Management of failed spinal anaesthesia for caesarean section

Failed spinal anaesthesia for caesarean section (CS) may be partial or complete and the subsequent discomfort is the most commonly cited cause of litigation in obstetric anaesthesia.

To determine if there is a standardised approach to: (i) testing the level of block of spinal anaesthesia; and (ii) the management of failed spinal anaesthesia for CS.

A structured questionnaire to ascertain the current practice of testing the level of block and management of three different scenarios of failed spinal anaesthesia was distributed to 51 government hospitals in KwaZulu-Natal, South Africa (SA). All obstetric anaes-thetic service providers, ranging from interns to specialist anaesthetists, were invited to complete the questionnaire.

A total of 375 responses were received from 42 of the 51 hospitals surveyed. Specialist anaesthetists managed failure of spinal anaesthesia significantly differently than other anaesthetic service providers. Specialists were more likely to convert to a general anaesthetic (GA), while others were more likely to repeat spinal anaesthesia or administer intravenous ketamine, midazolam and opioids. Only 212 respondents (56%) tested the level of block and there was no difference between the groups with regard to the method of assessment of height (p=0.15). Non-specialists, however, accepted a significantly lower level of block, using pinprick, than specialists (p=0.027), which could lead to a higher failure rate. More than one-third of non-specialists did not consider themselves competent to perform a GA and >90% of respondents agreed that a 'failed' spinal algorithm would be useful.

There is a need for standardised assessment of the adequacy of spinal anaesthesia for CS in SA, as well as a failed spinal algorithm.