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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 3 - Procedures

Local anaesthesia for caesarean

Local anaesthesia is a safe alternative to general, ketamine or spinal anaesthesia when these anaesthetics (or persons trained in their use) are not available.

The use of local anaesthesia for caesarean section requires that the provider counsel the woman and reassure her throughout the procedure. The provider must keep in mind that the woman is awake and alert and should use instruments and handle tissue as gently as possible

TABLE P-3 Indications and precautions for local anaesthesia for caesarean section



  • Caesarean section (especially in women with heart failure)

  • Avoid use in women with eclampsia, severe pre-eclampsia or previous laparotomy

  • Avoid use in women that are obese, apprehensive or allergic to lignocaine or related drugs

  • Avoid use if the surgeon is inexperienced at caesarean section.

  • Do not inject into a vessel.

  • Review general care principles and start an IV infusion.

  • Prepare 200 mL of 0.5% lignocaine with 1:200 000 adrenaline. Usually less than half this volume (approximately 80 mL) is needed in the first hour.

  • If the fetus is alive, give pethidine 1 mg/kg body weight (but not more than 100 mg) IV slowly (or give morphine 0.1 mg/kg body weight IM) and promethazine 25 mg IV after delivery. Alternatively, pethidine and promethazine may be given before delivery, but the baby may need to be given naloxone 0.1 mg/kg body weight IV at birth.

  • If the fetus is dead, give pethidine 1 mg/kg body weight (but not more than 100 mg) IV slowly (or give morphine 0.1 mg/kg body weight IM) and promethazine 25 mg IV.  

Talk to the woman and reassure her throughout the procedure. 

  • Using a 10 cm needle, infiltrate one band of skin and subcutaneous tissue on either side of the proposed incision, two finger breadths apart (Fig P-4).

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV injection of lignocaine occurs.

Figure P-4

 Infiltration of skin and subcutaneous tissue with local anaesthesia for caesarean section 


  • Raise a long wheal of lignocaine solution 3–4 cm on either side of the midline from the symphysis pubis to a point 5 cm above the umbilicus.

  • Infiltrate the lignocaine solution down through the layers of the abdominal wall. The needle should remain almost parallel to the skin. Take care not to pierce the peritoneum and insert the needle into the uterus, as the abdominal wall is very thin at term.

  • At the conclusion of the set of injections, wait 2 minutes and then pinch the incision site with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.

Anaesthetize early to provide sufficient time for effect. 

Note: When local anaesthesia is used, perform a midline incision that is about 4 cm longer than when general anaesthesia is used. A Pfannenstiel incision should not be used as it takes longer, requires more lignocaine and retraction is poorer.

The anaesthetic effect can be expected to last about 60 minutes. 


Proceed with caesarean section keeping the following in mind:

  • Do not use abdominal packs. Use retractors as little as possible and with a minimum of force.

  • Inject 30 mL of lignocaine solution beneath the uterovesical peritoneum as far laterally as the round ligaments. No additional anaesthetic is required. The peritoneum is sensitive to pain; the myometrium is not.

  • Inform the woman that she will feel some discomfort from traction when the baby is delivered. This is usually no more than occurs during vaginal delivery.

  • Remove the placenta by controlled cord traction.

  • Repair the uterus without removing it from the abdomen.

  • Additional local anaesthesia may be necessary to repair the abdominal wall.


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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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