Background and Aims We hereby present a case of a normally well 28-year-old primigravida, listed for a category 3 caesarean section (CS), who had multiple successful dural taps yet no adequate block.

Methods She was consented and siting the spinal with 2.5 mls of 0.5% ‘heavy’ bupivacaine was technically easy on first attempt. After 20 minutes, despite position optimisation, there was no motor or sensory block. A second spinal, with a new batch of bupivacaine, was sited at a higher lumbar space. This time, despite some objective lack of cold spray sensation to the L1 dermatome, no motor block was achieved. A decision was agreed to wait 2 hours and do a combined spinal epidural (CSE). Frustratingly, despite the CSE being straight forward to site, there was inadequate effect of the spinal anaesthetic. Cautious top ups of the epidural were given with no motor block albeit a sensory block to T10 was achieved. After the second epidural top up, there was a monitored fetal bradycardia; however, without an acceptable block level, the patient agreed to proceed with a general anaesthetic (GA).

Results The baby was born in good condition and the patient made a subsequent uneventful recovery.

Conclusions Neuraxial anaesthesia failure is quoted typically as 1% and can be due to technical (e.g. failed puncture), drug (e.g. inactivity) and patient factors (e.g. genetics, Ehlers Danlos)^1,2. For this case a GA was unavoidable, however advice from our neurologist, concluded that where neuraxial anaesthesia fails for no obvious reason, an MRI to rule out subdural septae should be considered.