Anaes · Obstetric anaesthesia
Caesarean anaesthesia: spinal, CSE, general anaesthesia and spinal hypotension
Also known as Caesarean section anaesthesia · LUSCS spinal · Spinal hypotension phenylephrine · Category 1 GA obstetrics
Exam-exhaustive neuraxial and general anaesthesia for caesarean section: exact spinal doses, phenylephrine-first spinal hypotension management with fetal acid-base rationale, oxytocin after delivery, IT morphine, Category 1 GA, and OAA/DAS failed intubation readiness.
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Red flags
- Phenylephrine is first-line for spinal hypotension — better fetal acid-base than ephedrine.
- Maintain left uterine displacement until delivery.
- Category 1 GA needs obstetric RSI and OAA/DAS failed-intubation plan.
- IT morphine 100–150 microg requires respiratory monitoring protocols.
- Avoid rapid large oxytocin IV boluses (hypotension).
Meet the patient
A 32-year-old in labour at 39 weeks has a non-reassuring CTG and is called for Category 1 caesarean. She has a working epidural that has been topping up slowly through the second stage. The registrar asks: top up the epidural, or convert to general anaesthetic? The answer depends on how reliably the block will build in the minutes you have — and whether you have a failed-intubation plan if it does not.[1]
Two sentences frame the entire topic: phenylephrine is first-line because it gives better neonatal acid-base than ephedrine, and Category 1 does not excuse an unplanned airway. Everything below is the craft behind those two statements.[1][6]
References8ShowHide
- [1]Lee A, Ngan Kee WD, Gin T A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery Anesth Analg, 2002.PMID 11916798
- [2]Cooper DW, Carpenter M, Mowbray P, et al. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery Anesthesiology, 2002.PMID 12459688
- [3]Ngan Kee WD, Khaw KS, Ng FF Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section Br J Anaesth, 2004.PMID 14977792
- [4]Ngan Kee WD, Khaw KS, Tan PE, et al. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery Anesthesiology, 2009.PMID 19672175
- [5]Singh PM, Singh NP, Reschke M, et al. Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes Br J Anaesth, 2020.PMID 31810562
- [6]Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics Anaesthesia, 2015.PMID 26449292
- [7]Palmer CM, Emerson S, Volgoropolous D, et al. Dose-response relationship of intrathecal morphine for postcesarean analgesia Anesthesiology, 1999.PMID 9952150
- [8]Carvalho JC, Balki M, Kingdom J, et al. Oxytocin requirements at elective cesarean delivery: a dose-finding study Obstet Gynecol, 2004.PMID 15516392