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Cesarean section is one of the most common surgical procedures worldwide.

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The vast majority of these are performed under neuraxial anesthesia.

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Neuraxial Anesthesia for Cesarean Section
TechniqueBasicsCommentsDose
Spinal (single shot)
  • Most commonly used in cases without a preexisting labor epidural in the United States
  • Rapid onset
  • Single shot limits duration of surgery (when combined with intrathecal fentanyl 25 μg):
    • 90 min with hyperbaric bupivacaine
    • 120 min with isobaric bupivacaine
    • 45 min with hyperbaric lidocaine
  • Reliable distribution of spread
  • Risk of PDPH with thin blunt tip spinal needles is <1%
  • Rapid-onset sympathectomy results in rapid drop in preload and afterload (hypotension)
    • Avoid in patients dependent on adequate preload and/or afterload
    • Have vasoactive drugs ready (phenylephrine infusion 30–60 μg/min recommended)
  • Cephalad spread is unpredictable
  • Usual doses for Cesarean section:
    • 10.5–12 mg (1.4–1.6 mL of 0.75%) hyperbaric bupivacaine
    • 8–10 mg (1.6–2 mL of 0.5%) isobaric bupivacaine
    • 75 mg (1.5 mL of 5%) hyperbaric lidocaine
    • All combined with 15–25 μg fentanyl and 200–300 μg preservative-free morphine
Spinal (continuous)
  • Has all the advantages of the single-shot spinal
  • Dosing can be titrated gradually
  • Duration of block can be extended
  • Current lack of availability of microcatheters in the United States limits usefulness of technique (large-bore needles result in PDPH incidence of >50%)
  • Repeat dosing of hyperbaric solutions is not recommended (risk of cauda equina syndrome)
  • Usual starting dose is 2.5 mg isobaric bupivacaine with 10 μg fentanyl
  • Repeat every 5–10 min until adequate level is achieved
Epidural
  • Most commonly used when labor epidural is present
  • Presence of adequate labor analgesia (T10 block) does not guarantee successful extension of block to surgical levels (>T5)
    • Once the full epidural loading dose is given and the block remains inadequate, conversion to spinal anesthesia may result in high cephalad spread (total spinal) even when the spinal dose is significantly reduced
  • Slower cephalad spread and limited sympathectomy produces better control of preload and afterload
    • Recommended technique as primary anesthetic if neuraxial block is considered in preload- or afterload-dependent patients
  • “Patchiness” of block remains most common cause of failure
  • Usual doses and onset times for Cesarean section
  • Lidocaine in newly inserted epidural catheter: 400–500 mg (20–25 mL) 2% lidocaine with 1:200,000 epinephrine in three to four divided doses—20–30 min
  • Lidocaine in well-established labor epidural: 350–400 mg (17.5–20 mL) 2% lidocaine in three to four divided doses—10–15 min
  • Use of adjuvant opioids is recommended
    • 100 μg fentanyl
    • 2–3 mg preservative-free morphine
  • In an emergency situation, when rapid onset is desired, load labor epidural catheter with 540–600 mg (18–20 mL) 3% chloroprocaine in two divided doses; onset time is about 5 min
  • Adjuvant neuraxial opioids do not have full effect when chloroprocaine is used
    • Reason remains unclear
    • Consider alternative modalities of postoperative pain control (PCA)
Combined spinal epidural
  • Combines advantages of the two techniques while eliminating some of the undesirable effects
  • Consider if
    • Longer than usual surgery is expected (history of intra-abdominal adhesions)
    • ...

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