The effect of COVID‐19 disease on general anaesthesia rates for caesarean section

We read with interest the article by Bhatia et al. [1] and congratulate the authors on the presentation of this interesting dataset comparing general anaesthesia rates for caesarean section (CS) before and during the first wave of the COVID-19 pandemic. In this, and their previous observational study [2], they demonstrated a significant reduction in general anaesthesia rates, both as a primary technique and as a result of failed neuraxial anaesthesia. They attribute this reduction to organisational changes during the pandemic, including increased consultant anaesthetist presence on the labour ward. We were surprised, however, that no data on decision-to-delivery intervals or neonatal outcome were presented in either manuscript. Although safety of the mother is of primary concern, the health of the baby should not be overlooked. The 2018 Each Baby Counts report highlighted the need to avoid inappropriate delays in delivery resulting from difficulties establishing neuraxial anaesthesia [3]. Significant changes in anaesthetic technique for emergency CS, as demonstrated in these two studies, are likely to result in changes to the decision-to-delivery interval with potential to affect neonatal outcome. Neuraxial anaesthesia is widely considered to be safer than general anaesthesia for CS, but evidence to support this assertion is limited. Reduction in anaesthesia-related maternal mortality in the UK is often attributed to the increase in neuraxial anaesthesia and the concomitant decrease in the use of general anaesthesia. However, this perception is possibly erroneous; due to the increase in CS rates, the absolute number of CS performed under general anaesthesia has not reduced significantly. Nevertheless, due to the feared but rare complications of general anaesthesia, including failed tracheal intubation, pulmonary aspiration of gastric contents and accidental intra-operative awareness, strategies to reduce general anaesthesia rates have remained a focus for obstetric anaesthetists. The main 'advantage' of general anaesthesia over neuraxial anaesthesia for CS is that of reliable speed, which is of particular relevance in the context of Category 1 CS where there is an immediate threat to the life of the mother or baby [4]. We would highlight that any reduction in general anaesthesia rates can only be viewed as successful if they do not come at the cost of increased neonatal morbidity and mortality, detail that is notably absent from Bhatia et al.'s recent publications.