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COVID‐19 pandemic reduces general anaesthesia rates for caesarean section

We are grateful to Drs Russell and Lucas [1] for their interest in our paper [2]. They comment correctly that we did not report data on decision-to-delivery intervals and neonatal outcomes at the time, which are mentioned as limitations. This, of course, was simply due to the delay that would be incurred in assimilating and analysing the additional data when we needed to expedite the reports of significantly lower general anaesthesia (GA) rates. Drs Russell and Lucas point out the limited evidence that neuraxial anaesthesia for caesarean section (CS) is ‘considered’ to be safer than GA. Multiple reviews have established that neuraxial anaesthesia is safer in terms of maternal as well as neonatal, morbidity and mortality in lowand middle-income countries [3]. However, we agree that the evidence for GA CS influencingmaternal mortality in the UK is limited. Nomortality was reported in the national study on failed tracheal intubation in the UK [4], or more recently in the study looking at GA and airway management practice for obstetric surgery in England [5]. A gastric aspiration rate of 8% was quoted in the first study and a difficult tracheal intubation rate of 1:19 was reported in the second study. The ‘published’ evidence on the incidence of serious but rare complications from anaesthesia in the UK tends to favour neuraxial anaesthesia (a lower risk of high block, local anaesthetic toxicity and permanent nerve damage with neuraxial anaesthesia compared with failed tracheal intubation and ‘can’t intubate can’t oxygenate’ with a GA). This was highlighted by the excellent analysis of the National Obstetric Anaesthesia Databasewhich was co-authored byDrs Lucas and Russell [6]. More evidence of maternal morbidity (at least in an emergency setting) also comes from reviews by Guglielminotti et al. which consistently reveal a higher incidence of anaesthesia-related adverse eventswith aGA [7]. We accept that widespread data onmaternal morbidity from neuraxial anaesthesia in the UK are lacking, although it has been widely adopted in enhanced recovery protocols for CS and this is an area for further research. The ‘morbidity gap’ between neuraxial and GA for CS has narrowed significantly, thanks to advances made in the field of airway, difficult airway guidelines and simulation, and is possibly minimal in an elective setting. Morbidity from neuraxial anaesthesia is not emphasised well enough in the anaesthetic literature and hence a ‘difficult or failed tracheal intubation’ may seem to make more headlines than a ‘high neuraxial block’. Drs Russell and Lucas correctly remind us of the need to avoid inappropriate delays in delivery resulting from difficulties establishing neuraxial anaesthesia, and then highlight that changes in anaesthetic technique could potentially affect decision-delivery times for category-1 CS and hence influence neonatal outcomes. We are currently compiling the neonatal outcomes for category-1 CS across the surveyed hospitals and hope to present the findings in due course. During the pandemic, a number of factors other than anaesthesia could potentially impact decision-delivery time for category-1 CS. These include: maternal comorbidities including COVID status; time taken to transfer the mother to theatre; time taken for donning personal protective equipment by theatre staff; and presence of senior obstetric and anaesthetic staff at the time of surgery. These factors need to be taken into consideration before anyone concludes that the anaesthetic chosen was potentially responsible for a poor neonatal outcome. There were many concerns about symptomatic and asymptomatic transmission, limited testing, false negative rates, aerosol generation, unquantified risks to healthcare workers and deficiencies in personal protective equipment provision during the early phases of the COVID19 pandemic. This resulted in an understandable trend away from GA towards neuraxial anaesthesia for CS. It will be of interest to see if this ismaintainedgoing forward.