Anesthesiology APPLIED Exam › Obstetric anesthesia

General anesthesia for cesarean delivery

Obstetric anesthesia·~5 min read· Physician-reviewed✓ Sourced · 2

Stem

A 32-year-old G2P1 at 38 weeks, 96 kg, has a placental abruption with heavy vaginal bleeding. Her platelet count is 62,000 and fibrinogen 140 mg/dL; blood pressure is 92/50 and heart rate 118. There is no epidural. The fetal heart rate is 80 bpm and the obstetrician wants to deliver now. Her airway examination is Mallampati 3 with normal mouth opening.

Question

How will you anesthetize her for this cesarean delivery?

Ideal answer

HeadlineGeneral: hemorrhage and coagulopathy contraindicate neuraxial, and there is no time.¹ I call for help and decide the failed-airway plan before induction.

Two large-bore lines, cross-matched blood, fibrinogen and platelets, because she is bleeding with both low.
Sodium citrate 30 mL, left uterine displacement, ramp, preoxygenate,² for a full stomach and fast desaturation: end-tidal oxygen above 0.9 or high-flow nasal oxygen during prep and drape.
Rapid sequence, surgeon scrubbed: ketamine 1 mg/kg or etomidate 0.3 mg/kg not propofol, as she is bleeding; succinylcholine or rocuronium 1.2 mg/kg.
Video laryngoscope, 6.0–6.5 tube, as airway edema raises failure risk.
Volatile 1 MAC to delivery, 0.5–0.7 after, as more relaxes the uterus; opioid and oxytocin; extubated awake, fully reversed.

Watch for: failed intubation, awareness, and atony atop her hemorrhage.

Breaking down the answer

Talk before the team cuts — WHO checklist and a huddle: who holds cricoid if used, which supraglottic device is open, wake or continue if intubation fails. Decided in the moment, it goes badly; this shows organization. Sodium citrate is a non-particulate antacid.²
Why video first — airway edema and enlarged breasts make laryngoscopy harder; failed intubation is roughly seven times more frequent than outside pregnancy.² Changes if: blood or secretions obscure the camera, then direct laryngoscopy.
Induction agent follows hemodynamics — propofol is what is available and is safe for the neonate at induction doses; changes if she is hemorrhaging, then ketamine or etomidate.
Rocuronium is acceptable — with sugammadex 16 mg/kg ready, high-dose rocuronium matches succinylcholine intubating conditions and gives a rescue path. I still choose succinylcholine for the shortest possible block.
Avoid awareness — highest incidence is in obstetric general anesthesia, from fear of atony and neonatal depression. At least 0.7–1 MAC before delivery, processed EEG if available, and nitrous oxide or midazolam after delivery rather than a volatile that falls too low.
Why lower volatile after delivery — above about 1 MAC it relaxes the uterus; if atony is a problem, opioids and a propofol infusion carry the anesthetic.
Extubate awake — sitting up, stomach suctioned, because extubation is where aspiration and obstruction kill mothers now.

Follow-up question

The first look with the video laryngoscope fails, and her saturation is 94% and falling. The fetal heart rate is still 80.

What do you do?

Follow-up answer

HeadlineFailed intubation, said aloud, and help called; oxygenation through a second-generation supraglottic airway comes first.

One more attempt only with a change (bougie, smaller tube, release cricoid), then the supraglottic airway. Proceed or wake is driven by the fetus and the mother: with this tracing and a working supraglottic airway, I proceed with surgery, lightly cuffed, spontaneous or gentle positive-pressure ventilation. If I cannot ventilate, front-of-neck access without delay. A non-urgent indication: I wake her and use neuraxial. I reassess oxygenation and ventilation continuously through delivery, then document, debrief, and tell her.

Pitfalls that cost points

Multiple attempts at intubation without changing anything.
Treating "wake up" as automatic when the baby is in distress; the obstetric failed-airway algorithms explicitly weigh both lives.
Extubating deep or before reversal is confirmed.

Rapid-fire

Q: Why is preoxygenation more urgent in pregnancy? A: Functional residual capacity falls about 20% and oxygen consumption rises, so desaturation after apnea is much faster.²

Q: Why left uterine displacement? A: The gravid uterus compresses the aorta and vena cava after about 20 weeks, cutting venous return and uteroplacental flow.²

Q: Does a 6-minute induction-to-delivery interval matter? A: Uterine incision-to-delivery time matters more than induction-to-delivery; prolonged uterine manipulation causes fetal acidosis.

Q: Why sodium citrate and not just an H2 blocker? A: Sodium citrate neutralizes acid already in the stomach within minutes; H2 blockers and metoclopramide need 30–60 minutes.

Numbers to know

Item	Value
Propofol induction	2 mg/kg IV
Succinylcholine	1–1.5 mg/kg IV
Rocuronium RSI	1.2 mg/kg; sugammadex 16 mg/kg for rescue
Sodium citrate	30 mL orally before induction
Volatile before delivery	About 1 MAC; reduce to 0.5–0.7 MAC after
Tube size	6.0–6.5 mm ID

Sources

1.Obstetric Regional Anesthesia · NYSORA · nysora.com
2.Changes in Maternal Physiology During Pregnancy (Update in Anaesthesia 21) · WFSA · resources.wfsahq.org

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.