What is the best paralytic to use for a caesarean (C-section) section?

Best Paralytic for Caesarean Section

Rocuronium is the preferred paralytic agent for caesarean section when general anesthesia is required, as it provides superior surgical conditions for fetal delivery compared to suxamethonium while maintaining comparable induction-to-delivery intervals. 1

Neuraxial vs. General Anesthesia for C-section

• Regional anesthesia (spinal or epidural) is the preferred method for cesarean delivery as part of an enhanced recovery protocol 2, 3
• General anesthesia with paralytic agents is primarily reserved for emergency situations or when neuraxial techniques are contraindicated 4

Paralytic Agents for C-section When General Anesthesia is Required

Rocuronium

• Provides acceptable (good to excellent) intubating conditions in 95% of patients undergoing cesarean section, comparable to suxamethonium (97%) 5
• At 0.6 mg/kg dosing, rocuronium enables excellent to good intubating conditions in 90% of patients within approximately 79 seconds 6
• Significantly better surgical conditions for delivery compared to suxamethonium, with higher Surgical Rating Scale for Delivery scores (median 4 vs 3 points) 1
• Results in shorter incision-to-delivery intervals (147 seconds vs 196 seconds with suxamethonium) 1
• No clinically significant effects on maternal heart rate or arterial pressure 6
• No untoward effects on neonates as evaluated by Apgar scores and other neonatal assessments 6

Suxamethonium (Succinylcholine)

• Traditionally used for rapid sequence induction due to its fast onset 4
• Shorter induction-to-intubation interval compared to rocuronium (68 seconds vs 106 seconds) 1
• However, provides inferior surgical conditions for delivery compared to rocuronium 1
• Associated with longer incision-to-delivery intervals 1

Algorithm for Selecting Paralytic Agents in C-section

1. First-line choice: Rocuronium 0.6-1.0 mg/kg for rapid sequence induction when general anesthesia is required 5, 1

   • Provides excellent surgical conditions
   • Enables shorter incision-to-delivery times
   • Safe for both mother and neonate

2. Alternative option: Suxamethonium 1 mg/kg when extremely rapid intubation is critical 1

   • Consider when seconds matter for maternal airway security
   • Be aware this may result in less optimal surgical conditions

Important Considerations

• Overall induction-to-delivery intervals are comparable between rocuronium and suxamethonium (268 seconds vs 276 seconds) 1
• When using rocuronium, be prepared to manage the longer duration of neuromuscular blockade compared to suxamethonium 6
• Have sugammadex available for rapid reversal of rocuronium if needed, especially in cannot-intubate-cannot-ventilate scenarios 4

Multimodal Pain Management After C-section

• For postoperative pain management, a multimodal approach is recommended including:
  • Intrathecal morphine 50–100 μg or diamorphine 300 μg if neuraxial anesthesia is used 7
  • Paracetamol and NSAIDs administered after delivery and continued regularly postoperatively 7
  • Intravenous dexamethasone after delivery in the absence of contraindications 7
  • Local anesthetic infiltration, continuous wound local anesthetic infusion, and/or fascial plane blocks if intrathecal morphine is not used 7

Common Pitfalls and Caveats

• Cricoid pressure should only be performed by trained personnel and released if intubation appears difficult 4
• Awareness remains a major concern in obstetric general anesthesia - ensure adequate depth of anesthesia 4
• The benefits of local and regional analgesic techniques are less apparent when intrathecal morphine is used 7
• Implement strategies to minimize systemic opioid utilization for postoperative pain management 7