Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:

Subscribers log in here

Anesthesia for cesarean delivery


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".)


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. 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). Laboratory testing is discussed separately. (See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Physiological changes related to pregnancy' and "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 [3]. The preference for neuraxial techniques in most cases is based on a desire to avoid general anesthesia for delivery, because of:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2014. | This topic last updated: Mar 26, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
  1. Afolabi BB, Lesi FE. Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev 2012; 10:CD004350.
  2. Djabatey EA, Barclay PM. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia 2009; 64:1168.
  3. Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology 2005; 103:645.
  4. Hawkins JL, Chang J, Palmer SK, et al. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol 2011; 117:69.
  5. Chang CC, Wang IT, Chen YH, Lin HC. Anesthetic management as a risk factor for postpartum hemorrhage after cesarean deliveries. Am J Obstet Gynecol 2011; 205:462.e1.
  6. Gajraj NM, Sharma SK, Souter AJ, et al. A survey of obstetric patients who refuse regional anaesthesia. Anaesthesia 1995; 50:740.
  7. Chan YL, Wong KL, Lin CF, et al. Views of obstetric patients who refuse regional anesthesia in cesarean section. Acta Anaesthesiol Sin 1998; 36:99.
  8. Crowgey TR, Dominguez JE, Peterson-Layne C, et al. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Anesth Analg 2013; 117:1368.
  9. Girgin NK, Gurbet A, Turker G, et al. Intrathecal morphine in anesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine. J Clin Anesth 2008; 20:180.
  10. Palmer CM, Emerson S, Volgoropolous D, Alves D. Dose-response relationship of intrathecal morphine for postcesarean analgesia. Anesthesiology 1999; 90:437.
  11. Singh SI, Rehou S, Marmai KL, Jones AP. The efficacy of 2 doses of epidural morphine for postcesarean delivery analgesia: a randomized noninferiority trial. Anesth Analg 2013; 117:677.
  12. Gregory TB. Hydromorphone: evolving to meet the challenges of today's health care environment. Clin Ther 2013; 35:2007.
  13. Cohen S, Lowenwirt I, Pantuck CB, et al. Bupivacaine 0.01% and/or epinephrine 0.5 microg/ml improve epidural fentanyl analgesia after cesarean section. Anesthesiology 1998; 89:1354.
  14. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 441: Oral intake during labor. Obstet Gynecol 2009; 114:714.
  15. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843.
  16. Paranjothy S, Griffiths JD, Broughton HK, et al. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev 2010; :CD004943.
  17. Paranjothy S, Griffiths JD, Broughton HK, et al. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev 2014; 2:CD004943.
  18. Dewan DM, Floyd HM, Thistlewood JM, et al. Sodium citrate pretreatment in elective cesarean section patients. Anesth Analg 1985; 64:34.
  19. O'Sullivan GM, Bullingham RE. The assessment of gastric acidity and antacid effect in pregnant women by a non-invasive radiotelemetry technique. Br J Obstet Gynaecol 1984; 91:973.
  20. Kjaer K, Comerford M, Kondilis L, et al. Oral sodium citrate increases nausea amongst elective Cesarean delivery patients. Can J Anaesth 2006; 53:776.
  21. Wyner J, Cohen SE. Gastric volume in early pregnancy: effect of metoclopramide. Anesthesiology 1982; 57:209.
  22. Lam AM, Grace DM, Manninen PH, Diamond C. The effects of cimetidine and ranitidine with and without metoclopramide on gastric volume and pH in morbidly obese patients. Can Anaesth Soc J 1986; 33:773.
  23. Dimich I, Katende R, Singh PP, et al. The effects of intravenous cimetidine and metoclopramide on gastric pH and volume in outpatients. J Clin Anesth 1991; 3:40.
  24. Manchikanti L, Colliver JA, Marrero TC, Roush JR. Ranitidine and metoclopramide for prophylaxis of aspiration pneumonitis in elective surgery. Anesth Analg 1984; 63:903.
  25. Olsson GL, Hallen B, Hambraeus-Jonzon K. Aspiration during anaesthesia: a computer-aided study of 185,358 anaesthetics. Acta Anaesthesiol Scand 1986; 30:84.
  26. McDonnell NJ, Paech MJ, Clavisi OM, et al. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth 2008; 17:292.
  27. Van de Velde M. Emergency Caesarean delivery: is supplementary maternal oxygen necessary? Br J Anaesth 2009; 102:1.
  28. Russell IF. Technique of anaesthesia for caesarean section (Chapter 8.8). In: Raising the Standards: A Compendium of Audit Recipies. The Royal college of Anaesthetists website. Available at: (Accessed on January 10, 2014).
  29. Bauer ME, Kountanis JA, Tsen LC, et al. Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials. Int J Obstet Anesth 2012; 21:294.
  30. Tao W, Nguyen AP, Ogunnaike BO, Craig MG. Use of a 23-gauge continuous spinal catheter for labor analgesia: a case series. Int J Obstet Anesth 2011; 20:351.
  31. Palmer CM, Voulgaropoulos D, Alves D. Subarachnoid fentanyl augments lidocaine spinal anesthesia for cesarean delivery. Reg Anesth 1995; 20:389.
  32. Lam DT, Ngan Kee WD, Khaw KS. Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation. Anaesthesia 2001; 56:790.
  33. Hillyard SG, Bate TE, Corcoran TB, et al. Extending epidural analgesia for emergency Caesarean section: a meta-analysis. Br J Anaesth 2011; 107:668.
  34. Cardoso MM, Leite AO, Santos EA, et al. Effect of dexamethasone on prevention of postoperative nausea, vomiting and pain after caesarean section: a randomised, placebo-controlled, double-blind trial. Eur J Anaesthesiol 2013; 30:102.
  35. Griffiths JD, Gyte GM, Paranjothy S, et al. Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. Cochrane Database Syst Rev 2012; 9:CD007579.
  36. Allen TK, Jones CA, Habib AS. Dexamethasone for the prophylaxis of postoperative nausea and vomiting associated with neuraxial morphine administration: a systematic review and meta-analysis. Anesth Analg 2012; 114:813.
  37. Kumar K, Singh SI. Neuraxial opioid-induced pruritus: An update. J Anaesthesiol Clin Pharmacol 2013; 29:303.
  38. Wu Z, Kong M, Wang N, et al. Intravenous butorphanol administration reduces intrathecal morphine-induced pruritus after cesarean delivery: a randomized, double-blind, placebo-controlled study. J Anesth 2012; 26:752.
  39. Priebe HJ. Cricoid pressure: an expert's opinion. Minerva Anestesiol 2009; 75:710.
  40. Lerman J. On cricoid pressure: "may the force be with you". Anesth Analg 2009; 109:1363.
  41. Gin T, Chan MT. Decreased minimum alveolar concentration of isoflurane in pregnant humans. Anesthesiology 1994; 81:829.
  42. Zhou HH, Norman P, DeLima LG, et al. The minimum alveolar concentration of isoflurane in patients undergoing bilateral tubal ligation in the postpartum period. Anesthesiology 1995; 82:1364.
  43. Chan MT, Gin T. Postpartum changes in the minimum alveolar concentration of isoflurane. Anesthesiology 1995; 82:1360.
  44. Robins K, Lyons G. Intraoperative awareness during general anesthesia for cesarean delivery. Anesth Analg 2009; 109:886.
  45. Sanders RD, Avidan MS. Evidence is lacking for interventions proposed to prevent unintended awareness during general anesthesia for cesarean delivery. Anesth Analg 2010; 110:972.
  46. Gin T, Yau G, Chan K, et al. Disposition of propofol infusions for caesarean section. Can J Anaesth 1991; 38:31.
  47. Abboud TK, Zhu J, Richardson M, et al. Intravenous propofol vs thiamylal-isoflurane for caesarean section, comparative maternal and neonatal effects. Acta Anaesthesiol Scand 1995; 39:205.
  48. Yau G, Gin T, Ewart MC, et al. Propofol for induction and maintenance of anaesthesia at caesarean section. A comparison with thiopentone/enflurane. Anaesthesia 1991; 46:20.
  49. Van de Velde M, Teunkens A, Kuypers M, et al. General anaesthesia with target controlled infusion of propofol for planned caesarean section: maternal and neonatal effects of a remifentanil-based technique. Int J Obstet Anesth 2004; 13:153.
  50. Yoo KY, Lee JC, Yoon MH, et al. The effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: a comparison among sevoflurane, desflurane, isoflurane, and halothane. Anesth Analg 2006; 103:443.
  51. Munson ES, Embro WJ. Enflurane, isoflurane, and halothane and isolated human uterine muscle. Anesthesiology 1977; 46:11.
  52. Turner RJ, Lambros M, Kenway L, Gatt SP. The in-vitro effects of sevoflurane and desflurane on the contractility of pregnant human uterine muscle. Int J Obstet Anesth 2002; 11:246.
  53. Dogru K, Yildiz K, Dalgiç H, et al. Inhibitory effects of desflurane and sevoflurane on contractions of isolated gravid rat myometrium under oxytocin stimulation. Acta Anaesthesiol Scand 2003; 47:472.
  54. Ngan Kee WD, Khaw KS, Ma KC, et al. Randomized, double-blind comparison of different inspired oxygen fractions during general anaesthesia for Caesarean section. Br J Anaesth 2002; 89:556.
  55. Crawford JS. Awareness during operative obstetrics under general anaesthesia. Br J Anaesth 1971; 43:179.
  56. Paech MJ, Scott KL, Clavisi O, et al. A prospective study of awareness and recall associated with general anaesthesia for caesarean section. Int J Obstet Anesth 2008; 17:298.
  57. Errando CL, Sigl JC, Robles M, et al. Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. Br J Anaesth 2008; 101:178.
  58. Heesen M, Kölhr S, Rossaint R, Straube S. Prophylactic phenylephrine for caesarean section under spinal anaesthesia: systematic review and meta-analysis. Anaesthesia 2014; 69:143.
  59. Banerjee A, Stocche RM, Angle P, Halpern SH. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anaesth 2010; 57:24.
  60. Loubert C. Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development. Can J Anaesth 2012; 59:604.
  61. McDonald S, Fernando R, Ashpole K, Columb M. Maternal cardiac output changes after crystalloid or colloid coload following spinal anesthesia for elective cesarean delivery: a randomized controlled trial. Anesth Analg 2011; 113:803.
  62. Myburgh JA, Finfer S, Billot L, CHEST Investigators. Hydroxyethyl starch or saline in intensive care. N Engl J Med 2013; 368:775.
  63. Phillips DP, Kaynar AM, Kellum JA, Gomez H. Crystalloids vs. colloids: KO at the twelfth round? Crit Care 2013; 17:319.
  64. Skhirtladze K, Base EM, Lassnigg A, et al. Comparison of the effects of albumin 5%, hydroxyethyl starch 130/0.4 6%, and Ringer's lactate on blood loss and coagulation after cardiac surgery. Br J Anaesth 2014; 112:255.
  65. Grylack LJ, Chu SS, Scanlon JW. Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis. Obstet Gynecol 1984; 63:654.
  66. Kenepp NB, Kumar S, Shelley WC, et al. Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet 1982; 1:1150.
  67. Smiley RM. Burden of proof. Anesthesiology 2009; 111:470.
  68. Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg 2002; 94:920.
  69. Ngan Kee WD, Khaw KS, Lau TK, et al. Randomised double-blinded comparison of phenylephrine vs ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective Caesarean section*. Anaesthesia 2008; 63:1319.
  70. Ngan Kee WD, Khaw KS, Tan PE, et al. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2009; 111:506.
  71. Habib AS. A review of the impact of phenylephrine administration on maternal hemodynamics and maternal and neonatal outcomes in women undergoing cesarean delivery under spinal anesthesia. Anesth Analg 2012; 114:377.
  72. Allen TK, George RB, White WD, et al. A double-blind, placebo-controlled trial of four fixed rate infusion regimens of phenylephrine for hemodynamic support during spinal anesthesia for cesarean delivery. Anesth Analg 2010; 111:1221.
  73. Siddik-Sayyid SM, Taha SK, Kanazi GE, Aouad MT. A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery. Anesth Analg 2014; 118:611.
  74. Veeser M, Hofmann T, Roth R, et al. Vasopressors for the management of hypotension after spinal anesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesthesiol Scand 2012; 56:810.
  75. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth 2013; 22:194.
  76. Lee AI, Wong CA, Healy L, Toledo P. Impact of a third stage of labor oxytocin protocol on cesarean delivery outcomes. Int J Obstet Anesth 2014; 23:18.
  77. George RB, McKeen D, Chaplin AC, McLeod L. Up-down determination of the ED(90) of oxytocin infusions for the prevention of postpartum uterine atony in parturients undergoing Cesarean delivery. Can J Anaesth 2010; 57:578.
  78. Jonsson M, Hanson U, Lidell C, Nordén-Lindeberg S. ST depression at caesarean section and the relation to oxytocin dose. A randomised controlled trial. BJOG 2010; 117:76.
  79. Svanström MC, Biber B, Hanes M, et al. Signs of myocardial ischaemia after injection of oxytocin: a randomized double-blind comparison of oxytocin and methylergometrine during Caesarean section. Br J Anaesth 2008; 100:683.
  80. Lewis G. Why Mothers Die 1997-1999: Confidential Enquiries into Maternal Deaths in the UK, Drife JO (Ed), RCOG Press, London 2001.
  81. Butwick AJ, Coleman L, Cohen SE, et al. Minimum effective bolus dose of oxytocin during elective Caesarean delivery. Br J Anaesth 2010; 104:338.
  82. Stephens LC, Bruessel T. Systematic review of oxytocin dosing at caesarean section. Anaesth Intensive Care 2012; 40:247.
  83. Dyer RA, Piercy JL, Reed AR, et al. Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia. Anesthesiology 2008; 108:802.
  84. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ 2011; 343:d4661.
  85. Güngördük K, Asicioglu O, Celikkol O, et al. Use of additional oxytocin to reduce blood loss at elective caesarean section: A randomised control trial. Aust N Z J Obstet Gynaecol 2010; 50:36.
  86. King KJ, Douglas MJ, Unger W, et al. Five unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg 2010; 111:1460.
  87. Conde-Agudelo A, Nieto A, Rosas-Bermudez A, Romero R. Misoprostol to reduce intraoperative and postoperative hemorrhage during cesarean delivery: a systematic review and metaanalysis. Am J Obstet Gynecol 2013; 209:40.e1.
  88. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for perinatal care, 7th ed, 2012.
  89. ACOG Committee on Obstetric Practice. ACOG committee opinion No. 433: optimal goals for anesthesia care in obstetrics. Obstet Gynecol 2009; 113:1197.