Cesarean Section (Spinal)

Last updated: February 9, 2026

  1. Patient in room, on monitors (SpO2, BP, EKG — consider skipping leads to avoid them being in the way), PIV fluid and phenylephrine hooked up.

  2. Spinal

    1. CHG prep stick for the back

    2. Local with lidocaine 1% (skin wheal as well as insert deep)

    3. Spinal introducer (metal cap ring) to start

    4. Needle (pink or clear hat, 24 gauge 90 mm pencil point) to puncture to get CSF, needle tip facing upwards

      1. Bupivacaine 0.75% in 8.25% dextrose, 2 mL (AJLee likes 1.6 mL)

      2. Fentanyl 15 mcg (0.3 mL), morphine 0.1 mg (0.1 mL), epinephrine 100 mcg (0.1 mL)

  3. Check level

    1. With pinprick or temperature cold. AJL prefers pinprick as cold will be higher than pinprick by two dermatomes. Need to hit T6 xiphoid for pinprick.

  4. Antibiotics: cefazolin 2 g (give slowly, can cause nausea)

  5. Ppx PONV: famotidine 20 mg, ondansetron 4 mg, metoclopramide 10 mg

  6. Surgeons perform Allis test.

  7. Tone concerns?

    1. Tranexamic acid 1000 mg IV

    2. Carboprost (Hemabate) 250 mcg IM. Contraindication: asthma.

    3. Methylergonovine (methergine) 0.2 mg IM. Contraindication: HTN or gHTN.

  8. Oxytocin

    1. 999 mL/hr for either 17 mL or 50 mL if low or high risk

    2. Followed by 15 units/hr or 30 units/hr

    3. Start immediately after the baby is delivered to promote uterine contraction, helps placenta separate safely.