Standard Protocol

Spinal Anesthesia for Cesarean

Evidence-based neuraxial technique

Section 1

Standard Drug Regimen

Core spinal recipe and adjuvants

Primary Agent

Local Anesthetic

Hyperbaric bupivacaine 0.75%

Dose Range
10-15 mg
(typical 12 mg)

Adjuvants

Adjuvant 1
Fentanyl
Dose
10-25 mcg
Intraop comfort
decreases visceral nausea
Adjuvant 2
Sufentanil
Dose
2.5-5 mcg
More potent than fentanyl
increased resp depression risk
Adjuvant 3
Morphine (PF)
Dose
100-200 mcg
Analgesia
12-24 h
delayed resp depression (6-18h)
Adjuvant 4
Epinephrine
Dose
0.1-0.2 mg
Improves block quality
increases duration (~15%)
Adjuvant 5
Clonidine (alpha2)
Dose
30-150 mcg
Increases analgesia
decreases shivering. Risk: hypotension, sedation
Adjuvant 6
Dexmedetomidine (alpha2)
Dose
-
Increases pain-free period
decreases shivering. Not FDA approved
Adjuvant 7
Neostigmine
Dose
<=100 mcg
Generally avoided
severe refractory N/V
Clinical Benefit

Better block quality + lower LA dose -> Decreases hypotension

Section 2

Hemodynamic Control

Most common issue: hypotension

Most Common Issue

Hypotension

Treat with phenylephrine infusion (first-line).

P
Gold standard First-line vasopressor

Phenylephrine infusion

Start immediately post-spinal

25-50 mcg/min 50-100 mcg IV
Target SBP
>= 90% baseline
Conditional
Ephedrine

Only if hypotension + bradycardia

5-10 mg IV
Fluids
Co-load > preload

~15 mL/kg crystalloid or colloid starting at injection

~15 mL/kg Co-load
Section 3

Technique & Positioning

Needle, positioning, target level

Immediate action

Left Uterine Displacement

Immediate left uterine displacement

~15 deg
Left tilt
Needle
Pencil-point (Whitacre/Sprotte) 25G or smaller

Decreases PDPH

Pencil-point <= 25G
T4
Nipple line

Uterine + peritoneal coverage

T4