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

Anesthesia for Cesarean Section with Twins

Neuraxial anesthesia (spinal or combined spinal-epidural) is the recommended first-line anesthetic technique for cesarean section involving twins, as it provides superior maternal and fetal safety compared to general anesthesia. 1, 2, 3

Primary Anesthetic Technique Selection

Neuraxial Anesthesia as First-Line

• Spinal anesthesia should be the preferred technique for elective twin cesarean sections due to its rapid onset (approximately 1 minute to maximum block), reliability, and reduced risk of systemic toxicity compared to general anesthesia. 2, 4, 3
• Combined spinal-epidural anesthesia (CSEA) represents an excellent alternative, offering the reliability of spinal block with the flexibility of epidural supplementation if needed for prolonged surgery (which may be more likely with twin deliveries). 5, 6
• If an epidural catheter is already in place from labor analgesia, extending the epidural block is appropriate for cesarean section. 2

When General Anesthesia May Be Required

• General anesthesia should be reserved primarily for Category 1 emergencies where there is immediate threat to maternal or fetal life, or when neuraxial techniques are contraindicated (patient refusal, severe hypovolemia, coagulopathy). 2, 3, 7
• Propofol is NOT recommended for cesarean section (including twin deliveries) as it crosses the placenta and may be associated with neonatal depression. 8
• Rocuronium is NOT recommended for rapid sequence induction in cesarean section patients due to poor intubating conditions when used with lower doses of thiopental. 9

Optimal Spinal Anesthesia Protocol for Twin Cesarean Section

Intrathecal Medication Regimen

• Administer intrathecal morphine 50-100 μg (or diamorphine up to 300 μg) as part of the spinal anesthetic for superior postoperative pain control. 1, 2, 10
• Lower doses of intrathecal morphine (≤100 μg) provide adequate analgesia with reduced side effects. 1
• If epidural catheter is used (CSEA technique), epidural morphine 2-3 mg or diamorphine 2-3 mg may be substituted. 1, 2

Pre-operative Preparation

• Administer oral paracetamol pre-operatively. 1
• Ensure adequate intravenous access and fluid preloading, as hypotension requiring treatment is more likely with spinal anesthesia compared to epidural techniques. 2, 4

Intra-operative Management (After Delivery)

• Administer intravenous paracetamol if not given pre-operatively. 1, 10
• Give intravenous non-steroidal anti-inflammatory drugs (NSAIDs) after delivery unless contraindicated. 1, 10
• Administer intravenous dexamethasone after delivery for improved pain control and anti-emetic prophylaxis (use caution in patients with glucose intolerance). 1, 2, 10

Regional Analgesia Techniques

• If intrathecal morphine was NOT used, implement one of the following regional techniques: single-injection local anesthetic wound infiltration, continuous wound local anesthetic infusion, or fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks). 1, 2, 10
• The additional benefit of these regional techniques is minimal when intrathecal morphine is already administered, so they should be reserved for cases where neuraxial opioids are contraindicated. 1, 10

Postoperative Pain Management

Basic Analgesic Regimen

• Continue scheduled oral or intravenous paracetamol postoperatively. 1, 10
• Continue scheduled oral or intravenous NSAIDs postoperatively. 1, 10
• Reserve opioids for rescue analgesia or when other recommended strategies are contraindicated. 1

Adjunctive Measures

• Consider transcutaneous electrical nerve stimulation (TENS) as an analgesic adjunct. 1, 2

Surgical Technique Recommendations to Reduce Pain

• Use Joel-Cohen incision technique rather than traditional Pfannenstiel incision. 1, 2, 10
• Implement non-closure of the peritoneum. 1, 2, 10
• Apply abdominal binders postoperatively. 1, 2, 10

Critical Considerations and Pitfalls

Hypotension Management

• Monitor for and treat hypotension promptly, as spinal anesthesia increases the need for vasopressor treatment compared to epidural techniques. 2, 4
• Have ephedrine or phenylephrine readily available for immediate treatment of hypotension. 5

Absolute Contraindications to Neuraxial Anesthesia

• Patient refusal 2
• Severe hypovolemia 2
• Coagulopathy or hemostasis disorders (particularly important to check in severe COVID-19 or other conditions causing thrombocytopenia) 1, 2

Medications to Avoid

• Do NOT use gabapentinoids pre-operatively despite previous recommendations, due to concerns about sedation and respiratory depression. 1
• Avoid intra-operative dexmedetomidine infusion due to concerns about prolonged hypotension and bradycardia that might impede ambulation. 1
• Avoid sub-anesthetic ketamine due to concerns about hallucinations that might impair birth experience recollection and mother-child bonding. 1

Twin-Specific Considerations

• While the evidence provided focuses on singleton cesarean sections, the same principles apply to twin deliveries. 1
• Twin cesarean sections may have longer operative times, making the flexibility of CSEA particularly advantageous. 5, 6
• The multimodal analgesia approach is especially important for twin deliveries given potentially larger incisions and increased tissue trauma. 1, 10