Corp.
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