Table 1 Key recommendations for best clinical practices
Key recommendations | Strength of recommendations | References |
|---|---|---|
Hypotension during SA needs prompt recognition and treatment, since it is frequent and has adverse effects on the mother and the fetus | High | |
A systolic NIBP of < 80% of baseline is considered hypotension, and SBP must be maintained at > 90% of baseline | High | |
Vasopressor should be used to manage SA–associated hypotension | High | |
Phenylephrine should be used as the first-line of vasopressor treatment to maintain the desired SBP in the absence of bradycardia | High | |
Phenylephrine can be given prophylactically to reduce the risk of hypotension and nausea and vomiting after SA | High | |
Phenylephrine may be administered as an infusion titrated at 25–50 µg/min after administration of SA, depending on blood pressure and heart rate with additional IV boluses if needed | High | |
Phenylephrine can be administered as a bolus of 50–100 µg on SA administration. For immediate management of hypotension, IV bolus of phenylephrine has a faster onset than an infusion | High | |
Phenylephrine and ephedrine bolus should be administered using prefilled syringe since it prevents medication errors, creates less waste, improves patient safety, and allows long-term cost savings | High | |
Intermittent IV boluses of 5–15 mg ephedrine must be administered in the presence of bradycardia and hypotension, but the cumulative dose before delivery should not exceed 15 mg to minimize fetal acidosis | High | |
Leg compression devices, manual left uterine displacement, wedge for left uterine displacement, and administration of 5HT3 antagonists (e.g., ondansetron) may be used as prespinal measures to prevent hypotension after SA | Medium | |
Crystalloid co-loading should commence together with prophylactic administration of vasopressors | Medium | |
Noradrenaline (norepinephrine) infusion (starting rate can be 0.1 µg /kg/min) or bolus (5–10 µg) may be used in limited-resource areas (using a central line or temporarily in large-bore peripheral line) | Low | |
An anticholinergic agent (glycopyrrolate or atropine) may be used for significant bradycardia with hypotension | Low |