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  • General anesthesia (GA) has largely been replaced by neuraxial due to decreased maternal mortality and morbidity and improved fetal outcomes (Chapter 47, “Neuraxial Anesthesia for Cesarean Delivery”).

  • Indications:

    • Maternal refusal of neuraxial anesthesia.

    • Severe psychiatric or developmental disorder.

    • Coagulopathy.

    • Local infection at the neuraxial site.

    • Severe, uncorrected hypovolemia.

    • Intracranial mass with increased intracranial pressure.

    • Failure of the neuraxial block to rise in urgent or emergent cesarean.

    • Umbilical cord prolapse with persistent fetal bradycardia.

    • Incomplete coverage of spinal anesthesia.

    • Multiple failed neuraxial placements.

    • Persistent intraoperative pain that is uncontrolled.

  • STAT or urgent intrapartum indications for GA should involve constant communication between the obstetrician and anesthesiologist. This ensures a continued need for GA and updates everyone on the current steps in the ongoing process.


  • Perform standard evaluation, consent, and multidisciplinary huddle.

  • Place a 16 or 18 G peripheral intravenous catheter and obtain a complete blood count and type and screen blood bank sample.

  • Administer nonparticulate antacid <30 minutes before induction.

  • May consider metoclopramide 10 mg and/or ranitidine 30 mg IV if >30 minutes prior to induction.

  • In patients with high body mass index may consider the placement of a ramp to optimize patient positioning for intubation.

  • If the patient is greater than 20 weeks of gestation (uterus at or above the umbilicus), it is vital to place the patient in left uterine displacement prior to induction.

  • Administer indicated antibiotics.

  • Perform preoxygenation with either 100% O2 for 3 minutes or 4 to 8 vital capacity breaths.1

  • Ensure the patient is prepped and draped, perform time-out, and confirm surgeon is ready for incision. This is done to shorten the time from induction to delivery, which minimizes the anesthetic effect on the neonate.


  • Initiate rapid sequence induction.

  • Propofol 2.0 to 2.5 mg/kg of ideal body weight (IBW) and succinylcholine 1.0 to 1.5 mg/kg of total body weight. Etomidate 0.3 mg/kg may be used with hypovolemia.

    • Avoid opioids and benzodiazepines before delivery, as they cross the placenta and may cause neonatal respiratory depression.

  • Wait ∼30 to 45 seconds, then perform tracheal intubation.

    • Ideally, a senior anesthesiologist or an attending should be the intubator.

    • Airway edema associated with pregnancy, labor and preeclampsia may necessitate video laryngoscopy; this should be ready if not the first choice.

    • Endotracheal tube size 6.5 or 6.0 mm should be considered in light of airway edema.2

  • Confirm placement and inform obstetricians that it is safe to initiate surgery.


  • Use volatile anesthetic (sevoflurane, isoflurane, or desflurane) at approximately 1 minimum alveolar concentration (MAC).

  • Recommended initial ventilator settings of 6 to 8 mL/kg of IBW and a respiratory rate of 14 to 18/min.

  • There is a compensatory respiratory alkalosis in pregnancy with a normal PaCO2 of 30 mm Hg. Ventilator settings should be titrated to maintain patients near this baseline.


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