Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Cesarean section is one of the most common surgical procedures worldwide. ++ The vast majority of these are performed under neuraxial anesthesia. ++Table Graphic Jump Location|Download (.pdf)|PrintNeuraxial Anesthesia for Cesarean SectionTechniqueBasicsCommentsDoseSpinal (single shot)Most commonly used in cases without a preexisting labor epidural in the United StatesRapid onsetSingle shot limits duration of surgery (when combined with intrathecal fentanyl 25 μg):90 min with hyperbaric bupivacaine120 min with isobaric bupivacaine45 min with hyperbaric lidocaineReliable distribution of spreadRisk 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 afterloadHave vasoactive drugs ready (phenylephrine infusion 30–60 μg/min recommended)Cephalad spread is unpredictableUsual doses for Cesarean section:10.5–12 mg (1.4–1.6 mL of 0.75%) hyperbaric bupivacaine8–10 mg (1.6–2 mL of 0.5%) isobaric bupivacaine75 mg (1.5 mL of 5%) hyperbaric lidocaineAll combined with 15–25 μg fentanyl and 200–300 μg preservative-free morphineSpinal (continuous)Has all the advantages of the single-shot spinalDosing can be titrated graduallyDuration of block can be extendedCurrent 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 fentanylRepeat every 5–10 min until adequate level is achievedEpiduralMost commonly used when labor epidural is presentPresence 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 reducedSlower cephalad spread and limited sympathectomy produces better control of preload and afterloadRecommended technique as primary anesthetic if neuraxial block is considered in preload- or afterload-dependent patients“Patchiness” of block remains most common cause of failureUsual doses and onset times for Cesarean sectionLidocaine 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 minLidocaine in well-established labor epidural: 350–400 mg (17.5–20 mL) 2% lidocaine in three to four divided doses—10–15 minUse of adjuvant opioids is recommended100 μg fentanyl2–3 mg preservative-free morphineIn 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 minAdjuvant neuraxial opioids do not have full effect when chloroprocaine is usedReason remains unclearConsider alternative modalities of postoperative pain control (PCA)Combined spinal epiduralCombines advantages of the two techniques while eliminating some of the undesirable effectsConsider ifLonger than usual surgery is expected (history of intra-abdominal adhesions)Morbid ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.