Introduction: General anaesthesia for caesarean delivery carries specific maternal and neonatal risks. Drug choice, dose and timing during induction of general anaesthesia may influence maternal and neonatal physiology and outcomes. The objective of this umbrella review was to systematically identify, summarise and appraise evidence for pharmacological techniques for induction of general anaesthesia for caesarean delivery.
Methods: Databases were searched for eligible studies, including meta-analyses, systematic reviews, randomised controlled trials not previously synthesised and relevant observational studies. Data extraction, methodological quality assessment and evaluation of evidence certainty were conducted. Interventions were grouped into four categories: induction opioids; induction hypnotics; drugs to obtund the pressor response to laryngoscopy; and neuromuscular blocking drugs.
Results: Seven meta-analyses, two systematic reviews, 26 randomised controlled trials and 15 observational studies were included. Moderate quality evidence indicated short-acting opioids offered maternal haemodynamic benefit without negative neonatal consequences. Low quality evidence indicated propofol was associated with equivalent early neonatal resuscitation requirements compared with thiopental, but with lower risk of maternal accidental awareness during general anaesthesia. Labetalol, dexmedetomidine, lidocaine and remifentanil attenuated maternal haemodynamic response to laryngoscopy, with minimal neonatal adverse effects. Rocuronium at dose of ≥ 1 mg.kg-1 provided comparable tracheal intubation conditions to suxamethonium without affecting neonatal outcomes, based on moderate quality evidence.
Discussion: Current evidence supports the safety of short-acting opioids, propofol as the preferred induction drug and rocuronium as a suitable alternative to suxamethonium during induction of anaesthesia for caesarean delivery. Overall, the evidence base is constrained by exclusion of high-risk pregnancies and emergency cases, thus limiting generalisability.
Keywords: caesarean delivery; general anaesthesia; obstetric anaesthesia; systematic review; umbrella review.
What we did: We searched medical databases to find studies about the medicines used for general anaesthesia for caesarean births. We collected and checked results from different types of studies, including large reviews and clinical trials. We grouped the medicines into four types: pain medicines; anaesthetic medicines; medicines to control blood pressure and heart rate during breathing tube placement; and medicines that relax the muscles.
Why did we do it: General anaesthesia for a caesarean birth can affect both the mother and the baby. The type of medicine used, how much is given, and when it is given can change how safe and comfortable this process is. We wanted to find out which medicines work best and are safest for mothers and babies when general anaesthesia is used for a caesarean birth.
What we found: Short‐acting pain medicines helped keep the mother's blood pressure and heart rate more stable and did not harm the baby. The anaesthetic propofol worked as well as another older medicine for babies and reduced the chance that the mother might be aware during surgery. Several medicines helped stop large rises in blood pressure and heart rate when the breathing tube was put in, with little effect on the baby. A muscle‐relaxing medicine called rocuronium worked as well as the usual drug used for this step and did not cause problems for newborns. Overall, the evidence suggests these medicines are safe choices, but most studies did not include very high‐risk or emergency cases, so the results may not apply to everyone.
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