This document discusses troubleshooting regional anesthesia techniques in obstetrics. It begins by defining troubleshooting and noting the increasing rate of cesarean deliveries in India. It then discusses the advantages of regional anesthesia in obstetrics compared to general anesthesia. The rest of the document outlines various patient, technical, and anesthesiologist-related factors that can cause difficulties with regional blocks, as well as strategies for addressing problems that may arise before or after block establishment such as failed or inadequate blocks. It focuses on techniques for spinal and epidural anesthesia.

1. TROUBLESHOOTING IN OBSTETRIC
REGIONAL: CRITICAL ANALYTICS &
ENHANCEMENT OF SUCCESSFUL
BLOCK
DR GEETA KARKI
ASSOCIATE PROFESSOR
DEPTT OF ANAESTHESIOLOGY
SRMS IMS BAREILLY

2. TROUBLESHOOTING
• It is a logical, systematic analysis of a problem
so that it can be solved.

3. INTRODUCTION
• The rate of caesarean delivery in India has
increased from 8.5% to 31-50.2% ( National
FamilyHealth Survey 2015-16)
• Use of spinal anaesthesia for surgical
procedures dates back to 1885.
• It wasn’t until 1940s, when Adriani and
associates established safe, standardised
techniques, became popular in obstetrics

4. ADVANTAGES OF REGIONAL
ANAESTHESIA IN OBSTETRICS
• Regional anaesthesia in obstetrics has several
advantages such as
• reduced risk of aspiration,
• avoid use of depressant anaesthetic drugs,
mother being awake at the time of birth,
• reduced operative blood loss and
• if aortocaval compression or hypotension is
avoided duration of antepartum anaesthesia
does not affect neonatal outcome.

5. • Regional anaesthesia is undoubtedly the most
popular technique of anaesthesia for
caesarean section.
• Regional anaesthesia in obstetrics differs from
regional anaesthesia in non-obstetrics in
several ways because of the anatomical,
physiological and pharmacological changes
associated with pregnancy.

6. DIFFICULTIES IN REGIONAL
ANAESTHESIA IN OBSTETRICS
• Anaesthetist related factors,
• Patient related factors,
• Technical factors
• Before establishment of block
• After establishment of block.

7. ANAESTHESIOLOGIST EXPERIENCE
• An important factor in determining the ease
of performance and success of block.
• A senior or more experienced
anaesthesiologist should always be available
to take over difficult procedure at an early
stage.

8. ANAESTHESIOLOGIST EXPERIENCE
• More experience greater chances of success
• ˂ 6 mths high failure, ˃ 5 yrs greater success rate
(DeOliveira Filhoetal.Predictorsofsuccessfulneuraxial block.Eur j
Anaesth.2002;19(6):447-51.)
• Approximately 20-25 procedures necessary
before improvement from baseline and for a
success rate of 90% 45 spinal & 60 epidural
attempts (Kopacz DJetal.Theregionalanesthesialearning
curve.Whatis theminimumnumberofepidural&spinal blocks to
reach consistency? RegAnesth.1996.)

9. PATIENT RELATED FACTORS
• Age - Neuraxial block is easier to perform in
younger patients due to less incidence of
spine deformities and better compliance
during procedure.
• Weight and BMI – Higher weight and BMI is
associated with poorly palpable spinous
processes and interspinous space.

10. PATIENT RELATED FACTORS
• Quality of anatomical landmarks
• Age
• Weight gain/ Obesity
• Pelvic rotation
• Increase in lumbar lordosis ,
• Tissue edema
• Spine deformities(kyphosis ,scoliosis) or
• Structural anomalies(degenerative disc disease,
ankylosing spondylitis, previous spine surgery)

11. PATIENT RELATED FACTORS
First puncture success associated with younger
age, lower weight and BMI.(Ruzman T et al. Factors
associated with difficultneuraxialblockade. Local and
RegionalAnesthesia 2014;7:47-52)
The quality of landmarks and abnormal spinal
anatomy correlated with technical difficulty as
measured by first attempt success and no. Of
attempts.
Sprung J et al. Predicting thedifficultneuraxialblock. Anesth
Analg.1999.

12. DIFFICULT NEURAXIAL BLOCK SCORE
• Patient asked to sit down, bend the head, neck
and shoulders towards chest as much as possible
in attempt to protrude the spinous processes.
• Grade 1 – spinous processes visible, Grade 2 –
spinous processes not seen but easily palpable,
Grade 3 – spinous processes not seen, not
palpable but interval between them palpated as
low land mark under thumb, Grade 4 – none
Karraz,Mazen A.Primaryscore predicting thedifficultyof
neuraxialblock.Anesth&Analg2002.94(2):476

13. ROLE OF ULTRASOUND
• USG can be used for preoperative assessment of spine
anatomy ( Creany M et al.US to identify lumbar space in women with
impalpable bony landmarks presenting for elective CS.Int J Obstet
Anesth.2016. RCT)
• USG guided neuraxial block may be performed-
increased efficacy & safety ( USG for neuraxial analgesia &
anesthesia in obstetrics. Schnabel et al. Uitraschall Med.2012. review)
• If none possible general anaesthesia is the alternative
Lie J,PatelS.USG for obstetric neuraxial anesthetic procedures. J Obs
Anesth Crit Care 2015;5:49-53.

14. UNCOOPERATIVE PATIENT
• Patient may be in labour pain,
• Apprehensive ,
• Uninformed and unwilling
• Thorough explanation of the procedure to patient
and premedication can result in better patient
compliance. (RayleneDias etal. Roleofpreopmultimedia
videoin allayinganxietyrelatedto spinal.RCT. IJA
2016;60(14):843-847)
• Use of LA infiltration intradermally and
subcutaneously prior to block may help.

15. POSITIONING
• Weight gain
• Gravid uterus causing difficulty in breathing
• Labour pain
• Position should be chosen as per
anaesthesiologist preference and patient
comfort.
• Patient positioning for spinal anaesthesia:
construction & validation of a flipchart. ( Sarah
de LimaPinto et al.Acta Paulistade Enfermagem.2018)

17. TECHNICAL FACTORS
• APPROACH –
• Midline approach is faster, easy to administer and less
painful in most patients
• Narrowing of space or scoliosis, increased lumbar
lordosis and difficulty in postioning, in such cases, a
lateral or paramedian approach may be used.
• Paramedian approach useful in difficult cases like
obese and pregnant,
• Does not require reduction of lumbar lordosis ,
decreases incidence of PDPH (Manisha kanagarajanet al.
Median & paramedian approach for spinal anaesthesia for
caesareandelivery. IJCA2017;4(4):518-22)

18. NEEDLE GAUGE AND TYPE
• Spinal anaesthesia in obstetrics is associated with
a high incidence of post dural puncture
headache(PDPH).
• Small diameter pencil point needles have been
suggested to decrease the incidence of PDPH.
VallejoMC etal. PDPH :RCT offive spinal needlesin obstetric
patients.AnesthAnalg.2000
BanoF etal.Comparison of25 gauge,Quincke&Whitacreneedles
forPDPH in obstetricpatients.RCT.JCollPhysicians Surg
Pak.2004

19. CHOICE OF DRUG
• Progesterone mediated increase in neural
sensitivity to local anaesthetics as well as
• The increased spread of LA in epidural and
subarachnoid spaces as a result of epidural
venous engorgement,
• Lowers the doses of local anaesthetic needed
per dermatomal segment of epidural or spinal
block.

20. DRUG BARICITY & DOSE
• The dose of hyperbaric bupivacaine providing adequate
surgical anaesthesia within 20 min in 50% subjects was
0.036 mg/cm height & ED95 was 0.06mg/cm height. ( Danelli
G et al. The minimum effective dose of0.5% hyperbaric spinal bupivacaine for
cesarean section. MinervaAnestesiol.2001.67(7-8):573-7.)
• Adjusting dose of isobaric bupivacaine to a patient’s height
&weight provides adequate anaesthesia for CS & decreased
incidence & severity of hypotension. ( Khalid Maudood Sidiqui et
al .KoreanJ Anaesthesiol 2016;69(2):143-48.)
• Hyperbaric bupivacaine had a more rapid onset of sensory
blockade to T4 than isobaric bupivacaine ( Sng BLetal.
Hyperbaricvsisobaric bupivacaine for spinal anaesthesia for caesarean section.
Cochrane Database Syst Rev 2016.)

21. PROBLEMS BEFORE
ESTABLISHMENT OF
BLOCK

22. IDENTIFICATION OF SUBARACHNOID
SPACE
• Clear flow of CSF is the end point for
• If reached the space but no CSF/or CSF flow not
adequate –
• Proper patient positioning- fetal, hip flexion, feet on
stool
• Poor needle positioning- parallel to bed, midline
• Bevel rotated in 90 degree increment until CSF appears
• Hitting bone - withdraw the needle an inch- redirect
• Increase cephalad angulation
• Try different interspace

23. IDENTIFICATION OF EPIDURAL
SPACE
• Loss of resistance to air/saline is the end point
for identification
• Pregnancy induced softening of tissues &
ligaments – increased false positive LOR
• In case of epidural space if loss of resistance
shows bounce, use some other method like
hanging drop

24. BLOODY TAP
• Either too deep or too lateral
• Usually due to puncture of epidural vein
• The gravid uterus compresses the vena cava
causing epidural vein distension
• Rotate the needle till CSF becomes clear.
• If its frank blood or CSF doesn’t become clear,
remove the needle and redo in another space.

25. BLOOD IN EPIDURAL CATHETER
• Blood is aspirated in epidural catheter,
• Can be withdrawn 1 cm at a time, flushed with
saline and then aspirated till no more blood is
aspirated or
• It can be totally removed and replaced.
• Lateral positioning, not advancing needle or
catheter during a contraction, limiting depth of
insertion to less than 5 cm and use of soft tipped
flexible epidural catheter reduces the risk.

26. DURAL PUNCTURE
• Accidental while performing epidural – incidence
1 %( DarvishB etal.ActaAnaesthesiolScand.2011)
• Give spinal drug (hyperbaric LA) through epidural
needle & convert it to spinal
• Advancing an epidural catheter into subarachnoid
space, injecting 10 ml saline & leaving the
catheter in place for 24 hrs (BoyleJAH etal.PDPH in
parturient.AnesthIntensiveCare Med.2010;11:302-4.)
• Epidural can be attempted at a higher level.

27. • Epidural catheter threading problem – inject
some saline to open up the space and then
insert the catheter.
• Paraesthesia – if patient complains of
paraesthesia during needle insertion withdraw
needle. LA should not be given to avoid likely
nerve injury.

28. PROBLEMS AFTER
ESTABLISHMENT OF
BLOCK

29. FAILED / INADEQUATE BLOCK
• Spinal – most reliable but occasional failure
• Failed spinal during caesarian – detrimental
implications for parturient and neonate
• More critical in obstetrics than non obstetric setting
• The Saving Mothers Report – death of 92 parturients-
10 deaths related to complications of a subsequent GA
when spinal failed
• Lack of clinical experience and inappropriate approach
to failure responsible
Africa GoS. Saving Mothers.Pretoria:Deptt of Health;2012. National
Committee on Confidential Enquiries into Maternal Deaths.

30. CLINICAL DEFINITIONS
• Not acted at all
• Acted but deficient in
a ) Quantity
b ) Quality
c ) Duration ??
Incidence 1% to 17 %
Acceptable 3 to 4 %

31. FAILED SPINAL

32. MECHANISM OF FAILURE
• OPERATOR RELATED
Inadequate drug dose or volume
Improper assessment of block
Inappropriate positioning
Failure to counsel or communicate
Seniority and personal experience
• TECHNIQUE RELATED
Faulty technique
Difficult back
Obesity
Misplaced injectate
Pseudopuncture

33. MECHANISM OF FAILURE
• EQUIPMENT OR DRUG RELATED
Blocked needle
Use of pencil point needles
Drug potency
Wrong drug
Drug resistance

34. CHOOSING APPROPRIATE OPTIONS
• Factors to consider –
• If skin incision already made
• Urgency of delivery
• Starvation status
• Difficult airway
• Ease of performance of regional block
• Co-morbidity
ParikhKS etal. Approach tofailedspinalanaesthesiafor
caesareansection.IJA 2018;62:691-7.

35. CHOOSING APPROPRIATE OPTIONS
• Before skin incision & no urgency to deliver in
˂30 minutes – REPEAT THE BLOCK
• Before skin incision & urgency to deliver in ˂30
minutes – assess, if performing block was easy &
pt. Cooperative – REPEAT, not possible try REVIVE
or RECOURSE TO GA
• After skin incision & no urgency to deliver in ˂30
minutes – REVIVE or RECOURSE TO GA
• After skin incision & & urgency to deliver in ˂30
minutes – RECOURSE TO GA

36. MEASURES TO REVIVE THE BLOCK
• BEFORE SKIN INCISION
Slight head low position
Left lateral position with head down
Limited hip flexion to straighten back
Valsalva maneuver, coughing (EVE)
Epidural volume expansion with saline
Local anaesthesia

37. MEASURES TO REVIVE THE BLOCK
• AFTER SKIN INCISION
Reassurance and communication
Systemic sedation and/or analgesia
Local anaesthetic infiltration
Sedation leading to LOC without
securing airway not recommended

38. REPEATING THE BLOCK
TYPE OF FAILURE CLINICAL ASSEESSMENT DOSE ADJUSTMENT
Complete failure No sensory or motor block
at all
After waiting for 20
minutes
Repeat the block, USE
Full dose of local
anaesthetic
Partial failure Inadequate level, patchy or
unilateral block
Repeat the block, BUT
Reduce dose by 25-30%
Consider CSE technique or
placing an epidural
catheter

39. COMPLICATION OF REPEAT SPINAL
INJECTION
• High spinal or total spinal
• Hypotension
• Cauda equina syndrome
• PDPH
• Nerve injury
• Epidural Haematoma

40. REASONS FOR EPIDURAL FAILURE
• Inadequate activation and maintenance dose
(volume & concentration)
• Incorrect needle and/or catheter placement
• Migration of epidural catheter
• Altered anatomy ( previous spinal surgery)
• Sacral sparing
• Unrealistic patient expectations and
• Low pain thresholds

41. WHAT TO DO IF THE EPIDURAL
CATHETER FAILS
• Incomplete block – missed segment, a patchy
block, unilateral block, sacral sparing, not
dense enough block or complete failure
• Thorough assessment
History from the patient – pain score,
location of pain(abdominal vs perineal), type
of pain(pressure?)
Examination – check the position of the
catheter, sensory/motor block

42. WHAT TO DO IF THE EPIDURAL
CATHETER FAILS
• Optimise the patient’s position
• Assess effectiveness of a bolus dose prior to
catheter manipulation and/or further boluses
with increased LA conc with/without
supplemental epidural narcotic

43. HYPOTENSION
• Most frequent complication
• More severe and rapid than in non pregnant
counterpart.
• Maternal systolic blood pressure below 70% to
80% of baseline or an absolute value of less than
90 mm of Hg
• Mother may feel faint or nauseous and may
vomit
• Excessive BP fall – loss of consciousness,
aspiration, apnea or cardiac arrest (risk to
mother), impaired placental perfusion, lack of
oxygen, fetal acidosis and brain damage ( risk to
baby)

44. PREVENTION STRATEGIES
• Proper maternal position with manual uterine
displacement or by placing a wedge under right
hip
• Physical interventions like leg wrappings may help
by preventing venous pooling of blood
( VanBogaert1998)
• Infusion of fluids to increase effective blood
volume – crystalloids high volume(15ml/kg)
coload (53%)/preload(83%) (Oh Ah Youngetal BMC
Anesth2014)

45. PREVENTION STRATEGIES
• Pharmacological treatments - phenylephrine,
ephedrine to vasoconstrict the pheripheral
circulation and heart rate ( Glosten2000)
• Colloids more effective than crystalloids
• Vasopressors more effective than fluids alone
• Ondansetron more effective than control
ChooiC etal. Techniques forpreventinghypotension during spinal
anaesthesiaforcaesareansection.Cochrane Databaseof
SystematicReviews 2017.

46. TREATMENT
• Lateral tilt of 15 degrees
• Fluids
• Oxygen inhalation
• Vasopressor (Phenylephrine 100mcg)
• Target SBP ≥ 90% of baseline till delivery
• Vigorous t/t for SBP ˂ 80% of baseline
• Prophylactic infusion better- 25 to 50
mcg/min & titrate to response
KinsellaSM et al .Anaesthesia2018;73:71-92.

47. MATERNAL CARE BUNDLE
• Multimodal approach
• Fixed low dose of bupivacaine (7.5mg+25mcg
fentanyl)
• Coloading with 15ml/kg RL
• Supine wedged position
• Ephedrine 9mg iv after intrathecal injection
• Placement of graduated compression stockings
• Incidence of hypotension 26.4 %
NadiaYoussefHelmyet al.EgyptianJ Anaesthesia2017;33:171-4

48. HIGH SPINAL/ TOTAL SPINAL
• HIGH SPINAL - Level of block that develops
cardiovascular and respiratory compromise
• TOTAL SPINAL – Intracranial spread of local
anaesthetic resulting in loss of consciousness
• Incidence – 1 in 5000 for elective CS and 1 in
3000 for emergency CS
• Volume of obstetric procedures under
regional anaesthesia is high

49. IDENTIFICATION OF HIGH/TOTAL
SPINAL
ROOT LEVEL SYSTEM AFFECTED EFFECTS
T1-T4 Cardiac sympathetic fibres
blocked
Bradycardia and
Hypotension
C6 - C8 Hands and arms Tingling and numbness
C3 – C5 Diaphragm and shoulders Shoulder weakness &
apnea
Intracranial spread Slurred speech, sedation,
loss of consciousness

50. PREVENTION OF HIGH/TOTAL SPINAL
• Consider the level of block required
• Local anaesthetic dose and volume
• Patient position
• Patient characteristics
• Technique – site of injection, direction of needle,
speed of injection,barbotage
• Assess level of block before top up
• Always confirm the position of needle/catheter
by test dose
• Never inject a bolus,give drug in increments of 3-
5 ml

52. MANAGEMENT OF HIGH/TOTAL
SPINAL
• Recognition and diagnosis
• Reassurance and communication
• Circulatory compromise – vasopressors and
atropine
• Intubation and ventilation

53. MIGRATION OF EPIDURAL CATHETER
• The epidural catheter may migrate into
subcutaneous tissue, subdural space, intrathecal
space or intravenous.
• Subcutaneous – no block, local tissue swelling,
• Subdural – minimal motor block ,high sensory
block, patchy block,
• Intrathecal – hemodynamic instability,
respiratory compromise, high/total spinal,
• Intravascular – LAST, hemodynamic collapse.

54. MIGRATION OF EPIDURAL CATHETER
• Test dose should be given after placement of
catheter and before every top up dose and LA
dose should be given in fractions.
• The incidence of migration can be minimized by
leaving 5 cm or less in epidural space and fixation
after repositioning the patient from flexed
position.
• Fixation devices and flexible catheter can prevent
• Subcutaneous migration more likely if less than 3
cm catheter is left.

55. SACRAL SPARING
• Sacral nerve roots are covered with thick dura
mater, have a large diameter and are further
away from the tip of catheter and the normal
propensity of LA solution to travel cephalad
can reduce diffusion to sacral nerve roots
leading to sacral sparing.
• CSE reduces sacral sparing.

56. LOCAL ANAESTHETIC SYSTEMIC
TOXICITY
• Pregnancy increases the risk for LAST.
• Early recognition of the problem,
• Effective airway management,
• High quality BLS/ACLS
• Lipid therapy and
• Urgent caesarean delivery are the mainstay of
management.

58. CHEST PAIN
• Seen during peritoneum stretching, uterus
manipulaion or rough handling of omentum etc –
referred pain
• High thoracic level causing discomfort of breath
& dyspnea, manifesting as chest pain
• Myocardial ischemia from oxytocin- oxytocin
causes tachycardia, hypotension & coronary
spasm,ECG changes ( Srivastava U etal. JObstetAnaesth
Crit Care 2015;5:73-7)
• Inadequate block height
• Reassurance, sedation may be helpful

59. CHEST PAIN
• Microembolism – When uterus is exteriorised
and placed above abdomen, microembolism
can occur due to concominant hypotension
and air entry into microvasculature
• Microemboli lodge in pulmonary circulation
leading to chest pain
• Prophylactic vasopressor to raise BP &
diminish chance of microemboli

60. INTRAOPERATIVE NAUSEA VOMITING
• High incidence of IONV during CS under spinal
upto 80%
• Pregnant women likely to suffer nausea &
vomiting
• Reasons – reduced tone of the esophagogastric
junction and an increased intraabdominal
pressure
• Hypotension & bradycardia is accompanied with
nausea & vomiting – reduced perfusion of brain,
ischemia activate the vomiting center in the
medulla oblongata

61. INTRAOPERATIVE NAUSEA VOMITING
• Unavoidable manipulation of the uterus and
peritoneum, exteriorisation of the uterus –
vagal activation
• Ureterotonic medications(oxytocin,methergin)
• Systemic opiods

62. PROPHYLAXIS OF IONV
• Controlling hypotension,
• Optimising the use of neuraxial & iv opioids
• Improving the quality of block,
• Minimizing surgical stimuli and
• Judicious administration of ureterotonic
agents.

63. MANAGEMENT OF IONV
• Women having a CS should be offered antiemetics
(pharmacological or acupressure) to reduce nausea &
vomiting (NICE guidelines )
• Adequate aspiration prophylaxis with histamine
antagonists
• A sufficient infusion of crystalloid or colloid solutions
• Deviations of BP corrected liberally
• Use of low dose LA
Yvonne Jeltinget al.Local & Regional Anesthesia.2017;10:83-90

64. INTRAOPERATIVE NAUSEA VOMITING
• A bolus dose of midazolam 2 mg more effective than
metaclopramide 10 mg for prevention of nausea &
vomiting in parturients undergoing CS under spinal (
RCT Shahriari A et al.J Pak Med Assoc. 2009)
• Many interventions (5 HT3 antagonists, dopamine
antagonists, sedatives, acupressure,corticosteroids,
antihistamines, anticholinergics), none superior to
another, no evidence combinations better than
single.(Review articleGrifiths JD et al.Cochrane DatabaseSyst
Rev.2012.)

65. ENHANCING A SUCCESSFUL BLOCK
• Obstetric patients when come to OR are very
apprehensive and often in labour pain.
• Despite a successful block i.e. adequate motor
and sensory effect sometimes the patient is not
comfortable .
• If it is an elective procedure, preoperative visit to
develope a rapport with the patient and win her
confidence.
• Anaesthesiologist should counsel the patient,
answer all the queries and clear doubts and fears
regarding the anaesthetic procedure.

66. ADJUVANTS
• Decrease the dose of LA
• Hasten the onset of block
• Improve quality of analgesia & anaesthesia
• Prolong duration of analgesia
• No effect on Apgar score
• Reduced total consumption of analgesics in
postop period

67. ADJUVANTS
• Fentanyl 5 -25 mcg with LA ( Grant GJ et al 2011)
• Sufentanil 5 mcg , morphine 100 mcg,
clonidine 75 mcg ( Braga AA et al. RevBras Anestesiol
2012)
• Intrathecal dexmedetomidine 5mcg(Xia F et al.
BMC Anesthesiol.2018)
• Intrathecal ketamine 0.05 mg/kg – rapid onset
& enhanced segmental spread ( UnlugencH et al
Eur JAnaesthesiol 2006.)

68. ENHANCING A SUCCESSFUL BLOCK
• Patient may be allowed to listen to music of her
choice with ear phones,
• A curtain may be put between patient and
surgeon,
• Ensure that positioning of hands,head etc. Is
comfortable.
• Adjunct medications like antacids, antiemetics,
sedatives and analgesics may be given
systemically to enhance a successful block and
increase patient satisfaction

69. SEDATION
• Parturients after delivery may be reluctant to remain awake in an
uncomfortable position potentially interfering with the end of surgical
procedure
• Improve comfort with minimal hemodynamic & respiratory effects
• Midazolam, ketamine, propofol, remifentanil and dexmedetomidine
• Dexmedetomidine – loading dose of 1 mcg /kg followed by maintenance
infusion 0.3 mcg/kg/hr, adequate sedation with minimal hemodynamic
instability and without delayed recovery ( AndreaCortegianiet al.TurkJ
AnaesthesiolReanim2017;45:249-50)
• IV dexmedetomidine prolong the duration of sensory block,
motor block & time to first analgesic( AbdallahFWet al.AnesthAnalg
2013)

70. SEDATION
• Ketamine used as rescue analgesic during
neuraxial anesthesia for CS
• Ketamine 5-10 mg or 02 to 0.4 mg/kg
increments to supplement incomplete spinal
or epidural block

71. MUSIC THERAPY
• Anxiety – Surgery
Lack of awareness of anaesthesia
methodology
Possible risks of anaesthesia
Expected pain
• Incidence of pre-op anxiety 11 – 80 %
• Raises stress hormone levels
• Without proper management- hamper health &
post-op recovery

72. MUSIC THERAPY
• Decrease preoperative anxiety & post-op pain
• Increase secretion of Beta endorphins
• Induce pleasant sensation
• Decrease pain
Wen-PingLee etal.ComplementaryTherapies inMedicine
31;2017:8-13.

73. MUSIC THERAPY
• Music may be an effective alternative to the
use of a drug (midazolam) to calm the nerves
before a regional anaesthesia
• Resultsof a clinical trial ,published in thejournal Regional
Anesthesia& PainMedicine

74. TAKE HOME MESSAGE
• Regional anaesthesia is the most popular and
safe techniue for caesarean section
• Regional anaesthesia in obstetrics is different
from regional anaesthesia in non obstetrics
• Knowledge of difficulties can help in
troubleshooting
• Should always have plan B ready in all cases
• Should not hesitate in use of adjuvants and
adjuncts to improve quality of block and patient
satisfaction

75. THANK
YOU