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Aberdeen Maternity Hospital Anaesthetic Guidelines, September 2009 Version 1.

2 42

Management of Blood Pressure during

Caesarean Sections under Spinal Anaesthesia
The current evidence suggests that for optimal management, maternal blood
pressure should be aggressively maintained at near baseline values1. The
definition of baseline blood pressure however varies between studies
Phenylephrine or Metaraminol are probably better than Ephedrine for the
management of hypotension in obstetrics since the risk of foetal acidosis is less24, as seen by the higher umbilical artery and vein pH and umbilical artery base
excess when compared with Ephedrine. Ephedrine also causes a dose related
increase in foetal catecholamine levels, heart rate and an abnormal increase in
variability5 when used in labour
A significantly lower incidence of nausea and vomiting under spinal anaesthesia
has been observed when using Phenylephrine when compared to Ephedrine3 and
seems to be unrelated to the systolic blood pressure
An infusion of Phenylephrine, rather than boluses, is more effective at reducing
the incidence, frequency and severity of hypotension, but does not eliminate
hypotension completely. The neonatal outcome is similar6. The benefits are
therefore only marginal
Crystalloid preloads do not reliably prevent hypotension7. Colloid preloading does
prevent hypotension, but with risks of anaphylaxis and high cost, their routine use
may not be clinically justifiable as the benefits are limited8
TED stockings help prevent hypotension7
The data currently available are mainly based on studies on ASA 1 & 2 mothers
with normal foetuses, undergoing elective LSCS under spinal anaesthesia.
Studies on emergency cases with feto-maternal compromise are not available

Recommended Management
1. Define baseline blood pressure 3 consecutive BP readings should be
taken which are within 10% of each other. The lowest systolic BP of the 3 should
be treated as the baseline BP
2. Measure BP every minute until delivery, once the spinal anaesthetic has
been performed and the patient placed supine with left lateral tilt
3. A fluid preload is not necessary but may be given based on clinical
judgement. Replacement should be done according to assessment
4. A drop in BP from baseline should be aggressively treated until delivery
using an IV infusion of Phenylephrine as per the flow diagram below.

Alternatively, IV boluses of up to 100 mcg Phenylephrine or 0.5 mg Metaraminol

can be used. Aim to maintain near baseline BP. Post delivery hypotension should
be treated with either bolused or infused Phenylephrine or Metaraminol, or with
volume replacement
5. Oxygen should be delivered by Hudson mask at 5 L/min if SpO2 < 95% or if
there is foetal distress or other significant complications
6. Bradycardia may be due to caval compression so increase the left tilt. Low
heart rates (< 50 bpm) should be treated if associated with BP lower than
baseline. Glycopyrrolate 200 400 mcg IV in the first instance may be preferable
as it does not cross the placenta. However atropine has a faster onset and there
is no evidence of harm to the foetus with the sort of doses used.
Aberdeen Maternity Hospital Anaesthetic Guidelines, September 2009 Version 1.2 43

Use of Phenylephrine Infusions

1. You must be familiar with the technique
2. Only appropriate for use for LUSCS or trial of instrumental delivery
3. Preparation of the infusion is the responsibility of the anaesthetist(s) and not to
be delegated to other staff
4. The following safety precautions are essential:
a. The strong, 100 mcg/ml, solution must be prepared in a 100 ml bag of 0.9%
Sodium Chloride and only drawn up into a 50 ml syringe. Both must be clearly
labelled with yellow infusion labels
b. All 10 ml syringes will continue to contain 20 mcg/ml of Phenylephrine drawn
up from a 500 ml stock bag kept in the theatre fridge
i. The infusion must be attached directly to the IV cannula and there must be a
non return valve on the IV fluid (gravity) side (e.g. use a protect a line infusion
c. Only the anaesthetist is to commence or alter the infusion rate

Flow Diagram for Phenylephrine Infusion up until Delivery

Less than 80% of baseline
Within 80% of baseline
After 3 minutes

SBP Baseline
SBP > Baseline
Baseline systolic BP* is lowest of 3 readings within 10%
100 mcg IV bolus Phenylephrine
Start Phenylephrine infusion (100 mcg/ml) at 60 ml/hr straight after spinal.
Measure BP every minute
*Systolic BP evidence is based on normotensive mothers. In presence of hypertension it is
probably not wise to aim for an SBP > 140 whatever the baseline readings.
#Stopping the infusion from a rate of 60 ml/hr tends to lead to a fall in BP below target.
Decreasing in steps to 50% and 25% usually produces smoother BP management (unless BP
has risen very high on initial infusion)
Stop or decrease infusion#
Measure BP every minute
Continue infusion Aberdeen Maternity Hospital Anaesthetic Guidelines, September 2009 Version 1.2

(1) 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; 92: 469-74
(2) Ngan Kee WD, Lee A. Multivariate analysis of factors associated with umbilical arterial pH
and standard base excess after caesarean section under spinal anaesthesia. Anaesthesia
2003; 58: 125-30
(3) Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS. Fetal and
maternal effects of phenylephrine and ephedrine during spinal anaesthesia for caesarean
delivery. Aesthesiology 2002; 97: 1582-90
(4) Ngan Kee,W. D.;Lau,T. K.;Khaw,K. S.;Lee,B. B. Comparison of metaraminol and
ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective
Cesarean section. Anesthesiology 2001; 95(2): 307-313
(5) Wright RG, Shnider SM, Levinson G, Rolbin SH, Parer JT. The effect of maternal
administration of ephedrine on fetal heart rate and variability. Obstetric Gynecol 1981; 57:
(6) Warwick D, Ngan Kee, Khaw KS, Ng FF, Lee BB. Prophylactic Phenylephrine infusion for
preventing hypotension during spinal anesthesia for Cesarean section. Anesth Analg 2004;
98: 815-21
(7) Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume
before spinal anesthesia for Cesarean delivery: A Qualitative Systematic Review. Anaesth
Analg 2001; 92: 997-1005
(8) Weeks S. Editorial. Reflections on hypotension during Cesarean section under spinal
anesthesia: do we need to use colloid? Can J Anesth 2000 / 47: 7 / pp 607610
Deepak Mathur, Bill Brampton, June 2006
Revised December 2008
Review date December 2011