Clinical practices in general anaesthesia for caesarean section

BACKGROUND: Anaesthesia is central to obstetric care, yet contemporary data on clinical practices, particularly concerning general anaesthesia (GA) for caesarean section (CS), remain scarce. Given evolving guidelines and technologies, an updated understanding of real-world anaesthetic management is needed. OBJECTIVE: Our aim was to evaluate current anaesthetic practices in obstetric care in Germany, focusing on the use of GA for CS, perioperative management, and adherence to guideline recommendations. DESIGN: Nationwide, anonymised, cross-sectional questionnaire survey. SETTING: The questionnaire targeted both experienced obstetric anaesthesiologists and other anaesthesiologists regularly working in obstetric anaesthesia in German hospitals. PARTICIPANTS: We analysed 567 completed questionnaires from anaesthesiologists actively involved in obstetric care, representing 171 geographic locations and institutions covering approximately half of all annual births in Germany. MAIN OUTCOME MEASURES: Contraindications for neuraxial procedures, estimated GA rates, perioperative management strategies, and conformity with guidelines. RESULTS: The survey yielded 29 984 individual responses. Neuraxial anaesthesia was strongly preferred over GA (Likert score 4.8/5), with a median GA rate of 5 [5 to 10]%. Postoperative nausea and vomiting prophylaxis was provided by 89.4% of respondents. Platelet thresholds for neuraxial anaesthesia were more liberal than in previous surveys, with reliance on individual risk-benefit assessment instead of fixed numerical thresholds. For GA induction, propofol has largely replaced thiopental, but suxamethonium remains the favoured neuromuscular blocking agent (71.7%). Balanced anaesthesia with sevoflurane predominated (84%), while nitrous oxide use has declined sharply (2.1%). Gaps in guideline adherence were noted regarding the timing of antibiotic prophylaxis, the use of active warming and intraoperative red blood cell salvage. Compared with international practice, postoperative analgesia was mainly opioid-based, with regional techniques underused (23%). CONCLUSIONS: Despite progress towards guideline adherence, substantial gaps persist between recommendations and clinical practice in German obstetric anaesthesia. Improvement opportunities include better implementation of evidence-based perioperative strategies and greater use of regional analgesic techniques postoperatively.