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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

Spinal (Subarachnoid) anaesthesia

TABLE P-4 Indications and precautions for spinal anaesthesia 



• Caesarean section

• Laparotomy

• Dilatation and curettage

• Manual removal of placenta

• Repair of third and fourth degree perineal tears

• Make sure there are no known allergies to lignocaine or related drugs

• Avoid use in women with uncorrected hypovolaemia, severe anaemia, coagulation disorders, haemorrhage, local infection, severe pre-eclampsia, eclampsia or heart failure due to heart disease

  • Review general care principles and start an IV infusion.

  • Infuse 500–1 000 mL of IV fluids (normal saline or Ringer’s lactate) to pre-load the woman and avoid hypotension. This should be done 30 minutes before anaesthesia.

  • Prepare 1.5 mL of the local anaesthetic: 5% lignocaine in 5% dextrose. Add 0.25 mL of adrenaline (1:1 000) if the anaesthetic needs to be effective for longer than 45 minutes.

  • Ask the woman to lie on her side (or sit up), ensuring that the lumbar spine is well flexed. Ask the woman to flex her head onto her chest and round her back as much as possible.

  • Identify and, if required, mark the proposed site of injection. A vertical line from the iliac crest upward will cross the woman’s vertebral column between the spines of the fourth and fifth lumbar vertebrae. Choose this space or the space just above it. 

Sterility is critical. Do not touch the point or shaft of the spinal needle with your hand. Hold the needle only by its hub. 

  • Inject 1% lignocaine solution using a fine needle to anaesthetize the woman’s skin.

  • Introduce the finest spinal needle available (22- or 23-gauge) in the midline through the wheal, at a right angle to the skin in the vertical plane.

Note: Fine needles tend to bend.

  • If the needle hits bone, it may not be in the midline. Withdraw the needle and reinsert it, directing it slightly upwards while aiming for the woman’s umbilicus.

  • Advance the spinal needle towards the subarachnoid space. A distinct loss of resistance will be felt as the needle pierces the ligamentum flavum.

  • Once the needle is through the ligamentum flavum, push the needle slowly through the dura. You will feel another slight loss of resistance as the dura is pierced. 

  • Remove the stylet. Cerebrospinal fluid should flow out the needle. 

  • If cerebrospinal fluid does not come out, reinsert the stylet and rotate the needle gently. Remove the stylet to see if the fluid is flowing out. If you fail two times, try another space.

  • Inject 1–1.25 mL of the local anaesthetic solution. For pregnant women who have not delivered, a smaller dose of the drug is needed since the available subarachnoid space is reduced due to engorged epidural veins.

  • Help the woman to lie on her back. Have the operating table tilted to the left or place a pillow or folded linen under her right lower back to decrease supine hypotension syndrome.

  • Recheck the woman’s blood pressure. A fall in blood pressure is likely. If there is significant hypotension, give the woman more IV fluids (500 mL quickly):

- If this does not raise her blood pressure, give ephedrine 0.2 mg/kg body weight IV in 3 mg increments;

- If blood pressure continues to fall after giving IV ephedrine boluses four times, give ephedrine 30 mg IM.

  • Give oxygen at 6–8 L per minute by mask or nasal cannulae.

  • After injecting the local anaesthetic solution, wait 2 minutes and then pinch the incision site with forceps. If the woman can feel the pinch, wait 2 minutes and then retest.

Anaesthetize early to provide sufficient time for effect. 

  • After surgery, keep the woman flat for at least 6 hours with only a single pillow beneath her head to prevent post-spinal headache. She must not sit up or strain during this period

  • After surgery, keep the woman flat for at least 6 hours with only a single pillow beneath her head to prevent post-spinal headache. She must not sit up or strain during this period

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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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