Anesthesia for cesarean delivery

Author
Gilbert J Grant, MD
Section Editor
David L Hepner, MD
Deputy Editor
Marianna Crowley, MD
Disclosures: Gilbert J Grant, MD Nothing to disclose. David L Hepner, MD Nothing to disclose. Marianna Crowley,
MD Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the content.
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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2015. | This topic last updated: Nov 21, 2014.
INTRODUCTION While regional anesthesia or general anesthesia are both acceptable for cesarean
delivery [1], the use of general anesthesia has fallen dramatically in the past few decades and is now
used in less than 5 percent of cesarean deliveries in the United States and United Kingdom [2].
This topic reviews anesthetic issues specific to the planning and management of anesthesia for cesarean
delivery. Management of anesthesia in pregnant patients and airway management of pregnant patients
are discussed separately. (See "Management of the pregnant patient undergoing nonobstetric
surgery" and "Airway management of the pregnant patient at delivery".)
PLANNING THE ANESTHETIC APPROACH The anesthetic plan for cesarean delivery must take into
account the wellbeing of two patients: the mother and the fetus.
Preanesthetic evaluation Planning for anesthesia in pregnant patients must consider the physiologic
changes of pregnancy and the status of the fetus. (See"Management of the pregnant patient undergoing
nonobstetric surgery", section on 'Physiological changes related to pregnancy'.)
The preanesthetic evaluation is similar to that for other preoperative patients, with a focus on assessment
of the airway, lower back, and coexisting maternal medical conditions. It is reasonable to schedule a
preadmission consultation with an anesthesiologist for patients at risk of complications during labor and
delivery and those with procedure-related risks, even if they are not planning an anesthetic (table 1).
Challenges and complications related to anesthesia are more common in obese parturients and include
difficulty with monitoring, positioning, airway management, and neuraxial techniques [3]. Therefore,
antepartum anesthesiology consultation is recommended. Scheduling the consultation in the early to mid
third trimester is prudent in case of preterm delivery. (See "Preanesthesia medical evaluation of the obese
patient" and "Anesthesia for the obese patient".)
Laboratory testing is discussed separately. (See "Cesarean delivery: Preoperative issues", section on
'Laboratory testing'.)
Rationale for neuraxial anesthesia Neuraxial anesthesia is the most common anesthetic technique,
used for over 95 percent of planned cesarean deliveries in the United States [4]. The preference for

neuraxial techniques in most cases is based on a desire to avoid general anesthesia for delivery, because
of:
Perception that general anesthesia is less safe than neuraxial anesthesia
Passage of anesthetic drugs from the mother to the fetus
Desire of parturients to remember the birth experience
In patients with specific medical issues, such as predicted difficult airway or (rarely) malignant
hyperthermia susceptibility, there are additional reasons to avoid general anesthesia. (See "Airway
management of the pregnant patient at delivery", section on 'Management of the difficult
airway' and "Susceptibility to malignant hyperthermia: Evaluation and management".)
Although neuraxial anesthesia techniques are perceived to be safer for the mother than general
anesthesia, the magnitude of benefit is unclear. The risk of anesthesia-related maternal mortality is
extremely low in the United States. It is reported higher with general anesthesia than regional anesthesia
(from 1991 to 2002: 6.5 versus 3.8 per million [5]); however, observational data may not fully account for
confounders, such as greater use of general anesthesia in emergent and medically complicated cases.
Anesthesiologists are using neuraxial techniques for urgent and emergent cesarean deliveries more often
than in the past, and this has been associated with an increase in reports of regional anesthesia-related
death, although overall anesthetic-related maternal mortality is decreasing.
General anesthesia-associated maternal morbidities include airway-related complications (eg, aspiration
of stomach contents, failed intubation). The consequences of airway problems may be severe, but the
incidence is low (see "Airway management of the pregnant patient at delivery", section on 'Incidence and
consequences of airway problems'). In addition, general anesthesia has been associated with a greater
degree of maternal blood loss than neuraxial anesthesia in both a systematic review of randomized trials
and a retrospective review of over 67,000 cesarean deliveries [1,6].
Although passage of anesthetic drugs to the fetus may result in transient neonatal depression, in a 2012
Cochrane review of randomized trials of regional versus general anesthesia for cesarean for any
indication, both approaches had similar neonatal outcomes (low Apgar scores, need for resuscitation) [1].
There is no strong evidence of long-term adverse effects on the child. (See 'Neonatal effects' below.)
Indications for general anesthesia General anesthesia is indicated for cesarean delivery if there is a
contraindication to neuraxial anesthesia (eg, coagulopathy, profound maternal hypovolemia, and certain
maternal medical conditions), urgency for the procedure due to fetal status, and patient refusal of
neuraxial anesthesia.
Factors that may lead the anesthesiologist to elect general anesthesia:
Coagulopathy is a contraindication to neuraxial anesthesia, due to the risk of spinal epidural
hematoma. Management of patients with coagulation abnormalities, and those on anti-thrombotic
medication, is discussed separately. (See "Adverse effects of neuraxial analgesia and anesthesia for
obstetrics", section on 'Neuraxial analgesia and low platelets' and "Neuraxial (spinal, epidural)
anesthesia in the patient receiving anticoagulant or antiplatelet medication".)
In patients with hypovolemia (eg, from acute hemorrhage) and certain cardiac pathologies (eg,
aortic stenosis), neuraxial anesthesia and its accompanying sympathetic block and vasodilation may
lead to severe maternal hypotension. While this can often be managed with fluid and vasopressors,
or can be mitigated by slow dosing of an epidural, in extreme cases general anesthesia may be a

more prudent choice. (See "Adverse effects of neuraxial analgesia and anesthesia for
obstetrics" and 'Fluid and hemodynamic management' below.)
Urgent attainment of surgical anesthesia may be of critical importance to the wellbeing of the
fetus and/or mother. The decision to use general rather than neuraxial anesthesia in an emergent
situation should be made in conjunction with the obstetrical team.
Although most anesthesiologists agree that general anesthesia is the most reliable means of rapidly
achieving operative anesthesia for cesarean, spinal anesthesia can often be achieved quickly and is
increasingly being used in all but the most emergent situations. Spinal anesthesia has a more rapid
onset of sensory and motor blockade than epidural anesthesia; however, if a functioning epidural
catheter is in place (eg, for labor analgesia), it should be dosed with a rapid-acting local anesthetic.
(See 'Choosing a neuraxial technique' below.)
Skin infection of the lower back, at the location of needle insertion, is a contraindication to
placement of neuraxial anesthesia.
Patient refusal of neuraxial anesthesia is most often due to fear of the needle and of backache
(although unsubstantiated) and/or to worry about witnessing the operation [7,8].
Planning postcesarean analgesia A single dose of preservativefree morphine or hydromorphone administered into the neuraxis may provide up to 24 hours of analgesia
for patients receiving spinal or epidural anesthesia for cesarean delivery. An advantage of administering
opioids via the neuraxial route is that they provide good pain control with minimal transfer of sedating
medication in breast milk to the newborn. The most common side-effects of neuraxial opioids are pruritus,
nausea, and vomiting. Respiratory depression is unlikely to occur in the postpartum period [9].
To minimize the incidence of side effects, a spinal morphine dose of 0.05 to 0.2 mg or an epidural
morphine dose of 3 mg or less may be used. A dose of 100 mcg intrathecal morphine results in equivalent
analgesia to 400 mcg, over 24 hours, with less pruritus [10,11]. The pain relief produced by 1.5 mg
epidural morphine has been shown to be noninferior to 3 mg epidural morphine, with fewer side effects
[12]. Neuraxial hydromorphone is less hydrophilic than morphine, leading to a faster onset and a shorter
duration of action [13]. In the Section Editors practice, an intrathecal dose of 50 to 100 mcg or an
epidural dose of 1 mg of hydromorphone are utilized for post cesarean delivery analgesia. In hospitals
where arrangements are in place to manage postpartum epidural catheters, patient-controlled epidural
analgesia with opioid, dilute local anesthetic, and epinephrine may be used to provide pain relief while
minimizing unwanted side effects [14].
Other options for treatment of postcesarean pain include patient-controlled IV opioid analgesia and
oral and/or parenteral opioids. Multimodal analgesia allows for good pain relief with a reduction in opioidrelated side effects; this should incorporate a nonsteroidal antiinflammatory drug (NSAID)
(eg, ketorolac [30 mg IV every six hours], oribuprofen PO [600 mg four times a day or 800 mg three times
a day], and/or acetaminophen 1 gm IV or PO every six hours). (See "Cesarean delivery: Postoperative
issues", section on 'Postoperative care'.).
PATIENT PREPARATION
Preoperative fasting We agree with the American College of Obstetricians and Gynecologists
(ACOG) and the American Society of Anesthesiologists (ASA) recommendation that patients abstain from
solid food for at least six hours prior to elective cesarean delivery (eight hours for fried or fatty foods)

[15,16]. Clear liquids, which have a more rapid gastric transit time, may be ingested until two hours prior
to surgery. The unpredictability of unplanned cesarean delivery makes it prudent that laboring women
avoid solid food and restrict their oral intake to clear liquids.
Reduction of gastric acidity It is the acidity of gastric aspirate that makes it particularly injurious to
the lungs (see "Aspiration pneumonia in adults", section on 'Pathophysiology'). When the risk of aspiration
is felt to be high, drugs may be given to decrease the acidity and thus mitigate the pulmonary effects,
although there is no high-quality evidence that any specific intervention improves clinical outcome [17].
We use the following regimen:
Scheduled cesarean delivery under general anesthesia (not in labor) Intravenous (IV)
histamine 2-receptor antagonist (H2 blocker) is administered at least 60 minutes prior to induction of
anesthesia.
H2 blockers (eg, ranitidine 50 mg IV) require 40 to 60 minutes to decrease secretion of gastric acid
and are sustained for eight hours, providing prophylaxis against aspiration pneumonitis upon
extubation. In a 2014 Cochrane Review, H2 antagonists were associated with a reduced risk of
intragastric pH <2.5 when compared with PPIs (RR 0.39, 95% CI 0.160.97) [18].
Emergency cesarean under general anesthesia (or patient in labor) Oral nonparticulate
antacid is given to mitigate damage from potential aspiration on induction. When time allows, IV H2
blocker is given to maintain decreased acidity through emergence and recovery.
Sodium citrate 30 mL immediately decreases the acidity of gastric contents; in healthy, non-laboring,
term parturients, it effectively increased mean gastric pH from 1.8 to 5.0 [19] and maintained the pH
of the gastric contents >3.0 for approximately 30 minutes [20]. It has an unpleasant sour taste (that
may itself lead to nausea [21]) and does not prevent continued acid production.
Metoclopramide (10 mg IV, slowly) may shorten transit time and increase lower esophageal sphincter
tone, and thus is sometimes used to decrease the risk of regurgitation. Some studies show a decrease in
gastric volume when metoclopramide is administered preoperatively to various patient populations [2225]. However, many anesthesiologists do not use it due to significant adverse reactions (eg, tardive
dyskinesia, extrapyramidal symptoms) and lack of evidence of efficacy.
Due to the low incidence of aspiration, and the difficulty in performing trials in pregnant women, these
recommendations are based primarily on observational studies, physiology, and expert opinion. Although
gastric emptying is not affected by pregnancy, and the risk of aspiration on induction of general
anesthesia for cesarean is low (approximately 15 per 10,000 [26,27]), most experts still feel that these
precautions are prudent.
These precautions are not necessary prior to neuraxial anesthesia, as the risk of aspiration is minimal in
conscious patients; however, patients with frequent reflux may obtain symptomatic relief from
nonparticulate antacid, and administration of an IV H2 blocker and an oral nonparticulate antacid may be
considered in patients considered at high risk of conversion to general anesthesia.
Antibiotic prophylaxis To reduce the risk of postoperative infection, a single IV dose of antibiotic
should be administered preoperatively 60 minutes prior to skin incision, to all women undergoing
cesarean delivery. (See "Cesarean delivery: Preoperative issues", section on 'Antibiotic prophylaxis'.)
MANAGEMENT OF ANESTHESIA Physiological changes related to pregnancy occur in virtually all
organ systems and impact the management of anesthesia; these are discussed separately.

(See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Physiological
changes related to pregnancy'.)
The parturient should be positioned supine with a 15 percent left lateral tilt to reduce aortocaval
compression and cardiovascular compromise. Alternatively, a wedge may be placed under her right hip.
(See "Cesarean delivery: Preoperative issues", section on 'Uterine displacement'.)
Neuraxial anesthesia Neuraxial anesthesia for cesarean delivery differs from analgesia for labor and
vaginal delivery in two major ways:
A more intense sensory and motor block is achieved by administering a higher concentration of
local anesthetic. A more intense sensory block is needed because the nociceptive stimulus of
surgery is more intense than the pain of labor; motor block is desirable to obtain abdominal muscle
relaxation.
The dermatomal block level required for cesarean delivery is higher than that required for labor
analgesia. For cesarean delivery the anesthetic level must extend to at least the fourth thoracic
dermatome to prevent nociceptive input from the peritoneal manipulation, whereas a sensory block
to the 10th thoracic dermatome is sufficient for labor analgesia.
Techniques, medications, and complications associated with neuraxial anesthesia are discussed
separately. (See "Neuraxial analgesia and anesthesia for labor and delivery: Options" and "Neuraxial
analgesia and anesthesia for labor and delivery: Drugs" and "Adverse effects of neuraxial analgesia and
anesthesia for obstetrics".)
In healthy women with a reassuring fetal heart rate pattern, supplemental oxygen is not necessary [28].
Recommendations for women with obstructive sleep apnea are reviewed separately. (See "Intraoperative
management of adults with obstructive sleep apnea".)
Choosing a neuraxial technique Cesarean delivery may be performed under epidural, spinal, or
combined spinal-epidural (CSE) anesthesia. It is also possible to use continuous spinal anesthesia, which
may be technically easier in select patient populations (eg, morbidly obese patients), but is an infrequent
choice due to the significant risk of a postdural puncture headache. Spinal anesthesia is the quickest to
place and has the most rapid onset; it is the most common type of anesthesia used for cesarean delivery.
Epidural anesthesia is used when an epidural catheter (eg, for labor analgesia) has previously been
placed, when there is an indication to establish the block slowly, or when surgery is anticipated to be
prolonged. CSE is preferred by some practitioners as it combines the qualities of spinal anesthesia with
the capability to prolong the block as needed.
In obese patients, neuraxial anesthesia can be challenging due to difficulty in palpating landmarks and the
patient's inability to assume an optimal position. Also, the catheter may become dislodged when the
patient changes position [29]. Although neuraxial techniques are more likely to fail in obese compared to
non-obese parturients, regional anesthetic techniques are usually safe and successful [30].
(See "Anesthesia for the obese patient".)
Spinal anesthesia is relatively easy to perform, as it involves a distinct endpoint: namely, the
emergence of cerebrospinal fluid from the hub of the spinal needle. Spinal anesthesia takes effect
more quickly than epidural anesthesia; however, there is no ability to increase the duration of
anesthesia when surgery is unexpectedly prolonged. Spinal anesthesia is indicated in situations
where there is an urgency to deliver the fetus quickly and there is no epidural catheter in place.

Epidural anesthesia is slightly more time consuming to initiate and has a slower onset of action
compared with spinal anesthesia, but has the advantage of being redosed to extend the duration of
anesthesia, if needed. The slower onset may be of benefit in patients with relative hypovolemia or
valvular disease (eg, aortic stenosis), as the clinician may more easily maintain an adequate blood
pressure with fluids and/or vasopressors during the onset of the sympathectomy.
Labor epidurals may be converted for operative anesthesia by injecting more concentrated local
anesthetic; adequate anesthesia is achieved within a few minutes in almost all patients (97
percent) [31]. This usually requires less time than replacing the existing epidural with a spinal
anesthetic; however, in some cases the redosed epidural results in inadequate anesthetic level for
surgery. In a meta-analysis, risk factors for failed conversion of labor epidurals to operative
anesthesia included an increasing number of clinician-administered boluses during labor, greater
urgency for cesarean delivery, and a non-obstetric anesthesiologist providing care [32]. In urgent
situations, with a marginally functioning catheter, the anesthesiologist may prefer to place a spinal
rather than attempt the conversion. The dose of local anesthetic required for cesarean, for both
spinal and epidural anesthesia, is lower in patients with prior neuraxial labor analgesia.
CSE is a technique that combines the quick onset and reliability of spinal anesthesia with the ability
to redose through the epidural catheter. Because it takes slightly longer to place than a standard
spinal anesthetic, it is not typically used in situations where delivery is very urgent.
A CSE technique may be preferable to a spinal technique in obese parturients to accommodate
unexpectedly prolonged surgeries. Although single-shot spinal is generally faster to perform than
CSE, this may not be the case in obese parturients, possibly because the epidural needle functions
as an introducer for the less-rigid spinal needle along its relatively long course to the dura [33].
Continuous spinal anesthesia is performed by introducing a catheter into the intrathecal space;
this facilitates controlled anesthesia for as long as necessary. However, it is an infrequent choice
due to the significant risk of a postdural puncture headache. Continuous spinal anesthesia is
advantageous for cesarean delivery when epidural anesthesia is problematic, but neuraxial block is
desirable. This includes technical difficulty with epidural placement (eg, morbid obesity), and
anticipated inadequate epidural block due to poor distribution of local anesthetic (eg, patients with
previous spinal surgery causing scarring in the epidural space). Continuous spinal may be
preferable to single-shot spinal when slow onset of the sympathetic block is physiologically indicated
(eg, cardiac disease) [34].
Dosing The choice of local anesthetic for spinal or epidural anesthesia is based on the speed of onset,
the quality of the block (density), and, for a spinal, the duration of action. If a patient has a partial
(patchy) block from prior labor analgesia, or a failed attempt at a spinal or epidural block for cesarean (in
which local anesthetic was injected but a satisfactory level was not achieved), the dose of anesthetic for a
subsequent attempt at spinal or epidural anesthesia should be decreased to avoid a high/total spinal. The
safest approach is to perform a CSE with 25 to 50 percent of the usual dose of local anesthetic given
intrathecally or an epidural anesthetic. The epidural catheter is then utilized to bring up the anesthetic
level slowly.
Spinal Onset of spinal anesthesia is similar for different local anesthetics, but duration differs
(table 2); bupivacaine is most commonly used. Small doses of intrathecal fentanyl (eg, 15 mcg) may
be used to prolong the duration of spinal anesthesia for cesarean [35].

Epidural Two percent Lidocaine with epinephrine is the most common anesthetic for
cesarean. Sodium bicarbonate may be added to speed its onset of action. For urgent cases, 3% 2chloroprocaine with bicarbonate has the quickest onset. When bicarbonate is added to 2% lidocaine,
the onset time for surgical anesthesia decreased from 9.7 +/-1.6 minutes to 5.2 +/- 1.5 minutes in
one study [36], making it close to the onset of 2-chloroprocaine, but with a longer duration of action.
Alternatives are 0.5% Bupivacaine, or 0.5% ropivacaine, but the onset is slower than with lidocaine
[37]. The risk of cardiac toxicity has limited the popularity of bupivacaine; 0.5% ropivacaine may be
less cardiotoxic. Specific doses and duration are presented in a table (table 3).
Adding fentanyl to local anesthetics may result in a significantly faster onset of the block [37]. When
epidural fentanyl and morphine are both given, the onset of analgesia from the morphine coincides
with the offset of the fentanyl, resulting in good analgesia for 18 to 24 hours.
CSE For CSE, options include either a standard spinal dose (eg, bupivacaine 10 to 15 mg) or a
lower dose, with the intent of dosing the epidural catheter to achieve an adequate block level. The
epidural catheter should be aspirated and tested (eg, 3 mL lidocaine 1.5% with
1:200,000 epinephrine) prior to administration of epidural local anesthetics.
Continuous spinal A reasonable choice for continuous spinal anesthesia is hyperbaric
0.75% bupivacaine administered incrementally, starting with 3.75 mg. Isobaric 0.5% bupivacaine
administered incrementally (starting with 5 mg and followed by 2 mg boluses as needed) is less
often used. Fentanyl 15 mcg or sufentanil5 mcg may be added.
A detailed description of neuraxial anesthetic techniques, side effects, and complications can be found
separately. (See "Neuraxial analgesia and anesthesia for labor and delivery: Options" and "Adverse
effects of neuraxial analgesia and anesthesia for obstetrics" and "Neuraxial analgesia and anesthesia for
labor and delivery: Drugs".)
Inadequate block After placement of the neuraxial anesthetic, the parturient is positioned supine, with
left uterine displacement while awaiting development of an adequate block. If there is a sense of urgency,
the skin is prepared for surgery, and surgical drapes placed while awaiting development of the block. If
the level and/orintensity of anesthetic block are insufficient to commence surgery, the options are:
Wait. Generally the level of block to temperature sensation indicates the final sensory level. The
level of a hyperbaric bupivacaine spinal may be extended cephalad a few dermatomes by tilting the
bed head-down, but this should be done with extreme caution, as this maneuver may cause an
excessively high level.
Inject additional local anesthetic. An epidural catheter may be redosed, or, if it is judged to have
failed, a spinal may be placed. Performing a new epidural anesthetic is also a possibility, but the risk
of cumulative local anesthetic causing systemic toxicity should be considered. If time is not an issue,
a one- to two-hour delay would allow the local anesthetic in the initial epidural to be metabolized. A
spinal placed in a patient with a partial neuraxial block should have a reduced dose to avoid an
excessively high spinal block level. In patients with a partial (patchy) epidural, or with an
inadequate spinal block, we decrease the dose of a subsequent spinal by approximately 50 percent,
and are reticent to perform spinal anesthesia in this circumstance if the patient has an obvious
difficult airway. In this situation, it is preferable to perform a CSE with a markedly reduced spinal
dose (eg, 75 percent reduction of standard dose) and then use the epidural to increase the cephalad
level of the block, if needed.
Convert to general anesthesia.

The decision on the best way to deal with an inadequate block must consider clinical urgency and
individual risks, and should also include a discussion with the obstetrician. If the interval from the sterile
prep and drape of the abdomen to surgical incision is prolonged while waiting for an adequate anesthetic
level, the fetal heart rate can be assessed with an external monitor placed in sterile sleeve.
High levels of block High thoracic levels of spinal or epidural blockade often lead to a subjective
feeling of dyspnea. For most patients, reassurance that this is a normal sensation is sufficient. Assessing
hand grip is a quick way to determine if the block involves the cervical roots. When a patient complains of
difficulty breathing, adequacy of spontaneous ventilation and ability to protect the airway must be
assessed; general anesthesia should be induced if they are compromised. (See 'Induction'below.)
Hypotension Dense neuraxial blockade includes sympathetic block. Hypotension may be avoided with
the use of IV fluids and/or vasopressors. (See 'Fluid and hemodynamic management' below.)
Anxiety and pain Some women may develop anxiety during cesarean delivery. This is first treated
with verbal reassurance and then, if necessary, an anxiolytic such as midazolam. Some patients prefer to
avoid midazolam prior to delivery, as its amnestic properties may inhibit memory of the moment of birth.
Pain may occur during cesarean delivery under neuraxial block, if the level of block is inadequate. If an
epidural catheter is in place, additional anesthetic should be administered, ideally, 3% 2-chloroprocaine
with bicarbonate or 2% lidocaine with epinephrine and bicarbonate. The obstetrician should be asked to
cease operating, if possible, until the anesthetic takes effect. In the interim, small doses of propofol;
opioids such as fentanyl or remifentanil; midazolam; or ketamine may be used. A reasonable approach is
midazolam (2 mg) followed by ketamine (10 mg starting dose titrated with incremental 10 mg doses to
response), as it is unlikely to lead to respiratory depression. One must exercise extreme caution when
administering these agents to parturients, as full stomach considerations apply. If deep levels of sedation
are required, it is prudent to induce general endotracheal anesthesia with a rapid sequence induction to
protect the airway.
Nausea and vomiting Nausea is a common complaint during cesarean delivery. It is often related to
hypotension from the sympathetic block, in which case restoring the blood pressure
(with phenylephrine or ephedrine) should reverse the symptoms. It can also be caused by an insufficient
block level, which can be treated by administering additional local anesthetic if an epidural catheter is in
place. Uterine manipulation may also cause nausea and vomiting, especially if it is exteriorized, with its
attendant peritoneal traction; this often resolves when the uterus is replaced. Nausea and vomiting is
common after spinal morphine administration, but less likely following neuraxial administration of lipophilic
opioids (eg, fentanyl, sufentanil). In one study, 31 percent of patients had both nausea and vomiting one
hour after administration of only 60 mcg of spinal morphine [38].
Nausea and vomiting as a result of neuraxial opioids may be treated with naloxone in 40 to 100 mcg IV
boluses, titrated every few minutes until the symptoms abate. If large doses of naloxone are needed,
reversal of analgesia may occur, although this would be more problematic postoperatively, after the
neuraxial local anesthetic block has dissipated. A mixed opioid agonist-antagonist, such as nalbuphine 4
mg, may be used to avoid the problem of analgesia reversal, but this may cause sedation. An antiemetic
such as ondansetron 4 mg may be indicated if a cause of nausea other than hypotension or inadequate
block level is suspected.
In a systematic review of randomized trials of interventions for preventing nausea and vomiting in women
with neuraxial aesthesia for cesarean delivery, three interventions were effective: 5-HT3 antagonists

(eg, ondansetron), dopamine antagonists (eg, metoclopramide), and small doses of sedatives
(eg, propofol 1 mg/kg/hour)[39]. In another systematic review, prophylactic dexamethasone led to
decreased nausea and vomiting from spinal morphine [40].
Pruritus Neuraxial opioids lead to pruritus in 60 to 100 percent of pregnant/post-partum women [41].
This may resolve with small doses of intravenous opioid agonist-antagonists (eg, butorphanol 1 mg,
followed by 0.2 mg/h [42]), or antagonists (eg, naloxone 0.25 to 1 mcg/kg/hr infusion) [41].
General anesthesia Whether general anesthesia is planned, or induced emergently due to failed
neuraxial anesthesia, the considerations and management are the same. The goal is to maintain
hemodynamic and respiratory homeostasis for both parturient and fetus, and minimize time between
induction and delivery. The patient is positioned and her abdomen prepared for surgery as she is
preoxygenated. Immediately following induction and confirmation of a secure airway with end tidal carbon
dioxide, the incision is made and delivery accomplished as efficiently as possible.
Induction Induction of general anesthesia for cesarean delivery routinely involves thorough
preoxygenation, rapid sequence induction with cricoid pressure, and endotracheal intubation; the basic
sequence is the following:
Preoxygenation with 100 percent oxygen is administered by tight-fitting face mask for three to five
minutes. If there is insufficient time for this, the patient should take eight vital capacity breaths over
60 seconds. (See "Airway management of the pregnant patient at delivery", section on
'Preoxygenation'.)
Preoxygenation is particularly important in obese pregnant women because they are more prone to
severe hypoxemia and rapid desaturation after induction of general anesthesia. Time to 90 percent
desaturation may be reduced to just 98 seconds in term parturients with very high body mass index
(BMI, 50 kg/m2 or higher) compared to 292 seconds in non-obese pregnant women [43].
Preoxygenation may be more effective in the sitting or partial head-up position [44,45].
Rapid sequence induction is performed, immediately followed by endotracheal intubation. Typically,
cricoid pressure is applied, and mask ventilation is avoided. However, some experts advocate
avoiding cricoid pressure, or performing gentle bag-mask ventilation with peak airway pressures
below 15 cm H2O [46,47]. (See"Airway management of the pregnant patient at delivery", section on
'Intubation'.)
The most common induction agents are propofol (2 to 3 mg/kg) and succinylcholine (1 to
1.5 mg/kg), but alternatives include etomidate (0.2 to 0.3 mg/kg), ketamine(1 to 2 mg/kg), and
nondepolarizing neuromuscular blockers, depending on the clinical situation. (See "Management of
the pregnant patient undergoing nonobstetric surgery", section on 'Induction'.)
Proper placement of the endotracheal tube should be confirmed prior to incision.
Airway management Management of the airway in pregnant women and management of the difficult
airway are discussed in detail separately. (See"Management of the pregnant patient undergoing
nonobstetric surgery", section on 'Induction of anesthesia' and "Airway management of the pregnant
patient at delivery".)
Maintenance Anesthesia is usually maintained with inhalation agents (eg, sevoflurane, isoflurane),
with or without nitrous oxide (N2O). A reasonable approach is to administer nitrous oxide (50 percent) and
an inhalation anesthetic (eg, isoflurane, sevoflurane 0.5 minimum alveolar concentration [MAC]) until

delivery. Nitrous oxide is often not used if there are fetal concerns, in which case higher concentrations of
inhalation agents are necessary. After delivery, nitrous oxide may be increased to 70 percent and opioids
are given, which may permit the inhalation agent to be decreased, as high concentrations can cause
uterine atony.
The optimal agent(s) and concentration(s) have not been determined. Considerations include:
Adequate depth of anesthesia to prevent awareness with recall. MAC for isoflurane is decreased in
pregnancy by about 30 percent [48-50]. Some experts advocate increasing N2O, especially when
decreasing inhalation agent concentration after delivery, but the effects on awareness and recall are
unclear [51,52]. (See'Awareness with recall' below.)
Minimization of medication that transfers to the fetus prior to delivery. Opioids are often given after
delivery. Opioids may be administered if needed prior to delivery, as naloxone can be used to
reverse opioid effects in the neonate. It is important that pediatricians attending the birth are
informed about medications the mother has received. Use of propofol for maintenance is usually
limited to patients with a medical reason to avoid inhalation anesthetics. Propofol does cross the
placenta [53], but there is no evidence of neonatal effects when used for induction, and in small
trials comparing propofol infusion to inhalation anesthetics for maintenance there were no
differences in neonatal assessments [54,55]. However, in one series of 10 cesarean deliveries with
propofol and remifentanil for maintenance, neonatal depression occurred in six, and brief assisted
mask ventilation was required [56].
Minimization of inhalation anesthetics, which cause dose-dependent reduction in uterine tone and
may lead to bleeding [57]. Doses as low as 0.5 MAC cause decreased contractility in vitro and may
reduce the contractile effects of oxytocin [58-60].
Appropriate oxygen concentration. Many anesthesiologists administer 100 percent oxygen prior to
delivery of the fetus, especially in cases of nonreassuring fetal heart rate tracing. Increasing oxygen
concentration to the parturient leads to increased fetal and neonatal oxygenation [61].
The abdominal muscle relaxation provided by inhalation agents may obviate the need to redose a
neuromuscular blocker when the induction dose has worn off.
Mechanical ventilation is adjusted to maintain the normal physiologic respiratory alkalosis of pregnancy,
with an end-tidal carbon dioxide of about 30 mmHg. (See"Management of the pregnant patient
undergoing nonobstetric surgery", section on 'Mechanical ventilation'.)
Emergence At the end of surgery, the patient is awakened prior to extubation to ensure that airway
reflexes are intact. Especially for obese patients, the head-up position is ideal to improve oxygenation and
decrease work of breathing. (See "Airway management of the pregnant patient at delivery", section on
'Extubation' and"Anesthesia for the obese patient", section on 'Extubation'.)
Awareness with recall Historically, the incidence of recall of intraoperative awareness following
cesarean delivery was as high as 26 percent [62], because low doses of anesthetics were used and
current inhalation anesthetics were not yet available. With current techniques for general anesthesia for
cesarean delivery, the risk of awareness with recall may be comparable to that of the general surgical
patient [63], although some studies indicate increased risk [64]. Midazolam (0.05 to 0.1 mg/kg)may be
used to minimize the risk of recall. (See "Awareness with recall following general anesthesia".)

Fluid and hemodynamic management Induction of both general and neuraxial anesthesia tends to
reduce maternal blood pressure. Hypotension is usually transient at induction of general anesthesia, but
of longer duration following placement of neuraxial anesthesia, as the neuraxial-induced sympathetic
block causes vasodilation with pooling of blood in capacitance vessels. The onset of block is more rapid
with spinal than epidural anesthesia; for this reason, significant hypotension occurs more commonly after
spinal anesthesia than after epidural anesthesia.
A practical strategy to minimize hypotension is to administer a rapid bolus of crystalloid at the time
of induction/neuraxial placement (co-load), possibly with a low-dosephenylephrine IV infusion. The benefit
of prophylactic vasopressor infusion was shown in a 2014 systematic review in which administration of a
prophylactic phenylephrine infusion to parturients having spinal anesthesia (with a fluid load) decreased
the incidence of hypotension by about 60 percent before and after delivery (RR 0.36 and 0.37,
respectively), as well as decreasing nausea and vomiting (RR 0.39); there were no differences in other
maternal or fetal endpoints or outcomes [65]. There is no need to delay neuraxial placement to pre-load
fluids, as co-loading fluids (either crystalloid or colloid) was as effective at minimizing hypotension as preloading colloid, and better than pre-loading crystalloid [66-68].
Most anesthesiologists administer crystalloid rather than colloid solutions for cesarean delivery because
they are less expensive and more readily available. Furthermore, the limited available data do not indicate
an absolute benefit to colloids over crystalloids [67,69]. In fact, data in cardiac patients and critically ill
non-obstetric patients show that resuscitation with hydroxyethyl colloids and albumin do not decrease
mortality and are more likely to lead to renal injury [70-72].
Glucose-free solutions should be used to prevent hyperinsulinemia in the fetus. Excessive placental
glucose transfer can result in compensatory release of fetal insulin (fetal hyperinsulinemia) and neonatal
hypoglycemia [73,74].
Fetal oxygenation depends upon placental perfusion; thus, a decrease in maternal blood pressure can
compromise fetal oxygenation, which can be manifested by changes in the fetal heart rate.
(See "Nonstress test and contraction stress test", section on 'Cardiovascular response to hypoxemia'.)
Vasopressor treatment Either phenylephrine or ephedrine is an acceptable vasopressor in parturients
[75-79]. Common doses for treatment of hypotension are ephedrine (5 to 10 mg IV boluses) and
phenylephrine (50 to 100 mcg IV bolus, or 25 to 100 mcg/min IV infusion), though rates of phenylephrine
75 to 100 mcg/min tend to lead to more maternal hypertension [80]. A study demonstrated that
prophylactic phenylephrine infusion following spinal anesthesia was associated with less nausea and
vomiting and decreased need for physician intervention compared to phenylephrine bolus [81].
The choice of therapy has often been guided by maternal heart rate. Phenylephrine may be preferred
when the maternal heart rate is relatively fast, since it tends to slow the heart rate. Conversely, in women
with a low heart rate, ephedrine may be preferable, as phenylephrine is more likely to produce maternal
bradycardia [82]. Phenylephrine may also be preferable when the fetal heart rate has not been normal. In
a systematic review of vasopressors for the management of hypotension after spinal anesthesia for
elective cesarean delivery, ephedrine was associated with an increase in true fetal acidosis (pH <7.20,
RR 5.29, 95% CI 1.62-17.25) compared with phenylephrine [82]. Phenylephrine may be associated with
less intraoperative nausea and vomiting compared with ephedrine [79].
PROPHYLAXIS AGAINST POSTPARTUM HEMORRHAGE For women undergoing cesarean
delivery, we suggest an oxytocin infusion without a bolus as first-line therapy. The dose and duration of

intravenous oxytocin infusion as a prophylactic agent vary widely among institutions; doses of 10 to 40
units of oxytocin in 1000 mL crystalloid over four to eight hours are effective [83]. A commonly used
method is to run a free-flowing infusion of 10 to 30 units of oxytocin per 500 mL 0.9% saline, with the rate
of infusion adjusted, as needed, to prevent uterine atony. Administration of oxytocin at a standardized rate
via a pump may improve safety by decreasing dosing errors and avoiding infusion of unnecessarily high
doses. In two retrospective studies, implementation of this approach was as effective as the authors
previous practice of free-flow infusion, and reduced the amount of oxytocin administered [84,85]. The
regimen used was 18 units oxytocin/hour beginning at cord clamping, increasing to 36units/hour in cases
of uterine atony, and decreasing to 3.6 units/hour after one hour in patients with stable bleeding. In a dose
finding study, 15 units/hour provided satisfactory uterine tone in 90 percent of women at low risk of
hemorrhage undergoing scheduled cesarean delivery, although confidence intervals were wide [86].
We avoid bolus injection of oxytocin. At least two trials in women undergoing cesarean delivery reported
that bolus injection (IV push) of 5 to 10 units of oxytocin was associated with ischemic electrocardiogram
changes [87,88]. At least two maternal deaths in the UK have been attributed to use of a 10 unit bolus
dose [89].
If a bolus injection is given, the minimum effective bolus dose of oxytocin after cesarean is unclear, but
appears to be 3 units [90,91]. Even a 2.5 unit bolus of oxytocin can produce adverse effects, including
tachycardia and hypotension, in preeclamptic patients [92]. A systematic review of randomized trials that
attempted to determine the optimal initial dose of oxytocin to prevent postpartum hemorrhage after
cesarean delivery in low-risk women suggested that those who underwent scheduled cesarean delivery
receive a 0.3 to 1 unit bolus over one minute and those who underwent cesarean delivery during labor
receive a 3 unit bolus over one minute; in both settings they suggested following the bolus with an
oxytocin infusion of 5 to 10 units/hour for four hours [91]. If the initial bolus injection was not effective, they
suggested repeating it once or twice and then trying a different uterotonic drug.
If a bolus injection is given after cesarean delivery, the addition of an oxytocin infusion appears to reduce
blood loss and the need for blood transfusion and/or additional uterotonic agents compared with bolus
injection alone [93,94]. However, the combination of a bolus injection and an infusion does not appear to
reduce the need for additional uterotonic agents compared with use of an infusion alone, despite causing
an initially stronger uterine contraction [95].
A 2013 systematic review of prophylactic misoprostol use at cesarean delivery concluded misoprostol was
associated with more side effects than oxytocin and evidence was insufficient to establish equivalence
with oxytocin. Therefore, oxytocin was recommended as the first-line agent for prevention of postpartum
hemorrhage at cesarean delivery [96]. However, the combination of misoprostol and oxytocin was more
effective than oxytocin alone for reducing intraoperative and postoperative blood loss during cesarean
delivery, leading the authors to consider use of misoprostol (400 mcg sublingually after cord clamping) in
addition to oxytocin in women at high risk of postpartum hemorrhage. We use oxytocin alone for
prophylaxis. Management of women with hemorrhage despite oxytocin administration is reviewed in detail
separately. (See "Management of postpartum hemorrhage at cesarean delivery".)
Tranexamic acid is an anti-fibrinolytic drug that has been useful for prevention and treatment of bleeding
in various clinical settings. It is currently under investigation for prevention or treatment of PP
hemorrhage, but it is not routinely used. (See "Pharmacologic management of the third stage of labor",
section on 'Tranexamic acid'.)

FETAL AND NEONATAL ISSUES

Fetal surveillance For low-risk patients undergoing scheduled cesarean delivery, the presence of a
normal fetal heart rate should be ascertained and documented before administration of anesthesia. For
patients undergoing unscheduled cesarean delivery, continuous fetal heart rate monitoring is maintained
until the abdominal sterile preparation has begun, at which time the external monitor is removed. If the
patient has an internal fetal monitor, it is removed when abdominal sterile preparation is complete [97].
Neonatal effects All anesthetic induction and maintenance agents cross the placenta and may result
in neonatal depression if used in large doses; appropriate resuscitative measures, including ventilatory
assistance, should be instituted in the newborn until the effects abate. Alternatively, specific reversal
agents for opioids (naloxone) and/or benzodiazepines (flumazenil) may be administered to the neonate.
Personnel other than the surgical team should be immediately available to assume responsibility for
resuscitation of the depressed newborn as the anesthesiologist and obstetrician are responsible for the
mother and may not be able to leave her to care for the newborn, even when a regional anesthetic is
functioning adequately [98].
There is no evidence that brief exposure to anesthetic agents during cesarean delivery causes
developmental problems in the neonate. (See "Management of the pregnant patient undergoing
nonobstetric surgery", section on 'Anesthesia drug issues'.)
SUMMARY AND RECOMMENDATIONS
Mortality rates for cesarean delivery are higher for general anesthesia than for neuraxial
anesthesia and are most often related to respiratory problems. However, while overall anestheticrelated maternal mortality is decreasing, rates for regional anesthesia-related death are rising,
perhaps due to the increasing use of neuraxial anesthesia in high acuity, emergent cases. General
anesthesia is associated with an increase in the risk of postpartum hemorrhage, when compared
with neuraxial anesthesia. (See 'Rationale for neuraxial anesthesia' above.)
The choice of neuraxial or general anesthesia is influenced by factors such as the urgency of the
procedure, maternal status, the presence of specific contraindications, and clinician and patient
preference. Neuraxial anesthesia is usually preferred unless there is a specific contraindication or
overwhelming clinical urgency. (See 'Planning the anesthetic approach' above.)
Patients should abstain from solid food for at least six hours prior to scheduled cesarean delivery
(eight hours for fried or fatty foods), but clear liquids may be ingested until two hours prior to surgery.
(See 'Preoperative fasting' above.)
For patients who are to undergo general anesthesia, we suggest administration of drugs to reduce
gastric acidity, in order to decrease pneumonitis in case of aspiration (Grade 2C). An effective
regimen includes an oral nonparticulate antacid (eg, sodium citrate 30 mL) within 30 minutes of
induction, and an intravenous (IV) histamine 2-receptor antagonist (eg, ranitidine 50 mg IV).
(See 'Reduction of gastric acidity' above.)
When general anesthesia is used, we preoxygenate by tight-fitting face mask for three to five
minutes, or eight vital capacity breaths over 60 seconds. We follow with rapid sequence induction
with cricoid pressure, using propofol or etomidate, and succinylcholine. We administer 50
percent nitrous oxide in oxygen (100 percent oxygen if there is evidence of fetal compromise) with
0.5 minimum alveolar concentration (MAC) sevoflurane until delivery; after delivery we increase
nitrous oxide to 70 percent, and administer IV opioids, which may permit the inhalation agent to be

decreased. Neuromuscular blockers are used as needed and reversed prior to awake extubation.
(See 'General anesthesia' above.)
A reasonable strategy to prevent neuraxial anesthesia-induced hypotension includes volume
expansion with a glucose-free intravenous crystalloid at the time of local anesthetic injection and
administration of low-dose phenylephrine infusion. Left uterine displacement should be used. If
hypotension occurs, it should be treated with vasopressor administration (phenylephrine
or ephedrine) and IV fluids. (See 'Fluid and hemodynamic management' above.)
Oxytocin infusion is uses to prophylax against postpartum hemorrhage. We use 10 to 30 units of
oxytocin per 500 mL 0.9% saline; effective doses begin at about 15units/hour and are adjusted as
needed to prevent uterine atony. During the recovery period, infusion of 10 to 40 units of oxytocin in
1000 mL crystalloid over four to eight hours is generally effective; oxytocin infusion may be
discontinued after completion of this infusion if postpartum uterine bleeding is not excessive and the
mother is stable in the postpartum unit. (See 'Prophylaxis against postpartum hemorrhage' above.)
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