General Anesthesia

Although the use of general anesthesia for cesarean delivery has dramatically declined during recent decades, it is still necessary for the management of several situations, including maternal hemorrhage, overt coagulopathy, life-threatening fetal compromise, or cases in which patients refuse regional anesthesia. A recent study found that anesthesia-related maternal mortality associated with regional anesthesia has declined but that the number of deaths involving general anesthesia has remained relatively constant. Thus, the relative risk of fatality during general anesthesia has increased to more than 16 times that for regional anesthesia.^[191] General anesthesia has the advantages of speed of induction, control of the airway, and superior hemodynamics. The frequency of the use of general anesthesia is dependent on many factors, including the number of patients who receive epidural analgesia for labor, the percentage of high-risk parturients, and the skills of the anesthesiologist. Although there are no absolute contraindications to general anesthesia, in certain conditions, such as malignant hyperthermia or a patient with a difficult airway, a modified anesthetic technique may be required. Potential problems associated with general anesthesia for cesarean section include failed intubation, pulmonary aspiration of gastric contents, neonatal depression, and maternal awareness. The technique for general anesthesia is outlined in Table 58-8 . Although this "cookbook" recipe highlights the basics, it is essential that every anesthesiologist working on the labor and delivery floor be comfortable with the algorithm for the management of failed intubation as illustrated in Figure 58-11 .