Best Practice & Research Clinical Anaesthesiology 37 (2023) 101e108

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Best Practice & Research Clinical

Anaesthesiology
journal homepage: www.elsevier.com/locate/bean

Spinal anaesthesia in obstetrics

Vincent Pirenne, Trainee in Anesthesia,
Geertrui Dewinter, Professor in Anesthesia,
Marc Van de Velde, Professor in Anesthesia *
Department of Cardiovascular Sciences, KULeuven, Department of Anaesthesiology, UZ Leuven, Herestraat
49, 3000, Leuven, Belgium

Keywords:
This article provides a comprehensive review of the technique,
single-shot spinal anaesthesia
drugs of choice, and potential side effects and complications
caesarean section
technique associated with the drugs used and the single-shot spinal anaes-
drugs thesia (SSS) technique for caesarean delivery. Although neuraxial
complications analgesia and anaesthesia are generally considered safe, all in-
terventions come with potential adverse effects. As such, the
practice of obstetric anaesthesia has evolved to minimize such
risks. This review highlights the safety and efficacy of SSS for
caesarean delivery while also discussing potential complications
such as hypotension, postdural puncture headache, and nerve
injury. In addition, drug selection and dosages are examined as
well, emphasizing the importance of individualized treatment
plans and close monitoring for optimal outcomes.
© 2023 Elsevier Ltd. All rights reserved.

Introduction

Globally, more than 300 million surgical interventions are performed annually. The most performed
type of surgical intervention worldwide is a caesarean section (CS). In some countries, up to 50% of
deliveries are performed through CS. Single-shot spinal (SSS) anaesthesia is a simple, cheap, and
reliable technique used by many anaesthetists as their first option to provide effective anaesthesia
during operative delivery of the neonate, especially during planned CS. In the present state-of-the-art
review, we will discuss the technique and side effects of SSS during obstetric anaesthesia.

* Corresponding author.
E-mail address: marc.vandevelde@uzleuven.be (M. Van de Velde).

https://doi.org/10.1016/j.bpa.2023.03.006
1521-6896/© 2023 Elsevier Ltd. All rights reserved.

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 V. Pirenne, G. Dewinter and M. Van de Velde Best Practice & Research Clinical Anaesthesiology 37 (2023) 101e108

Indications

SSS is an easy-to-use, reliable, and inexpensive anaesthetic technique frequently used for CS.
Because of the single-shot aspect, it can only be used for surgical interventions having a duration of less
than 90e120 min. As routine CS is usually completed within 60 min, SSS is ideally suited. However, half
of the CS are unplanned secondary sections usually having a labour epidural catheter in place that can
be used to provide anaesthesia. However, in some urgent CS (grade 1 or 2) a rapid onset is required and
either an SSS or a general anaesthetic can be used.

Technique

Before starting spinal anaesthesia, it is recommended to use the standard American Society of
Anesthesiologists' monitors, including blood pressure, electrocardiography, and oxygen saturation.
Additionally, strict aseptic technique should be applied throughout the procedure [1]. Optimal patient
positioning is crucial for successful neuraxial procedures as it helps in preventing spinal rotation and
creates a straight path for needle insertion between the vertebrae. Flexion of the spine is especially
important for midline approaches as it opens up the space between the spinous processes. To achieve
the proper sitting position for spinal anaesthesia, the patient's legs should be hanging off the side of the
bed, with their feet resting on a non-mobile stool. The backs of the knees should be placed against the
edge of the bed so that the patient is as close as possible to the clinician on the opposite side. The
patient is then instructed to ‘slouch’ symmetrically, aligning their shoulders with their hips, to enable
flexion of the lumbar spine. It is crucial to ensure that the patient does not lean forward as this would
exacerbate the lumbar lordosis [2]. The use of a small-diameter needle with an introducer is recom-
mended to minimize the risk of postdural puncture headache (PDPH). The preferred size is typically
24e27 gauge as larger diameter needles and cutting needle tips are associated with a higher incidence
of PDPH compared to smaller diameter and pencil-point needles [3,4]. To avoid the risk of puncturing
the spinal cord, spinal anaesthesia is typically performed at the mid-to low-lumbar vertebral level,
never above the L2eL3 interspace [5,6]. Clinicians often use the intercristal line as a rough guide for
spinal needle placement, which crosses the body of L4 in many patients. However, this line may vary
and be higher in females and patients with obesity. Therefore, to ensure safe needle placement below
the conus of the spinal cord, the spinal needle should be inserted at or below the intercristal line as
relying solely on landmarks may not accurately predict the lumbar interspace [7,8].

Drugs

Hyper-versus isobaric drugs

SSS for elective CS can be performed using either isobaric or hyperbaric bupivacaine. However, there
is no clear evidence to suggest which one is better. Results showed no significant differences between
the two in terms of the risk of conversion to general anaesthesia or the need for supplemental anal-
gesia, although the quality of evidence was very low. Hyperbaric bupivacaine was found to be quicker
in reaching a sensory block height of T4, with a mean difference of
1.06 min (95% CI:
1.80 to
0.31).
Although hyperbaric bupivacaine has more predictable spread compared with glucose-free bupiva-
caine, it is associated with an increased risk of hypotension due to its higher spread [9e11].

Choice of local anaesthetic drug

 Bupivacaine is classified as a long-acting amide local anaesthetic, with doses ranging from 6 to
15 mg (e.g. 12 mg for caesarean delivery). The duration of surgical anaesthesia ranges from 1.5 to
2.5 h. In recent years [12,13], levobupivacaine, the pure S(2) enantiomer of racemic bupivacaine, has
been used for spinal and epidural anaesthesia in obstetrics. A recent study that aimed to determine
the optimal dosage revealed that the effective dose for 50% (ED50) and 95% (ED95) of patients was
6.2 mg (95% CI: 2.6e7.6) and 12.9 mg (11.1e17.9), respectively [14e16]. Levobupivacaine was found
to produce a significantly shorter and less pronounced motor blockade than racemic bupivacaine,
regardless of the kind and dose of opioid that was added. In particular, the duration of motor block

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Bromage 3 was 53 ± 14 min, 23 ± 18 min, and 41 ± 8 min with levobupivacaine compared with
65 ± 25 min, 70 ± 19 min, and 65 ± 22 min with bupivacaine. This difference in motor block duration
was statistically significant [16].
 Ropivacaine is a pure L-enantiomer amide local anaesthetic that is frequently used for spinal
anaesthesia outside the United States. It is roughly 40% less potent than bupivacaine [17] and may
achieve a lower motor to sensory block ratio compared with bupivacaine, resulting in a less dense
motor block relative to the density of the sensory block. While the onset time of sensory and motor
blockage is longer for ropivacaine [ED50 16.7 mg (14.1 ± 18.8 mg) and the ED90 as 26.8 mg for CS
anaesthesia], it produces a parallel and effective clinical profile to bupivacaine [ ED50 and ED95
5.67 mg (95% confidence interval [CI]: 5.20e6.10 mg) and 8.82 mg (95% CI: 8.14e9.87 mg),
respectively] with a shorter duration of sensory and motor block [18e20]. There were no significant
differences in terms of blood pressure. Ropivacaine can be an alternative to bupivacaine for CS, with
no observed added risks during spinal block placement [12,17,18].
 Prilocaine is an amide local anaesthetic with a rapid onset and intermediate duration of action. The
recommended dose is between 30 and 60 mg, and the duration of surgical anaesthesia is around
60 min [21]. The duration of motor block following spinal anaesthesia was compared between
prilocaine and bupivacaine in a prospective randomized double-blind study. Patients were
randomly assigned to two groups: the prilocaine group received 60 mg of intrathecal prilocaine for
spinal anaesthesia while the bupivacaine group received 12.5 mg of intrathecal heavy bupivacaine.
Both groups received 2.5 mg sufentanil and 100 mg morphine. There were no differences between
the groups in terms of maternal intraoperative hypotension, Apgar score, umbilical cord blood pH,
maternal postoperative pain, or patient/obstetrician satisfaction. The study concluded that hyper-
baric prilocaine produces a shorter and more consistent motor block than hyperbaric bupivacaine
for women with uncomplicated pregnancies undergoing elective CS [22].
 2-Chloroprocaine is a short-acting ester local anaesthetic typically used for brief gynaecological,
urological, orthopaedic, and general surgical procedures. Initially, there were concerns about
neurotoxicity that were linked to the presence of the preservative sodium bisulphite. The recom-
mended dose ranges from 20 to 60 mg. The duration of surgical anaesthesia generally lasts between
30 and 50 min [23e27]. The onset of action for 2-chloroprocaine is fast, resulting in a high-quality
sensory and motor block. It undergoes rapid hydrolysis in the bloodstream due to pseudocholin-
esterase. During CS, bupivacaine and 2-chloroprocaine were compared for spinal anaesthesia. At the
5-min mark post-spinal injection, the sensory block level was higher for both groups with 2-
chloroprocaine compared with the bupivacaine group. The predictability of motor recovery is
greater for 2-chloroprocaine and may have advantages for initiating breastfeeding [27].

Lipophilic opioid adjuvants

Opioids added to intrathecal local anaesthetic solution have been shown to prolong effective
analgesia in several studies, regardless of the type of opioid used. Fentanyl and sufentanil are the most
commonly used intrathecal lipophilic opioids worldwide [28,29]. In pregnant women undergoing
elective CS, a recent prospective, randomized, double-blind study compared fentanyl 25 mg with
sufentanil 2.5 and 5.0 mg added to hyperbaric bupivacaine. The duration of analgesia was significantly
longer with sufentanil 2.5 mg (214 min [189e251]) and 5 mg (236 min [190e372]) compared with
fentanyl 25 mg (187 min [151e230]) (P < 0.01). Morphine consumption at T1 þ 4 h was lower in the
sufentanil groups [30].

Other adjuvants

 Clonidine: Several trials were conducted to examine the effects of neuraxial administration of ɑ2-
agonists, such as clonidine and dexmedetomidine. A meta-analysis indicated that neuraxial cloni-
dine resulted in a longer duration and better quality of analgesia, and reduced morphine con-
sumption. However, this approach was also associated with more side effects, including
hypotension and intraoperative sedation. No improvements in analgesia were observed with the
intrathecal or intravenous administration of clonidine, whether administered alone or in combi-
nation with intrathecal morphine [5,31].

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 V. Pirenne, G. Dewinter and M. Van de Velde Best Practice & Research Clinical Anaesthesiology 37 (2023) 101e108

 The addition of epidural dexmedetomidine to combined spinaleepidural (CSE) anaesthesia led to

better intraoperative and postoperative analgesia and reduced the need for opioid rescue [52].
However, when intrathecal dexmedetomidine was compared with intrathecal morphine, there
were no significant differences in the duration of analgesia, pain scores, or the need for rescue
analgesia [5,32e34].
 Neostigmine: Neostigmine, when administered neuraxially, can significantly decrease the con-
sumption of local anaesthetics without causing any serious adverse effects to the mother or the
foetus. Nevertheless, its use is limited to epidural administration as intrathecal use has been
associated with a higher incidence of maternal nausea and vomiting [35,36].

Hydrophilic opioids
Patients who received morphine had a significantly longer time before requesting the first analgesic
compared with those who received sufentanil (19.5 ± 4.7 h vs. 6.3 ± 5.2 h, P < 0.05). Additionally,
morphine prolonged postoperative analgesia without causing adverse effects in mothers or newborns
compared with sufentanil [5,37,38].
For spinal anaesthesia, intrathecal administration of morphine at a dose of 50e100 mg or dia-
morphine at a dose of 300 mg is recommended. Alternatively, epidural administration of morphine at a
dose of 2e3 mg or diamorphine at a dose of 2e3 mg can be used, particularly in a CSE technique
involving an epidural catheter [5].
Diamorphine's higher lipid solubility leads to a faster onset of action compared with morphine.
While intrathecal morphine may take up to 60e90 min to reach its peak effect, providing limited
intraoperative analgesia, morphine's hydrophilic nature (octanolewater coefficient of 1.4) suggests a
longer duration of action and prolonged postoperative analgesia. However, the duration of action of
intrathecal diamorphine is influenced by more than just the concentration of cerebrospinal fluid (CSF),
despite its shorter half-life of 6e8 min compared with intrathecal morphine's 14e360 min [39]. As a
pro-drug, diamorphine lacks intrinsic opioid activity, but its high lipid solubility allows it to quickly
diffuse into neural tissue where esterases release the active compounds 6-acetylmorphine and
morphine. These agents are much less lipid soluble and thus remain in high concentrations within the
substance of the cord, which contains mu opioid receptors, and only slowly diffuse from the peri-
receptor aqueous phase back into the CSF [40].

Side effects

Neurological injury
Neurological complications associated with neuraxial anaesthesia are exceedingly rare [7] and
can result from needle or catheter trauma, drug toxicity, spinal epidural haematoma (SEH), or
infection, leading to injury to the spinal cord, nerve roots, or neuraxial vasculature [8]. Needles or
catheters can cause direct trauma to the spinal cord, conus medullaris, and spinal nerve roots. In the
majority of adults, the spinal cord ends at the L1 vertebral body, but in a minority of patients, it
terminates below L2 [6]. Neuraxial injuries associated with obstetric patients were largely caused by
meningitis and abscess, accounting for 46% of such injuries. In comparison to general surgical pa-
tients, obstetric patients appear to have a lower incidence of meningitis and epiduralespinal abscess.
Spinal techniques involving a single shot appear to pose a lower risk than the techniques involving
residual catheters [41].
Staphylococcus aureus is the most common organism responsible for epidural abscess [42]. The
infection source may be direct contamination from the skin or other sources, or through hematogenous
spread.
Spinal epidural haematoma is another rare but serious complication that can occur during spinal
and epidural procedures, resulting from bleeding into the neuraxis due to needle or catheter puncture
of a blood vessel. While it can occur spontaneously in any patient, it is more likely to occur in those
with coagulation disorders or taking anticoagulants. The incidence of spinal epidural haematoma is
reported to be lower in obstetric patients compared with the other populations. Retrospective studies
have reported an incidence rate ranging from 0 to 0.6 per 100,000 epidural catheterizations in obstetric
patients [43e45].

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The risk of SEH is lower with a single-shot spinal technique because the spinal needle used is
relatively small and there is no indwelling catheter [46]. However, SEH can still occur, and its diagnosis
can be difficult due to its concealed nature, requiring a high level of suspicion. Progressive motor and
sensory block, as well as bowel or bladder dysfunction, is the most common symptom of neurologically
significant SEH while back pain is only reported in 25 percent of cases [46]. To reduce the risk of SEH,
low-dose neuraxial techniques for labour analgesia can be used to produce minimal motor block and
enable continuous monitoring of lower extremity function in patients who are at risk for developing
neuraxial haematoma.

PDPH
PDPH is a type of positional headache that occurs due to the leakage of CSF through a dural puncture
after spinal anaesthesia or unintentionally with an epidural needle [47]. The mechanism of headache is
not entirely understood, but it is thought to involve cerebral vasodilation and/or traction on intra-
cranial structures. Pregnant women with a low body mass index are at the highest risk of PDPH. Ac-
cording to a meta-analysis of over 300,000 obstetric patients, the risk of PDPH after unintentional dural
puncture with an epidural needle is approximately 52%, with a risk of 1.5% for dural puncture with a
spinal needle. The size and type of spinal needle used can significantly affect the risk of PDPH. Most
PDPHs will resolve in 7e10 days without treatment. Symptomatic therapy, such as oral analgesics or
caffeine [47e49], may be used to manage the symptoms. Epidural blood patch (EBP) is recommended
for severe, debilitating PDPH, and has been reported to provide complete or partial relief in 95% of
obstetric patients with PDPH [50]. However, PDPH may recur after EBP. A non-invasive treatment
approach using a sphenopalatine ganglion block has also been described, but its efficacy is limited
based on case series and a small randomized trial [51].

Spinal-induced hypotension
Depending on the definition used, up to 75% of cases involving spinal block experience hypotension
as the most frequent side effect [52e54]. The vasodilation resulting from spinal block-induced sym-
patholysis can lead to maternal hypotension, potentially compromising uterine blood flow and foetal
circulation, ultimately causing foetal hypoxia, bradycardia, and acidosis. Clinical practice employs
various measures for the prevention and treatment of spinal block-induced hypotension, including
preloading and co-loading with crystalloid and/or colloid infusion [52,53], wrapping lower limbs with
compression stockings or bandages, optimizing the dose of local anaesthetic [55] and achieving an
optimal spinal block level and left tilt positioning. These interventions took root in the idea that hy-
potension was mainly caused by aorto-caval compression by the uteroeplacental complex. Thus hy-
potension was believed to be caused by reduced cardiac preloading resulting in reduced cardiac output
and interventions that were aimed at remediating this loss of preload. More recently insights, however,
show that as the spinal block takes effect, systemic vascular resistance drops, resulting in hypotension
with an increased cardiac output. More recent literature and interventions, therefore, focus on
restoring blood pressure by means of treating the dilation of the vascular bed using vasopressors. The
latest algorithms recommend prophylactic administration of vasopressor infusion instead of waiting
for a drop in blood pressure to occur. Even though phenylephrine was feared to have deleterious effects
on foetal blood flow due to placental vasoconstriction in animal studies, these animal models did not
translate into clinical results in human trials. Indeed, phenylephrine is now the preferred vasocon-
strictor due to its lower incidence of foetal acidosis and maternal nausea and vomiting compared with
other vasoconstrictors, mainly ephedrine, the previous drug of choice for its beta effect and its
perceived benefits for maintenance of placental blood flow and cardiac output. Noradrenaline has
shown promising results and may be a good alternative to currently used vasopressors, maintaining
blood pressures above 80% of baseline with better maintenance of cardiac output and less reflex
bradycardia [56,57].
To achieve optimal blood pressure management during spinal anaesthesia for CS, a combination of
co-loading with 1000e2000 mL of crystalloids and a continuous infusion of phenylephrine at a rate of
25e50 mg/min should be administered immediately after intrathecal anaesthetic injection [52,54,58].
Phenylephrine infusion should be titrated based on blood pressure (measured at least every 2 min) and
pulse, with additional boluses given as necessary. The objective is to maintain systolic arterial pressure

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 V. Pirenne, G. Dewinter and M. Van de Velde Best Practice & Research Clinical Anaesthesiology 37 (2023) 101e108

90% of the baseline measured before spinal anaesthesia and prevent a decrease to <80% of the
measured baseline. Over the past few years, many studies have been published on the use of ondan-
setron to prevent hypotension and bradycardia during spinal anaesthesia. The mechanism of action of
ondansetron is thought to be related to its ability to block serotonin receptors (5-HT3), which in-
terrupts the cardioinhibitory BezoldeJarisch reflex. However, due to the variations in samples, local
anaesthetic mixtures, results, and dosages used in these studies, it is still premature to recommend
routine use of ondansetron in obstetric spinal anaesthesia for CS.

Conclusions

Spinal anaesthesia offers several benefits, including a straightforward technique and rapid onset,
which make it suitable for urgent CS. Its use can also reduce the need for general anaesthesia in such
cases. By adding opioids to spinal anaesthesia, the local anaesthetic dose can be lowered while still
providing superior analgesia and shorter duration of motor blockade. However, if low-dose spinal
anaesthesia is not used as part of a CSE technique, there is a risk of inadequate spinal block and sub-
sequent maternal general anaesthesia. Hypotension can be prevented through the use of crystalloid/
colloid loading, left lateral tilt positioning, and pre-emptive administration of vasoactive drugs. Current
evidence seems to favour phenylephrine over ephedrine, with norepinephrine showing similar results
in the maintenance of blood pressure while maintaining cardiac output and heart rate.

Practice points

- Prevent hypotension (drop below 90% of baseline blood pressure) be co-loading and main-
taining left lateral tilt positioning as well as the prophylactic infusion of vasoactive drugs, such
as phenylephrine or norepinephrine.
- Adding intrathecal opioids reduces the overall dosage requirement of local anaesthetic.
- While low-dose spinal anaesthesia is beneficial with regard to preventing spinal hypotension,
one should be aware of the fact that there is no way of topping up in the setting of a single-
shot technique, like one has with an epidural or CSE technique. So if low-dose spinal is used,
it should be part of a combined spinal epidural technique.

Research agenda

- Evaluate new adjuvants such as dexmedetomidine.

- Study further the place of prilocaine and 3-chloroprocaine for CS.

Declaration of competing interest

MVDV has received support for lectures and research from Nordic Pharma.

Acknowledgement

None declared.

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