General anaesthesia for operative obstetrics

General anaesthesia in obstetrics is reducing with a reported use in only 8% of caesarean sections in 2013. Obstetric surgery is often urgent, requiring effective team communication and a rapid, focused preoperative assessment. Physiological changes of pregnancy increase the incidence of aspiration, desaturation and failed intubation. In addition, the rapidly evolving circumstances add additional stress impacting on performance. Hypotension from aortocaval compression is common and minimized by left lateral tilt or uterine displacement. Rapid sequence induction with tracheal intubation remains gold standard but supraglottic devices are advocated in the event of failed intubation. Awareness remains relatively common and adequate depth of anaesthesia should be maintained and monitored. Complications are more common in obese pregnant patients, whilst women with pre-eclampsia are at particular risk of hypertensive responses to intubation and extubation, intravenous opiates can ameliorate this. There is no difference in maternal or neonatal adverse outcomes between general and regional anaesthesia. Improved multidisciplinary communication on the delivery suite allows for pre-emptive assessment of patients at risk of requiring an operative delivery. With diminishing individual experience of general anaesthesia in obstetrics and delivery suite often being covered by junior doctors, simulation exercises can improve confidence, performance and team working.