Anesthesia for Cesarean Section

It is often necessary to perform cesarean sections in spite of your best efforts or desires to deliver vaginally. This may be planned (such as for breech or placenta previa), unplanned but not urgent (for stalled labor), or emergent (in which the health of the mother or baby may be in jeopardy). In each of these cases, some special preparation will be necessary to prepare you for anesthesia. First, an intravenous line will be started in order to administer medications and fluids. A medical history will be taken by the anesthesiologist or nurse to find out any conditions which may be affected by anesthesia. Next, an antacid is administered to reduce the acidity of any stomach contents. This is done as a safety measure to protect the lungs if vomiting occurs during or after the anesthetic. Nausea is an unfortunate but often unavoidable problem during c-sections (occurring in 1 of 4 cases) and is often due to traction on the internal lining of the abdomen. It is usually temporary and does not often bother patients after the operation.

Patients having a cesarean section are allowed to have one family member or friend in the operating room for delivery. When the patient is taken back to the operating room, they will be asked to wait in the hall until she has been positioned and the anesthesiologist is satisfied with the room setup.

Cesarean section may be performed under several types of anesthesia: general anesthesia, epidural anesthesia, or spinal anesthesia. A brief explanation of each along with the advantages and disadvantages is given below.

The final decision as to the type of anesthetic used will be made by the anesthesiologist after consultation with both the patient and the obstetrician.

Epidural Anesthesia: Epidural anesthesia can be used for cesarean section in either the laboring patient who requires an unexpected c-section or for the patient who has a scheduled section. In the patient who already has a labor epidural in place, no additional procedures are necessary. The infusion of local anesthetic is simply stopped and replaced with a stronger solution to provide adequate anesthesia for an operation. This results in a more profound anesthesia at a higher level than is seen with a labor epidural. For those patients who choose to have an epidural for a scheduled c-secton, the epidural is placed in the labor room and the anesthetic is given before taking the patient to the operating room. In both cases, the patient is examined to ensure that she is numb before leaving the labor room. Once the patient is positioned on the operating table, she is tested once again before beginning the operation. While the epidural will keep you from feeling pain during most of the operation, it often cannot entirely obliterate some discomfort or sense of pressure just as the baby is being delivered.

In addition to the local anesthetic, a long lasting morphine will often be injected into the epidural after the baby is delivered. This medication will reduce the amount of pain felt after the operation and is effective for about 10 hours.

Occasionally, a patient with an epidural will require an emergent c-section, and the anesthesiologist will not have enough time to get the patient numb enough to start the operation as quickly as required. In these cases, the patient will receive a general anesthetic, but will still receive the epidural morphine as described above.

Spinal Anesthesia: Spinal anesthesia is similar to epidural anesthesia in that the purpose is to numb the body from mid chest to the toes for the operation, but allow the patient to remain awake for delivery. With a spinal anesthetic a small needle is used to find the intrathecal space (which holds the spinal fluid) and inject a small amount of concentrated local anesthetic to provide anesthesia. Along with the local anesthetic, some narcotics (morphine and fentanyl) are injected to provide long lasting pain relief after the operation has ended. The spinal is placed in the operating room and provides almost immediate numbing of the lower body.

There are also several important differences between a spinal and an epidural: 1. The incidence of spinal headache is higher with a spinal than with an epidural. The membrane that contains the spinal fluid is punctured during placement of the spinal. This may lead to a spinal headache if spinal fluid continues to leak out of the puncture site. The incidence of spinal headache is 1-2% with a spinal as opposed to 1/2% with an epidural. 2. The incidence of side effects from the narcotics (nausea and itching) appear to be slightly higher in patients who receive a spinal. 3. A spinal does, however, provide a more profound anesthesia as compared to the epidural. Patients are less likely to complain of discomfort due to tugging or pressure on the internal organs.

General Anesthesia: General anesthesia is available, but is usually not the anesthetic of choice for most cesarean sections. It is usually reserved for one of the following situations: 1. A patient refuses to have a spinal or epidural,  2. The c-section has to be done emergently to preserve the life or health of the mother and/or baby, 3. The mother is critically ill and cannot tolerate a regional anesthetic, and 4. A spinal or epidural cannot be placed or becomes ineffective after the incision has been made.

Preparation for a general anesthetic differs from a spinal or epidural in that placement of all instruments and drapes is completed while the patient is still awake. She is put to sleep just before the incision is made in order to minimize the effects of anesthesia on the baby. There are also additional risks with a general anesthetic which the patient must be aware of. 1. The patient is more likely to aspirate stomach contents into the lungs and suffer from a resulting pneumonia. 2. The incidence of recall (remembering or feeling part of the operation) is higher with general anesthesia compared to other patients since every effort is made to reduce the amount of anesthesia to which the infant is exposed. Since recovery from a general anesthetic requires more intensive care from the nurse, the patient's family and friends are usually asked to remain in the waiting area until she is fully awake.