Intubation conditions and neonatal outcomes with rocuronium versus suxamethonium in cesarean sections: A systematic review and meta-analysis

Abstract

Background: While general anesthesia is necessary for some emergency deliveries, it carries risks such as failed intubation and neonatal complications. This study investigates whether rocuronium and suxamethonium (also known as Succinylcholine) provide equivalent conditions for airway management and neonatal outcomes during cesarean sections. Ensuring the safety and efficacy of these agents is crucial due to the physiological and hemodynamic changes associated with pregnancy and delivery. Method: We conducted a systematic review and meta-analysis following PRISMA guidelines. We included studies involving pregnant women undergoing cesarean sections that used rocuronium as an intervention and suxamethonium as a comparator, reporting outcomes such as Apgar scores, surgery duration, and time-related metrics. A comprehensive search of databases was performed up to July 2025. Statistical analyses were performed using RevMan Software, assessing heterogeneity and summarizing findings through mean differences and risk ratios. Results: Our metaanalysis of six studies comprising 1,122 patients showed that succinylcholine significantly reduced the time from induction to umbilical cord clamping compared with rocuronium (mean difference [MD] 19.21 s; 95% CI 5.15 to 33.27; P = 0.007; I² = 0%). There was no significant difference between groups in time from incision to delivery (MD − 12.72 s; 95% CI − 84.84 to 59.41; P = 0.73; I² = 94%) or in total surgery duration (MD − 1.20 min; 95% CI − 3.70 to 1.30; P = 0.34; I² = 63%). Newborns in the succinylcholine group were more likely to achieve favorable 1 min Apgar scores (risk ratio [RR] 1.87; 95% CI 1.31 to 2.67; P = 0.0006; I² = 0%) and 5 min Apgar scores (RR 2.52; 95% CI 1.21 to 5.25; P = 0.01; I² = 30%), whereas 10 min Apgar scores did not differ significantly (RR 2.51; 95% CI 0.66 to 9.64; P = 0.18; I² = 34%). In the subgroup of scheduled cesarean deliveries, only the 1 min Apgar score remained significantly higher with succinylcholine (RR 1.75; 95% CI 1.10 to 2.77; P = 0.02; I² = 0%). Conclusion: This review suggests that suxamethonium offers benefits like shorter induction-to-cord clamping times and better early Apgar scores. The current evidence is still limited and further well-designed randomized controlled trials are needed to explore the relationship between rocuronium levels and neonatal outcomes.