General anesthesia for cesarean delivery
Why examiners ask this
General anesthesia for cesarean is now rare, which is exactly why examiners use it: it combines the highest-risk airway in the hospital with a time pressure that tempts candidates to cut corners. The stem forces a judgment call (is there time to extend the epidural?) and then tests organization when the airway does not go as planned. It also probes application of knowledge about aspiration, awareness, and uterine tone.
The 60-second answer
I choose general anesthesia only when neuraxial is contraindicated (for example uncontrolled hemorrhage or coagulopathy) or there is no time to establish it, and I say that out loud with the reason.1 I give a non-particulate antacid such as sodium citrate,2 place her in left uterine displacement with a ramp, and preoxygenate to an end-tidal oxygen above 0.9 or with high-flow nasal oxygen while the abdomen is prepped and draped. Surgeon scrubbed and ready, I perform a rapid sequence induction with propofol 2 mg/kg and either succinylcholine 1–1.5 mg/kg or rocuronium 1.2 mg/kg with sugammadex available, using a video laryngoscope and a 6.0–6.5 tube. I maintain with about 1 MAC of volatile until delivery, then drop to 0.5–0.7 MAC, add an opioid and start oxytocin. My main concern is failed intubation, and my plan for it is decided before I induce.
Decision points and the "why"
- Talk before the team cuts — I have the WHO checklist and a pre-induction huddle: who will hold cricoid if used, which supraglottic device is open, and whether we wake her or continue if intubation fails. Deciding this in the moment produces bad decisions.
- Video laryngoscope first, small tube — airway edema and enlarged breasts make laryngoscopy harder; failed intubation is roughly seven times more frequent than in the non-pregnant population.2 I change to direct laryngoscopy only if blood or secretions obscure the camera.
- Propofol, not thiopental by default — propofol is what is available and is safe for the neonate at induction doses. In a hemorrhaging patient I use ketamine 1 mg/kg or etomidate 0.3 mg/kg for hemodynamic stability.
- Rocuronium is acceptable — with sugammadex 16 mg/kg ready, high-dose rocuronium matches succinylcholine intubating conditions and gives a rescue path. I still use succinylcholine when I want the shortest possible block.
- Avoid awareness — the incidence is highest in obstetric general anesthesia because of fear of uterine atony and neonatal depression. I keep at least 0.7–1 MAC before delivery, use processed EEG if available, and add nitrous oxide or midazolam after delivery rather than letting the volatile fall too low.
- Lower volatile after delivery — volatile agents above about 1 MAC relax the uterus; I reduce it once the baby is out and rely on opioids and propofol infusion if atony is a problem.
- Extubate awake — fully reversed, sitting up, after suctioning the stomach, because extubation is where aspiration and obstruction kill mothers now.
The complication they will inject
The first look with the video laryngoscope fails and saturation is 94% and falling. I call for help and say "failed intubation" aloud. I make one more attempt only with a change (bougie, smaller tube, release cricoid), then place a second-generation supraglottic airway and oxygenate. The decision to proceed or wake is driven by the fetus and the mother: with a category 3 tracing and a working supraglottic airway I proceed with surgery, lightly cuffed, maintaining spontaneous or gentle positive-pressure ventilation. If I cannot ventilate, I go to front-of-neck access without delay. If the indication is non-urgent, I wake her and do the case under neuraxial. Afterward I document, debrief, and tell her.
Pitfalls that cost points
- Going straight to general anesthesia without asking whether the epidural can be extended or a spinal is feasible.
- Forgetting the post-delivery uterotonic and volatile reduction, then being surprised by atony.
- Multiple attempts at intubation without changing anything.
- Treating "wake up" as automatic when the baby is in distress; the obstetric failed-airway algorithms explicitly weigh both lives.
- Extubating deep or before reversal is confirmed.
Rapid-why
Q: Why is preoxygenation more urgent in pregnancy? A: Functional residual capacity falls about 20% and oxygen consumption rises, so desaturation after apnea is much faster.2
Q: Why left uterine displacement? A: The gravid uterus compresses the aorta and vena cava after about 20 weeks, cutting venous return and uteroplacental flow.2
Q: Does a 6-minute induction-to-delivery interval matter? A: Uterine incision-to-delivery time matters more than induction-to-delivery; prolonged uterine manipulation causes fetal acidosis.
Q: Why sodium citrate and not just an H2 blocker? A: Sodium citrate neutralizes acid already in the stomach within minutes; H2 blockers and metoclopramide need 30–60 minutes.
Numbers to know
| Item | Value |
|---|---|
| Propofol induction | 2 mg/kg IV |
| Succinylcholine | 1–1.5 mg/kg IV |
| Rocuronium RSI | 1.2 mg/kg; sugammadex 16 mg/kg for rescue |
| Sodium citrate | 30 mL orally before induction |
| Volatile before delivery | About 1 MAC; reduce to 0.5–0.7 MAC after |
| Tube size | 6.0–6.5 mm ID |
Links
- Rapid sequence induction and full stomach, Anticipated difficult airway and the ASA algorithm, Cannot intubate, cannot oxygenate, aspiration, Intraoperative awareness and depth monitoring (coming), Uterotonics and tocolytics (coming)
- Atlas: Monitor atlas: quantitative NMB and fetal heart rate (2026) (coming)
- OAA/DAS guideline for obstetric difficult and failed tracheal intubation; ASA Practice Guidelines for Obstetric Anesthesia
Sources
- 1.Obstetric Regional Anesthesia · NYSORA · nysora.com
- 2.Changes in Maternal Physiology During Pregnancy (Update in Anaesthesia 21) · WFSA · resources.wfsahq.org
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.