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Recommended Management
1. Define baseline blood pressure 3 consecutive BP readings should be
taken which are within 10% of each other. The lowest systolic BP of the 3 should
be treated as the baseline BP
2. Measure BP every minute until delivery, once the spinal anaesthetic has
been performed and the patient placed supine with left lateral tilt
3. A fluid preload is not necessary but may be given based on clinical
judgement. Replacement should be done according to assessment
4. A drop in BP from baseline should be aggressively treated until delivery
using an IV infusion of Phenylephrine as per the flow diagram below.
SBP Baseline
SBP > Baseline
Baseline systolic BP* is lowest of 3 readings within 10%
100 mcg IV bolus Phenylephrine
Start Phenylephrine infusion (100 mcg/ml) at 60 ml/hr straight after spinal.
Measure BP every minute
*Systolic BP evidence is based on normotensive mothers. In presence of hypertension it is
probably not wise to aim for an SBP > 140 whatever the baseline readings.
#Stopping the infusion from a rate of 60 ml/hr tends to lead to a fall in BP below target.
Decreasing in steps to 50% and 25% usually produces smoother BP management (unless BP
has risen very high on initial infusion)
Stop or decrease infusion#
Measure BP every minute
Continue infusion Aberdeen Maternity Hospital Anaesthetic Guidelines, September 2009 Version 1.2
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References:
(1) Kee WD, Khaw KS, Ng FF. Comparison of Phenylephrine infusion regimens for
maintaining maternal blood pressure during spinal anaesthesia for caesarean section. Br J
Anaesth 2004; 92: 469-74
(2) Ngan Kee WD, Lee A. Multivariate analysis of factors associated with umbilical arterial pH
and standard base excess after caesarean section under spinal anaesthesia. Anaesthesia
2003; 58: 125-30
(3) Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS. Fetal and
maternal effects of phenylephrine and ephedrine during spinal anaesthesia for caesarean
delivery. Aesthesiology 2002; 97: 1582-90
(4) Ngan Kee,W. D.;Lau,T. K.;Khaw,K. S.;Lee,B. B. Comparison of metaraminol and
ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective
Cesarean section. Anesthesiology 2001; 95(2): 307-313
(5) Wright RG, Shnider SM, Levinson G, Rolbin SH, Parer JT. The effect of maternal
administration of ephedrine on fetal heart rate and variability. Obstetric Gynecol 1981; 57:
734-8
(6) Warwick D, Ngan Kee, Khaw KS, Ng FF, Lee BB. Prophylactic Phenylephrine infusion for
preventing hypotension during spinal anesthesia for Cesarean section. Anesth Analg 2004;
98: 815-21
(7) Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume
before spinal anesthesia for Cesarean delivery: A Qualitative Systematic Review. Anaesth
Analg 2001; 92: 997-1005
(8) Weeks S. Editorial. Reflections on hypotension during Cesarean section under spinal
anesthesia: do we need to use colloid? Can J Anesth 2000 / 47: 7 / pp 607610
Deepak Mathur, Bill Brampton, June 2006
Revised December 2008
Review date December 2011