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Epidural Top-Up for Caesarean Section — FRCA Final MCQ

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ModerateObstetric AnaesthesiaEpidural Top-Up for Caesarean SectionFRCA Final

A 34-year-old woman (ASA I, 60 kg) in established labour requires a category 2 caesarean section. Her epidural infusion contains bupivacaine 0.1% with fentanyl 2 micrograms/mL at 10 mL/hour. It has provided consistently effective bilateral analgesia without breakthrough pain or rescue boluses, and aspiration through the catheter is negative. Examination demonstrates a bilateral sensory block to T10. There is sufficient time to extend a reliable neuraxial block. What is the most appropriate anaesthetic management?

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Correct answer: B — Extend the epidural with 15–20 mL lidocaine 2% with adrenaline 1:200,000 in incremental doses

The correct answer is B. A consistently effective bilateral labour epidural should usually be extended for a category 2 caesarean section when urgency permits. Lidocaine 2% with adrenaline has a rapid onset and produces dense epidural anaesthesia; 15–20 mL contains 300–400 mg lidocaine, below the eMC maximum single dose of 500 mg with adrenaline. It should be administered incrementally with aspiration, monitoring and repeated assessment, and surgery must not start until an adequate bilateral surgical block is confirmed. Bupivacaine 0.5% can provide surgical anaesthesia but has a slower average onset. A spinal is unnecessary when the epidural is demonstrably reliable and may produce an unexpectedly high block after recent epidural dosing. General anaesthesia is appropriate if neuraxial anaesthesia is contraindicated, inadequate or too slow for the clinical urgency—not simply because the birth is urgent. An unchanged infusion and a T10 block are inadequate for surgery.

Reference: Reschke MM et al. Choice of local anaesthetic for epidural caesarean section: a Bayesian network meta-analysis. Anaesthesia. 2020;75:674–682. https://pubmed.ncbi.nlm.nih.gov/31867718/