Induction-to-delivery time and neonatal resuscitation after cesarean delivery under general anesthesia: a multicenter retrospective cohort study

Purpose: General anesthesia (GA) remains essential for cesarean delivery in emergencies or when neuraxial anesthesia is contraindicated, but it is associated with less favorable neonatal outcomes. Among potential contributors, the induction-to-delivery (ID) time—defined as the interval from the administration of general anesthetic agents to fetal expulsion—has emerged as a key and potentially modifiable factor. This study aimed to assess the relationship between ID time and the need for neonatal resuscitation during GA cesarean delivery, and to identify perioperative and maternal factors associated with increased resuscitation risk. Methods: A multicenter retrospective study was conducted among women with singleton pregnancies who underwent cesarean delivery under GA for pregnancy termination. Baseline maternal, anesthetic, and neonatal variables were collected. Categorical variables were analyzed using the Chi-square test, and continuous variables using the Wilcoxon rank-sum test. Univariable and multivariable logistic regression models were applied to identify independent risk factors for neonatal resuscitation, and a restricted cubic spline (RCS) model was used to evaluate the relationship between ID time and the probability of resuscitation. Results: A total of 1,523 cases were included; 212 neonates (13.9%) required resuscitation. Prolonged ID time was independently associated with an increased likelihood of neonatal resuscitation (OR = 1.04 per minute; 95% CI 1.01–1.06, p = 0.003). Additional predictors included gestational age < 34 weeks (OR = 17.11, 95% CI 10.49–28.17), gestational age 34–37 weeks (OR = 3.59, 95% CI 2.47–5.26), American Society of Anesthesiologists Physical Status  III–IV (OR = 1.82, 95% CI 1.13–2.88), and anesthetic regimens involving propofol + sevoflurane (OR = 1.94, 95% CI 1.09–3.34) or mixed agents (OR = 8.86, 95% CI 4.55–17.45) compared with propofol + remifentanil. RCS analysis showed a nonlinear positive association between ID time and the probability of neonatal resuscitation. Conclusion: Prolonged ID time under GA constitutes a modifiable risk factor for neonatal resuscitation. Shortening ID time may help improve neonatal outcomes. Clinical trial number: not applicable.