General anaesthesia for caesarean delivery

General anaesthesia (GA) is most often indicated for category 1 (immediate threat to life of mother or baby) caesarean delivery (CD) or when neuraxial anaesthesia has failed or is contraindicated. Secure intravenous access is essential. Jugular venous cannulation (with ultrasound guidance) is required if peripheral access is inadequate. A World Health Organization surgical safety checklist must be used. The shoulders and upper back should be ramped. Left lateral table tilt or other means of uterine displacement are essential to minimize aortocaval compression, and a head-up position is recommended to improve the efficiency of preoxygenation and reduce the likelihood of gastric contents reaching the oropharynx. Cricoid pressure is controversial. In the United Kingdom, thiopental remains the induction agent of choice, although there is scant evidence upon which to avoid propofol. In pre-eclampsia, it is essential to obtund the pressor response to laryngoscopy with remifentanil or alfentanil. Rocuronium is an acceptable alternative to succinylcholine for neuromuscular blockade. Sugammadex offers the possibility of swifter reversal of rocuronium than spontaneous recovery from succinylcholine. Management of difficult tracheal intubation is focused on ‘oxygenation without aspiration’ and prevention of airway trauma. The Classic™ laryngeal mask airway is the most commonly used rescue airway in the United Kingdom. There is a large set of data from fasted women of low body mass index who have undergone elective CD safely with a Proseal™ or Supreme™ laryngeal mask airway. Sevoflurane is the most popular volatile agent for maintenance of GA. The role of electroencephalography-based depth of anaesthesia monitors at CD remains to be established. Intraoperative end-tidal carbon dioxide tension should be maintained below 4.0 kPa.