General anesthesia for cesarean delivery: a single-center sequential mixed methods study on labor nurses', obstetricians' and anesthesiologists' knowledge, attitudes and practices.

BACKGROUND

Neuraxial anesthesia is preferred for cesarean deliveries, yet general anesthesia use remains notably high in certain locations. We aimed to quantify general anesthesia use for cesarean delivery and explore obstetric unit provider perspectives on contributing factors.

METHODS

We conducted a single-center explanatory sequential mixed-methods study at a quaternary referral academic center. Cesarean deliveries from July 1, 2023, to June 30, 2024, were identified from the institutional Multicenter Perioperative Outcomes Group (MPOG) database. Primary outcome was rate of general anesthesia, grouped by case-timing and emergency-status. Semi-structured interviews were conducted with anesthesiologists, obstetricians, and labor nurses (n = 23). The interviews were analyzed using the Knowledge-Attitudes-Practices framework.

RESULTS

Among 1894 cesarean deliveries, 223 (11.8%) were performed under general anesthesia, which was more frequent after-hours (13.8% [142/1033] vs. 9.4% [81/861]) and in emergencies (13.9% [130/938] vs. 9.7% [93/956]). Providers preferred neuraxial anesthesia when feasible and viewed general anesthesia as rapid and reliable but associated with maternal airway risk, adverse patient experience, and neonatal risk. Reported drivers of general anesthesia included emergency workflow compression, after-hours resource limitations, inefficient team communication, absent or failed labor epidural analgesia, and pain during cesarean delivery. A functioning labor epidural catheter was considered protective. Efficient communication at both the system- and provider levels was the most frequently suggested improvement.

CONCLUSIONS

General anesthesia was more frequent after-hours and in emergency cases. Mixed methods integrated analysis suggests that improving provider and system-level communication and clarifying decision-making roles may improve neuraxial feasibility under time-pressure and reduce avoidable general anesthesia.