Structured Preprocedural Reassessment After Previous Inadequate Neuraxial Anesthesia for Cesarean Delivery: A Case Report

Inadequate neuraxial anesthesia during cesarean delivery can cause intraoperative pain and anxiety before subsequent surgery.We report a parturient undergoing her third cesarean delivery after inadequate spinal anesthesia during both previous cesarean deliveries.She expressed strong concern about recurrent intraoperative pain.During the second cesarean delivery, combined spinal-epidural anesthesia was performed.A lower-limb motor block developed, but complete cold sensory loss was limited to L1 at 20 minutes after the initial intrathecal injection.The initial epidural catheter was replaced because malposition was suspected.The cold sensory level reached only T10 after repeat spinal injection and epidural supplementation; operative pain required local infiltration and intravenous medication.Before the third delivery, we reviewed the anesthetic record and postoperative abdominal radiograph from the second delivery.The radiological intercristal line, joining the superior aspects of the iliac crests, crossed around L5-S1.Preprocedural lumbar ultrasonography was used to identify the lumbar interspaces.An individualized combined spinal-epidural plan included epidural supplementation and conversion to general anesthesia as rescue options.After intrathecal administration of hyperbaric bupivacaine and fentanyl at the ultrasound-identified L2-L3 interspace, bilateral loss of cold sensation to T4 was confirmed within 10 minutes.No rescue epidural supplementation, intravenous sedative or opioid, or conversion to general anesthesia was required.Planned postoperative epidural analgesia was started toward the end of surgery, before wound closure.Previous inadequate neuraxial anesthesia for cesarean delivery should prompt structured reassessment and an individualized anesthetic plan that addresses the patient's concerns and includes predefined rescue options.