What is the recommended anesthesia for a cesarean (C-section) section?

Spinal Anesthesia for Cesarean Section: Optimal Approach

Neuraxial anesthesia, specifically spinal anesthesia, is strongly recommended as the first-line anesthetic technique for cesarean section due to its superior safety profile, rapid onset, and effectiveness compared to general anesthesia. 1, 2

Primary Anesthetic Recommendation

• Spinal anesthesia is the preferred technique for elective cesarean section, offering simplicity, rapid onset, reliable block density, and reduced risk of systemic toxicity 2, 3
• For emergency cesarean sections where an epidural catheter is already in place for labor analgesia, extending the epidural block is appropriate 4, 5
• General anesthesia should be reserved primarily for Category 1 cesarean sections (immediate threat to maternal or fetal life) or when neuraxial techniques are contraindicated 2

Optimal Spinal Anesthetic Protocol

Medication Regimen

• Add intrathecal morphine 50-100 μg or diamorphine 300 μg to spinal anesthesia for postoperative pain management 1
• When epidural catheter is used (e.g., as part of combined spinal-epidural technique), epidural morphine 2-3 mg or diamorphine 2-3 mg may be used as an alternative 1, 4
• Administer intravenous dexamethasone after delivery (in absence of contraindications like glucose intolerance) to reduce pain scores and opioid consumption while providing anti-emetic effects 1

Multimodal Pain Management

• Prescribe paracetamol and NSAIDs administered after delivery and continued regularly postoperatively as basic analgesics 1
• If intrathecal morphine is not used, implement one of the following regional techniques:
  • Single-injection local anesthetic wound infiltration
  • Continuous wound local anesthetic infusion
  • Fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 1

Technical Considerations to Reduce Failure

• Position the patient properly - improper positioning increases failure risk by 14.43 times 6
• Limit the number of attempts to ideally one, as multiple attempts increase failure risk by 9.26 times 6
• Ensure adequate bupivacaine dosing (≥10 mg) as lower doses increase failure risk by 2.72 times 6
• Consider patient BMI - obesity (BMI ≥30 kg/m²) increases failure risk by 2.03 times 6
• Anesthetist experience matters - practitioners with <1 year experience have 4.12 times higher failure rates 6

Surgical Technique Recommendations

• Use Joel-Cohen incision technique 1
• Implement non-closure of the peritoneum 1
• Consider using abdominal binders postoperatively 1
• Transcutaneous electrical nerve stimulation can be used as an analgesic adjunct 1

Management of Failed Spinal Anesthesia

• For complete failure: repeat spinal anesthesia or convert to general anesthesia based on urgency and patient factors 6
• For partial failure: administer supplementary analgesics while monitoring for high block 6, 7
• When performing spinal anesthesia after inadequate epidural labor analgesia:
  • Avoid epidural boluses in the 30 minutes preceding spinal anesthesia
  • Use reduced spinal dose (approximately 9.38 mg of 0.75% hyperbaric bupivacaine)
  • Leave patient sitting for 2 minutes before positioning supine with left uterine displacement 7

Cautions and Contraindications

• Monitor for and treat hypotension promptly, as spinal anesthesia increases the need for treatment of hypotension compared to epidural techniques 5
• Avoid pre-operative gabapentinoids, intravenous ketamine, dexmedetomidine, and neuraxial adjuvants like clonidine or dexmedetomidine due to limited evidence and concerns about side effects 1
• Absolute contraindications include patient refusal, severe hypovolemia, and coagulopathy 4