Epidural augmentation for urgent Cesarean Section : a nationwide Israeli survey


Cesarean section ; epidural augmentation ; anesthesia ; survey ; institutional protocols

Published online: Mar 28 2022


Y. Giladi (* ,#), D. Shatalin (*,#), C.F. Weiniger (**), R. Ifraimov (***), S. Orbach-Zinger (****), P. Heesen (*****), A. Ioscovich (*)

# The first two authors contributed equally to this study.
(*) Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, affiliated with Hebrew University, Jerusalem, Israel
(**) Division of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
(***) Faculty of Medicine, The Hebrew University of Jerusalem, Israel
(****) Department of Anesthesia, Rabin Medical Center (Beilinson Campus), Petah Tikvah, Tel Aviv University, Tel Aviv, Israel
(*****) Faculty of Medicine, University of Zurich, Zurich, Switzerland


Background : Epidural augmentation to convert analgesia to emergency cesarean delivery anesthesia is a common practice. In this survey we examined the common augmentation practices in different hospitals in Israel. We investigated whether practices vary by hospital size and if written protocols for conversion correlate with intra-hospital homogeneity.

Methods : A questionnaire containing 39 questions was sent to obstetric anesthesia unit heads and to four additional anesthesiologists (attending and residents) in 24 obstetric anesthesia units nationwide. Answers were received online anonymously using web-based survey site.

Results : 99/120 participants responded to the survey. 80% of large hospitals have a detailed epidural augmentation protocol. The existence of a written protocol does not affect intrahospital management variability. Overall, 18 different drug mixtures for epidural augmentation were reported, and the most used drug combination is lidocaine, fentanyl and bicarbonate. In large hospitals, 72% add epinephrine and 96% initiate augmentation before operating room arrival. Most respondents reported a final administered total volume of 15-20 ml. In most hospitals there is no maternal or fetal monitoring during patient transfer from delivery room to the operating room, lasting 3.68 minutes on average, with a relative low risk of significant complication as a result of augmentation.

Conclusion : We report variations in common practices, depending on hospital size. We recognized low rate of intra-hospital concordance between centers with or without a written protocol of augmentation. Regarding points for improvement, we would recommend adhering to the accepted institutional protocol.