General Anaesthetic for a Caesarean

Why most caesareans are not done this way

NICE's recommendation to maternity teams is unambiguous: "offer women who are having a caesarean birth regional anaesthesia in preference to general anaesthesia", including women with a diagnosis of placenta praevia. The Obstetric Anaesthetists' Association puts the same point in plainer words: "Most caesarean births are done with you awake but under regional anaesthesia."

A general anaesthetic means "giving you medicines to make you sleep (unconscious)", so you are not awake and do not feel pain during the operation.

The reasons one is used

The OAA lists them, and the first one on the list is not a complication at all:

• Some people choose to have a general anaesthetic.
• The caesarean is needed very urgently and there is no time for a spinal or epidural to work.
• Certain conditions in which the blood does not clot properly, which can make a spinal or epidural unsafe.
• Abnormalities in your back that make a regional anaesthetic difficult or impossible.
• Occasionally a spinal or epidural "can't be put in the right place, or doesn't work properly".

That last one matters. A general anaesthetic is sometimes the answer to a block that has failed, not to an emergency.

What happens, step by step

The OAA describes the sequence. A cannula goes into a vein in your arm. You may be given an antacid medicine, which NICE also recommends: teams should "offer women antacids and drugs ... to reduce gastric volumes and acidity before caesarean birth".

In theatre you are given oxygen through a facemask and a urinary catheter is placed in your bladder. The obstetricians clean your abdomen before you are asleep, "so they can deliver your baby as soon as you are asleep". The anaesthetic goes in through the cannula.

As you fall asleep you may feel pressure on your neck. The OAA explains that this is "to avoid any acid in your stomach going into your airway". NICE describes the same practice in clinical terms: include "pre-oxygenation, cricoid pressure and rapid sequence induction in general anaesthesia for caesarean birth to reduce the risk of aspiration".

Once you are asleep, your baby and the placenta are delivered, painkillers are given while you are under, and you may also be given local anaesthetic injections into your abdomen to help afterwards. Then you are woken up.

Where your birth partner is

This is the part that upsets people most, and it is worth knowing before the day. The OAA: "Your birth partner will not be able to be with you during the operation, but they will be nearby. The team will update them once your baby is born. They can join you in the recovery area when you are awake."

The HSE says the same about Irish units — a partner "can wait close by and will be updated during the procedure". The OAA's separate guidance on birth partners in theatre confirms that the presence of a partner is normal for regional anaesthesia and not for a general.

What happens to your baby while you are asleep

A member of the neonatal team is present at the birth. The OAA: "The midwife will dry your baby and check them over. If your baby is well, they will be looked after by your midwife until you are awake." If a baby needs extra support with breathing, the neonatal team takes over.

Skin-to-skin therefore happens later than it would after an awake caesarean, and often with your birth partner first. NICE's general expectation still applies once you are able.

Waking up

The OAA is honest about this: "When you wake up, you may feel quite sleepy. Some pain after the operation is normal. You may feel sickly. Painkillers and anti-sickness medication will be available if you need them." The NHS lists the common after-effects of a general anaesthetic in any operation: feeling thirsty or drowsy, a hoarse voice or sore throat from the breathing tube, shivering, feeling or being sick, soreness from the injection, and feeling confused or having memory loss. It adds that these "will usually get better within a few minutes or hours".

The numbers the anaesthetists publish

The OAA states that in the United Kingdom "around 15,000 patients have a caesarean birth under general anaesthesia each year" and that the majority are very straightforward. It publishes its risk figures as frequencies rather than percentages:

• Sore throat: 1 in 2. Shivering: 1 in 3. Feeling and being sick: 1 in 10.
• Accidental awareness, meaning memories of events in theatre: 1 in 212 to 1 in 670. The OAA notes that most patients who are accidentally aware do not feel pain.
• Stomach acid entering the lungs: 1 in 1,000. Damage to an eye: 1 in 1,000. Damage to teeth: 1 in 4,500.
• Severe allergic reaction: 1 in 10,000. Brain damage or death caused directly by anaesthesia: 1 in 100,000 or less.

These are the OAA's averages for caesarean birth in the UK. Your own risk may be higher or lower, and the anaesthetist meeting you is the person who can say which of them apply to you. ACOG's patient material on caesarean birth in the United States lists allergic reaction to anaesthesia among the risks of the operation but does not publish an equivalent frequency table, so the two cannot be compared directly.

What you can ask for

NICE asks that every maternity unit has "a set of procedures for failed intubation during obstetric anaesthesia" — that plan exists whether or not anyone mentions it. You can ask to meet an anaesthetist antenatally if you know a general anaesthetic is likely, ask what will be explained to your partner and when, and ask for a debrief afterwards. You can also ask for a general anaesthetic, and the OAA lists choice as a legitimate reason for one.