General Anaesthesia For Caesarean Section Research Articles

Remifentanil at induction of general anesthesia for cesarean section: Double blind, randomized clinical trial

Remifentanil, with its rapid activity onset and short duration of action, may be more effective than other opioids for providing hemodynamic stability during obstetric anesthesia. However, there is some evidence of adverse effects on neonatal respiratory function. We investigated maternal and fetal effects of Remifentanil during cesarean section surgery. Eighteen women with singleton term pregnancies, and physical class status of I or II as defined by the American Society of Anesthesia (ASA), who were undergoing general anesthesia for semi-elective cesarean section were randomized into two groups (40 in each group) that received either an intravenous bolus of 0.5 µg/kg Remifentanil or the same dose of saline as a placebo. Maternal hemodynamic variables and neonatal umbilical artery pH and Apgar score at first and fifth min were evaluated in both groups. Systolic and diastolic blood pressure were significantly lower after tracheal intubation and skin incision in the Remifentanil group as compared with the control group (p <0.05). There were no significant differences regarding heart rate between groups at any time (p > 0.05). Apgar scores at first and fifth min were not significantly different among groups (p>0.05). No neonate required assisted ventilation or naloxan administration. Remifentanil may be a safe and effective drug for the induction of general anesthesia and surgical stimulation without subsequent neonatal depression.

Birth Outcome after Caesarean Section among Mothers who Delivered by Caesarean Section under General and Spinal Anesthesia at Gondar University Teaching Hospital North-West Ethiopia

Introduction: Intrapartum death is the leading cause of child mortality in the world. In Africa, 62 new borns die out of 1000 live births. Anesthesia is responsible for 89 intrapartum deaths per 1000 live births and 3-12% maternal deaths; which are almost associated with the use of general anesthesia. The objective of this study was to assess neonatal outcomes using APGAR score among mothers delivered by caesarean section at Gondar University Hospital, North west Ethiopia. Methods: An institution based cross sectional study was used to assess neonatal outcomes after caesarean sectionamong mothers delivered by caesarean section under anesthesia. All mothers that came for caesarean section from January1, to April 30, 2012 were included in this study Data were collected using structured questionnaires. All pre delivery questionnaires were filled during pre operative preparation after taking informed consent and other intra operative events were recorded intra operatively in the operation room. Data entry and analysis was done using SPSS version 16, each variable was entered to bivariate analysis, variables with P value <0.2 were taken to multivariate analysis using logistic regression. Results: The use of general anesthesia for caesarean section in this particular study was more frequent when compared with spinal anesthesia (65%). The risk of Low APGAR score 5 was increased in babies born under general anesthesia as compared with babies born under Spinal anesthesia (AOR=3.19,95% C.I.(1.73, 5.90)). Low Fetal weight was associated with low APGAR score of new borns (AOR=1.38 with 95% C.I. (1.10, 1.70)). Pre anesthetic fetal heart rate and uterine incision to delivery time were also found to be associated with APGAR score 5 of neonates (AOR=2.12, (95% CI, 1.20; 3.60) and 2.57, (95% CI, 1.20, 3.50)) respectively. Conclusion: Neonates born under Spinal anesthesia had better physiologic profile as evidenced by APGAR score 5. The use of general anesthesia should be reduced and reserved for special indications that are contra indicated to spinal anesthesia only. Low birth weight, prolonged uterine incision to delivery of the baby and pre anesthetic fetal heart beat has affected APGAR score 5 of newborns.

Obstetric anaesthesia: Is there anything new under the sun?

Recent years have seen considerable sophistication in the practice of obstetric anaesthesia in the developed world. Important areas include regional anaesthesia in labour, regional anaesthesia for caesarean section (CS), categorization of the urgency of CS, and clearer definition of fetal indications for CS. The physiological basis for management of spinal hypotension is now well understood. Regional anaesthesia for patients with preeclampsia is established, and is rapidly developing in those with cardiac co-morbidities. Maternal awareness during general anaesthesia for CS has been considerably reduced. A better understanding of the pharmacology of oxytocic drugs has facilitated the management of obstetric haemorrhage. However, anaesthesia-related maternal morbidity and mortality in South Africa remains unacceptably high, and a major effort, including the development of a Special Interest Group, is necessary to address the specific problems in obstetric anaesthesia in our country.

Choice of anaesthetic agents for caesarean section: A UK survey of current practice

BackgroundA national survey of current practice and preferred drug choices for both induction and maintenance of general anaesthesia for caesarean section was undertaken. MethodsFollowing approval by the Obstetric Anaesthetists’ Association, all UK consultant members were invited to respond to an electronic survey. ResultsThe response rate was 56% (691/1228). Ninety-three percent of respondents use thiopental for induction: 58% (15% definitely and 44% probably) would support a change to propofol for induction. Thiopental was used in most cases for historical reasons (37%) or to reduce awareness (31%); other considerations included a clear end-point, dose predictability, cardiovascular stability, effects on the baby and drug licence concerns. Fifty-seven percent indicated that their trainees were encouraged to use thiopental for non-obstetric anaesthesia. Fifteen percent of respondents use opioids during rapid-sequence induction. Eighty-five percent use nitrous oxide; 53% of respondents use sevoflurane (51.6%) or desflurane (1.6%) for maintenance of anaesthesia, and this would increase to over 80% if financial constraints were removed. ConclusionOur survey suggests that while thiopental remains the induction agent of choice in the UK, a reasonable body of medical opinion would support a change to propofol for induction. This is reassuring as thiopental becomes more difficult and expensive to obtain.

Regional versus general anaesthesia for caesarean section

Regional anaesthesia (RA) and general anaesthesia (GA) are commonly used for caesarean section (CS) and both have advantages and disadvantages. It is important to clarify what type of anaesthesia is more efficacious. To compare the effects of RA with those of GA on the outcomes of CS. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011). We updated the search on 20 August 2012 and added the results to the awaiting classification section of the review. Randomised and quasi-randomised controlled trials evaluating the use of RA and GA in women who had CS for any indication. Cluster-randomised trials and trials using a cross-over design are not included. Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. Twenty-two out of 29 included studies (1793 women) contributed data to this review.The included studies did not report some our primary outcomes: maternal death, incidence of maternal postoperative wound infection, maternal postoperative other infection such as endometritis and urinary tract infection, neonatal death.Compared to women who had GA, women who had either epidural anaesthesia or spinal anaesthesia were found to have a significantly lower difference between pre and postoperative haematocrit. For epidural, the mean difference (MD) was 1.70% and 95% confidence interval (CI) 0.47 to 2.93 (one trial, 231 women) and for spinal anaesthesia, the MD was 3.10% and 95% CI 1.73 to 4.47 (one trial, 209 women). Compared with GA, women having either an epidural anaesthesia or spinal anaesthesia had a lower estimated maternal blood loss (epidural versus GA: standardised mean difference (SMD) -0.32 mL; 95% CI -0.56 to -0.07; two trials, 256 women; spinal versus GA anaesthesia: SMD -0.59 mL; 95% CI -0.83 to 0.35; two trials, 279 women). There was evidence of a significant difference in terms of satisfaction with anaesthetic technique - compared with the epidural or spinal group, more women in the GA group stated they would use the same technique again if they needed CS for a subsequent pregnancy (epidural versus GA: risk ratio (RR) 0.80; 95% CI 0.65 to 0.98; one trial, 223 women; spinal versus GA anaesthesia: RR 0.80; 95% CI 0.65 to 0.99; one trial, 221 women).No significant difference was seen in terms of neonatal Apgar scores of six or less and of four or less at five minutes and the need for neonatal resuscitation with oxygen. There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.

Conversion from regional to general anaesthesia for caesarean section: are we meeting the standards?

Conversion from regional to general anaesthesia for caesarean section: are we meeting the standards?

Conversion from regional to general anaesthesia for caesarean section: we are meeting the standards!

Conversion from regional to general anaesthesia for caesarean section: we <i>are</i> meeting the standards!

Anesthetic management during labor and delivery: a 21-year review of women with cancer in a tertiary care center

Study ObjectiveTo describe the anesthetic management of labor and delivery in patients presenting with cancer during pregnancy at one institution. DesignRetrospective data collection of pregnant cancer patients who delivered between January 1988 and December 2009. SettingUniversity-affiliated teaching hospital. MeasurementsClinical data on cancer diagnosis and treatment and obstetric, neonatal, and anesthetic management of the study patients were compiled. Analysis was done based on whether the cancer was diagnosed before or during pregnancy. Main ResultsThe incidence of cancer during pregnancy at our institution was 0.1%. No difference was noted in the incidence of cancer diagnosed before and during pregnancy was noted. Women with a cancer diagnosis during pregnancy had more clinical symptoms, a higher rate of inductions (37% vs 11%; P = 0.0002) and premature deliveries (48% vs 20%; P = 0.0003) than those with a cancer diagnosis before delivery. No differences between groups in neonatal outcome were noted. Most patients received regional anesthesia for labor and delivery (75%); a significant number (22%) also received general anesthesia for cesarean section. Life-threatening complications were seen in those with mediastinal tumors or metastases. ConclusionWomen with cancer diagnosed during pregnancy are likely to require prompt therapeutic intervention and have a potential for premature delivery. Anesthetic management should be tailored to the individual type of cancer, depending on the severity of symptoms, stage of cancer, and associated systemic involvement.

Anestesia general y hemorragia obstétrica con transfusión en la cesárea. Experiencia durante un año en un hospital universitario

IntroductionObstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population. MethodsA retrospective study was conducted on all caesarean section discharge reports from PACU in 2008. ResultsGeneral anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards. ConclusionsThe most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

Antibiotic or induction agent? Another problem from a possible solution

We read with interest the correspondence regarding the risks of antibiotic prophylaxis in caesarean section [1]. In our unit, after a single incident involving the administration of thiopental instead of co-amoxiclav to a mother following delivery under spinal anaesthesia, and in consultation with our pharmacy, we decided to introduce pre-filled thiopental syringes. These are prepared in our pharmacy department and stored in specially labelled packets for use within seven days of preparation, with stocks regularly replenished by the hospitals’ pharmacists. Thiopental powder ampoules remain available for anaesthetic staff to use, according to personal preference. Since the introduction of pre-filled thiopental syringes, however, we have had two incidents of failed induction of anaesthesia in category-1 caesarean section. The second incident occurred in spite of our reducing the shelf-life of the thiopental syringes to just four days. On each occasion, the problem was quickly recognised and propofol was given before neuromuscular blockade. Indeed, several anaesthetists have now changed their practice, routinely using propofol instead of thiopental when inducing general anaesthesia for caesarean section. Contrary to recent guidance [2], we continue to administer antibiotic prophylaxis just after delivery, as it remains hospital policy to use co-amoxiclav, which is not recommended for use before delivery of the baby. This is not routinely prepared until the baby has been delivered safely, and it is counter-checked by the anaesthetic assistant before injection. We agree that human error is the real problem here, and would also welcome any further suggestions on how to deal with this problem. Fortunately, drug errors in anaesthesia are rare in comparison with ward-based care [3], but we can always do better.

Maternal and foetal effects of remifentanil for general anaesthesia in parturients undergoing caesarean section: a systematic review and meta‐analysis

Remifentanil has been suggested for the induction of general anaesthesia for caesarean section. We aimed to define remifentanil effects on maternal stress response as well as neonatal effects. Relevant articles were retrieved by a systematic literature search. Randomized, controlled trials comparing remifentanil use before delivery with placebo were selected. Maternal outcome parameters were blood pressure and heart rate; neonatal effects included the need for mask ventilation and intubation, base excess, pH values, Apgar < 7 at 1 and 5 min. The random effects model was used for meta-analysis; risk ratio or weighted mean difference (WMD) and 95% confidence interval (95% CI) were calculated. Five articles including 186 patients were identified. Highest and lowest systolic blood pressure were significantly lower in the remifentanil group (WMD: -29.98, -50.90 to -9.07 mmHg, 95% CI; P = 0.005; and WMD: -12.46, -18.21 to -6.71 mmHg, 95% CI; P < 0.0001), the lowest heart rate was significantly lower after remifentanil treatment (WMD: -8.22, -11.67 to -4.78, 95% CI; P < 0.00001). Base excess was significantly higher in infants of remifentanil-treated mothers (WMD: 1.15, -0.27 to 2.03, 95% CI; P = 0.01); pH was also higher in the remifentanil group, but significance was missed (P = 0.07). No differences were observed for Apgar values or the need of airway assist. Remifentanil was found to attenuate the maternal circulatory response to intubation and surgery. Higher base excess and pH suggest a beneficial effect on the neonatal acid-base status. A trial with adequate power is warranted that addresses neonatal side-effects of remifentanil.

Keep our guard up against general anesthesia for cesarean section!

Obstetric airway has been recognized as a challenge to anesthesiologists [1–3]. In this issue, Tao et al. reported that unanticipated difficult airway accounted for 0.56 % of all pregnancy-related surgical patients, and that more than 99.9 % of all obstetric patients could be intubated [4]. I believe this report is valuable because it shows an actual ratio of unanticipated difficult airway in parturients in their hospital. However, I write this editorial to express some concerns, because some readers may misread this article to be optimistic. First, it should be noted that Tao et al. report a ratio of unanticipated difficult airway. Hence, there must exist some cases with anticipated difficult airway. It is a great pity, however, that they showed neither number nor ratio of anticipated difficult airways in spite of their careful preoperative or prenatal airway evaluation. The most frequently cited article to discuss the risk of general anesthesia for cesarean section is the one by Hawkins et al. [5] reporting that, during the 1970s and 1980s, 17 women died as a result of general anesthesia for every 1 woman who died of regional anesthesia-related causes. This article has played an important role in building the consensus that general anesthesia should be avoided for cesarean section. Simultaneously, monitors for respiratory status and devices for airway management were developed, contributing to the improved safety of general anesthesia for cesarean section. As a result, the gross number of maternal deaths decreased dramatically. Furthermore, the resulting risk ratio between the two techniques also decreased, to 1.7 [6]. However, some maternal deaths still occur related to anesthesia, and anesthesiologists possibly involved in obstetrics should not be optimistic [7, 8]. Until today, several strategies have been proposed and practiced to avoid general anesthesia for cesarean section. Placement of an epidural catheter for labor analgesia can contribute to the reduction of general anesthesia by offering an epidural anesthesia for urgent cesarean section during delivery. Prenatal anesthetic evaluation and explanation, including a parturient who is not willing to receive an epidural, can also contribute in avoiding, by screening, high-risk parturients for general anesthesia and by encouraging an epidural for their delivery or planned cesarean section. With these efforts, it is reported that the ratio of general anesthesia to cesarean section can be decreased to less than 1 % [9]. Recently, a new strategy to avoid general anesthesia for cesarean section has been proposed by Kinsella et al. [10]. They state that most urgent cesarean sections can be managed by spinal anesthesia, naming this strategy rapid sequence spinal anesthesia (RSS), imitating rapid sequence induction (RSI) for general anesthesia. I believe that Tao’s hospital was also making every effort to avoid general anesthesia for cesarean section; however, it should be noted that the general anesthesia ratio is relatively high in their hospital. And again, it is a pity that they could not show the number of parturients with anticipated difficult airways, and they could not explain how they treated them. On the other hand, it is also important to improve the safety of general anesthesia for cesarean sections as it This comment refers to the article available at doi:10.1007/s00540-012-1338-1.

Conversion from regional to general anaesthesia for caesarean section: are we meeting the standards?

Conversion from regional to general anaesthesia for caesarean section: are we meeting the standards?

Difficult and failed intubation in obstetrics

Obstetric general anaesthesia is associated with a number of deleterious effects and it has long been recognized that airway management can be challenging and tracheal intubation more likely to fail. Failed intubation and subsequent inadequate ventilation is an important cause of maternal mortality and morbidity. General anaesthesia for Caesarean section has dramatically declined in many nations around the world and it is used disproportionately more frequently for category 1 Caesarean section (immediate risk to life of mother or fetus) because of the perceived need for urgent delivery of the fetus. 1 In this pressured situation, patient assessment, positioning, and preoxygenation may be compromised and anxiety may impair the performance of the anaesthetist. A number of interesting developments have occurred over the last 5 yr which may already be influencing how the obstetric airway is managed. Rigid indirect laryngoscopy has become increasingly popular for performing tracheal intubation, established notions of the role muscle relaxation plays in difficult airway management have been questioned, 2 and a novel drug which permanently reverses nondepolarizing neuromuscular block has entered clinical practice. These changes have implications for the modern and safe management of difficult and failed intubation in obstetrics. Factors contributing to failed

Reduced frequency of apnea and bradycardia episodes caused by exposure to biological maternal sounds

The specific effects of maternal auditory stimulation on short-term physoiological stability, however, are still unclear. This case study was conducted as part of a larger study currently underway at Brigham and Women’s Hospital. The infant’s mother gave written, informed consent. Case report A female infant was born at 26 weeks 6 days gestational age (GA) by emergency cesarean section for abruption with vaginal bleeding of approximately 1 h duration and fetal bradycardia. Birthweight was 750 g, length was 31 cm and head circumference was 31 cm. Prenatal history was benign. Ultrasound at 12 weeks appeared normal. Pregnancy was complicated by abruption on day of delivery. The mother received general anesthesia for cesarean section. The infant was born limp, pale, with a heart rate (HR) 60 beats/min. The infant was intubated at 5 min of life.Apgar scores were 1, 2, and 8 at 1, 5, and 10 min, respectively. The

Evaluation of Intubating Dose of Rocuronium and Propofol-Ketamine Association for Rapid Sequence Induction of General Anaesthesia for Caesarean Section in Extremely Urgent Settings

Purpose: Anaesthetic practice for caesarean section (C&S) has changed during the last decades. Although, general anesthesia (GA) for C&S still seems to be the method of choice in extremely urgent settings, past anesthetic evidence has shown that GA is with increased risk of anesthesia-related maternal and neonatal mortality. Rocuronium bromide (RB) provides the shortest onset of action of nondepolarizing blocking agents. Ketamine has been shown to improve intubating conditions when used in association with RB. Propofol is known to depress laryngeal reflexes. We investigated conditions of tracheal intubation and the Apgar scores of the newborn after administration optimum dose of RB-propofol-ketamine association for rapid sequence induction of anaesthesia in 86 parturients undergoing C&S. Methods: After preoxygenation, then induced in rapid sequence with propofol 2mg/kg, ketamine 1mg/kg, RB 0.4 or 0.6mg/kg. Retrospectivly, the patients were evaluated intubating dose of rocuronium bromide, conditions of tracheal intubation and the Apgar scores. Results: Tracheal intubation was being easily performed at 30 seconds after the administration of RB in all patients. At the end of the procedure, which lasted 25-40min, the T4/Tl ratio ranged >75%; neuromuscular blockade was not antagonized in 78 patients. Neuromuscular blockade was antagonized with a mixture of atropine 0.02mg/ kg and neostigmine 0.05mg/kg in 8 patients who induced 0.6mg/kg RB. Although having C&S for foetal distress undertaken, the Apgar scores at 1 and 5 minutes were >7 and >9 on the 86 neonates in this our survey. Conclusions: The optimum dose of RB is 0,4mg/kg and propofol-ketamine association can be safely used for rapid sequence induction for C&S.

Central neuraxial anesthesia for caesarean section in parturients with uncorrected tetralogy of fallot: Two cases

Tetralogy of fallot (TOF) is the most commonly encountered congenital cyanotic heart disease in pregnant females and maternal mortality approaches 10% in unrepaired TOF. General anesthesia is classically considered the technique of choice for incidental surgery in TOF and neuraxial anesthesia is considered relatively contraindicated. However, general anesthesia for caesarean section can increase maternal morbidity. We report two cases of caesarean section performed under combined spinal epidural (CSE) anesthesia and epidural anesthesia respectively in patients with uncorrected TOF. Adequate preloading to maintain hydration, continuous invasive monitoring, gradual extension of neuraxial blockade by epidural/CSE technique, and judicious use of phenylephrine infusion enabled us to successfully manage both the cases without any complication.

Failure to Predict Difficult Tracheal Intubation for Emergency Caesarean Section

Background and aim Difficult tracheal intubation following induction of general anaesthesia for caesarean section is a cause of morbidity and mortality. Our aim was to evaluate five bedside predictors that might identify women with potential intubation difficulty immediately prior to emergency caesarean section. Patients and methods Women requiring emergency caesarean section with general anaesthesia and tracheal intubation who had been assessed by the same experienced anaesthesiologist preoperatively were included in this study. Mallampati score, sternomental distance, thyromental distance, interincisor gap and atlantooccipital extension were all measured. The same anaesthesiologist performed laryngoscopy and graded the laryngeal view according to Cormack and Lehane. Exact logistic regression was used to identify significant independent predictors for difficult intubation (Cormack and Lehane grades ≥ 3) with two-sided P value less than 0.05 considered as significant. Results In 3 years, 239 women were recruited. Cormack and Lehane grades of 2 or less (easy) were found in 225 and grade of at least 3 (difficult) in 14 women. Patients' characteristics (age, height, weight, BMI or weight gain) were not significantly associated with difficulty of intubation. The incidence of difficult intubation was 1/17 women [95% confidence interval (CI) from 1/31 to 1/10]. A positive result from any of the five predictors combined had a sensitivity of 0.21 (95%CI 0.05-0.51), a specificity of 0.92 (95%CI 0.88-0.96), a positive predictive value of 0.15 (95%CI 0.032-0.38) and a negative predictive value of 0.95 (95%CI 0.91-0.97) for a Cormack and Lehane grade of at least 3 at laryngoscopy. Conclusion Airway assessment using these tests cannot be relied upon to predict a difficult intubation at emergency caesarean section as the low sensitivity means that 79% (95%CI 49-95) of difficult intubations will be missed.

Maternal and neonatal effects of nalbuphine given immediately before induction of general anesthesia for elective cesarean section

Background:Although nalbuphine was studied extensively in labour analgesia and was proved to be acceptable analgesics during delivery, its use as premedication before induction of general anesthesia for cesarean section is not studied. The aim of this study was to evaluate the effect of nalbuphine given before induction of general anesthesia for cesarean section on quality of general anesthesia, maternal stress response, and neonatal outcome.Methods:Sixty full term pregnant women scheduled for elective cesarean section, randomly classified into two equal groups, group N received nalbuphine 0.2 mg/kg diluted in 10 ml of normal saline (n=30), and group C placebo (n=30) received 10 ml of normal saline 1 min before the induction of general anesthesia. Maternal heart rate and blood pressure were measured before, after induction, during surgery, and after recovery. Neonates were assisted by using APGAR0 scores, time to sustained respiration, and umbilical cord blood gas analysis.Result:Maternal heart rate showed significant increase in control group than nalbuphine group after intubation (88.2±4.47 versus 80.1±4.23, P<0.0001) and during surgery till delivery of baby (90.8±2.39 versus 82.6±2.60, P<0.0001) and no significant changes between both groups after delivery. MABP increased in control group than nalbuphine group after intubation (100.55±6.29 versus 88.75±6.09, P<0.0001) and during surgery till delivery of baby (98.50±2.01 versus 90.50±2.01, P<0.0001) and no significant changes between both groups after delivery. APGAR score was significantly low at one minute in nalbuphine group than control group (6.75±2.3, 8.5±0.74, respectively, P=0.0002) (27% of nalbuphine group APGAR score ranged between 4–6, while 7% in control group APGAR score ranged between 4–6 at one minute). All neonates at five minutes showed APGAR score ranged between 9–10. Time to sustained respiration was significantly longer in nalbuphine group than control group (81.8±51.4 versus 34.9±26.2 seconds, P<0.0001). The umbilical cord blood gas was comparable in both groups. None of the neonates need opioid antagonist (naloxone) or endotracheal intubation.Conclusion:Administration of nalbuphine before cesarean section under general anesthesia reduces maternal stress response related to intubation and surgery, but decreases the APGAR score at one minute after delivery. So, when nalbuphine was used, all measures for neonatal monitoring and resuscitation must be available including attendance of a pediatrician.

Update on general anaesthesia for Caesarean section

The increased use of regional anaesthesia for Caesarean section (CS) has been a consequence of the risk of failed intubation associated with general anaesthesia (GA) for CS, as well as the provision of an improved birth experience and quality of postoperative analgesia. This trend has led to a lack of experience in the practice of rapid sequence intubation and GA in trainee anaesthetists, 1 prompting the suggestion that simulators may become an essential part of anaesthesia training in this scenario. 2 In the USA during the period 1984-2002, the case fatality rate for general anaesthesia decreased from 32.3 to 6.5 per million, while the rate of regional anaesthesia was lower, but increased from 1.9 to 3.8 per million. 3