Conduct of anaesthesia for caesarean section

The following information offers guidelines for the safe conduct of general, spinal and epidural anaesthesia for caesarean section. It is relevant for all anaesthetic staff working on Central Delivery Suite and is available for obstetric and midwifery staff to support their understanding of the process of anaesthetising women for caesarean delivery.

Relevant recent publications

Bolton NHS Foundation Trust

February 2016

Frimley Health NHS Foundation Trust

December 2018

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

June 2017

Lancashire Teaching Hospitals NHS Foundation Trust

May 2016

General Points on the examples

• Good description of top up with bicarbonate lignocaine mixture.
• Doesn’t tell you what a good block is only what a poor block looks like.
• “Repeat the spinal after 20 minutes. Give the same dose of heavy Bupivacaine again but omit opioid” - this could lead to an excessive block depending on the individual situation.
• Prophylactic use of treanexamic acid for high risk cases > 2 previous CS is very controversial.

What we liked

• Post op angalgesia and observations.
• Key Points.
• If an epidural has been sited, ensure it has been removed at the end of surgery, unless there is a good reason to keep it in.
• Clear Guidance on TAP blocks.
• Spinal Anaesthesia following inadequate epdiural analgesia.
• Indications for post-delivery Syntocinon infusion.
• Pain during regional anaesthetic very good.
• Guidance on Birthing parter in theatre.
• Guidance on EROS.
• Advice on challenging cases.
• Clear guidance on monitoring in recovery.
• Comprehensive description of Optiflow.
• B@Ease checklist for the obstetric GA.
• Comprehensive.
• Overall quite brief and mostly bullet points. Could be used as a useful check list.

What we didn’t like

• Cautions to intrathecal opioids if eczema or pre-existing itch.
• No cautions around recent epideural top-ups and subsequent dose reduction when removing an epidural and siting a spinal.
• Nothing about topups in room, transfer or cautions.
• GA for Grade 4 placenta praevia.
• Testing block not clear and no mention of motor block.
• Large number of options for epidural top up.
• No advice on where to top up and if started in room advice on monitoring, cell salvage and interventional radiology.
• No mention of DAS failed intubation guidance.
• May still be an excessive dose. No information on more important positioning. If the epidural is not functioning and a spinal is required consider reducing your spinal dose by 10% if a recent epidural Top-Up (20mls) has been given.
• No mention of motor block. Assess the block height. This must be to light touch and record the level and time clearly on the chart.
• Block testing section too brief: For a caesarean section you should aim for "anaesthesia to T5", testing using light touch with a neurotip. 1 for forceps and retained placentas to T10 is needed and for perineal work sacral blocks are needed. Remember to check the lower end of your bloc, and for missed segments.
• From a check list to more of a philosophical question. "Not enough detail for a useful guideline. To top up or to spinal? That is the question”.

Related guidelines

Regional analgesia Remifentanil Postoperative analgesia Neurological monitoring