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Anesthesia for Cesarean Section

(Originally posted 17 August 1998 on About Anesthesiology)

INTRODUCTION
Cesarean section has become more and more common in the United States. Rates as high as 20-25% are often seen - especially in large hospitals with "high-risk" patients. By "high-risk" I mean patients with pregnancy induced hypertension, pre-eclampsia, eclampsia, diabetes, prematurity, lack of prenatal care, etc. The reasons why the rate of cesarean section is so high and whether that is good or bad is a topic to be discussed elsewhere and in more detail. Here we will focus on what you can expect in terms of anesthesia if the time comes that you need a cesarean section.

GENERAL CONCEPTS
First, as a general statement, there is obviously some risk to the mother when she requires a cesarean section. From the anesthesia standpoint however, the incidence of complications has steadily decreased due to better techniques and monitoring - this has occurred even with the tremendous increase in the number of these surgeries that are being done. This is not to downplay the seriousness of a surgical procedure - only to reassure you that serious risks and complications are (luckily) very rare.

The choice of what anesthetic technique is safest and most appropriate for an individual patient depends on a number of factors. What is right for one patient may not be right for another. Each case must be looked at individually and there are a number of things to consider. Some of these things include the reason for the cesarean section, whether the operation is an emergency, the medical status of the patient, the needs and wishes of the patient, the needs of the obstetrician performing the surgery, etc. Ultimately the choice of anesthesia should be made once the anesthesiologist looks at all the data available and discusses the risks and benefits of each choice with the patient.

General goals in choosing anesthesia are (1) the safety of the mother; (2) the safety of the baby; (3) the comfort of the mother and (4) the ability to perform the surgery under that anesthetic technique.

TYPES OF ANESTHESIA
Basically there are two general categories of anesthesia for cesarean section - general anesthesia and regional anesthesia. Regional anesthesia includes both spinal and epidural techniques. General anesthesia is usually reserved for patients that must have anesthesia "right away" because their surgery is being done for a true emergency. In these situations, regional techniques can take too long to perform. However, there are some risks associated with general anesthesia (see below) that can be avoided with regional anesthesia. Therefore, regional anesthesia is almost universally preferred when time is not as much of a factor.

GENERAL ANESTHESIA
General anesthesia has the following advantages: it can be given very quickly, blood pressure is more easily controlled, breathing is more easily controlled once the ability to breathe for the patient is obtained. In addition, there are some situations where general anesthesia is preferred because there is a medical reason not to do regional anesthesia. Some examples of this include patients with bleeding and clotting abnormalities, patients with neurological problems, patients with infections that might be spread to the spinal area if regional anesthesia is done, etc.

The main disadvantages of general anesthesia include the fact that the mother is unconscious and therefore unable to participate in the process of birth or interact with the baby once it is delivered. After the operation, general anesthesia wears off relatively quickly and can result in greater postoperative pain. The other disadvantage is that there are some significant risks associated with general anesthesia.

The main risk to the mother involves the fact that the anesthesiologist must secure and control the ability to breathe. This involves what is known as an endotracheal tube - basically a small plastic tube that is placed into the lungs to allow regular and adequate breaths to be given. Two things can occur when this tube is being placed that place the mother at risk.

The first is that the tube may be difficult to place in the correct place. Pregnancy in and of itself makes the placement of this tube more difficult. In addition, there may be factors associated with the patient that make this process difficult such as a small mouth opening, inability to move the neck fully, etc. Obviously, if the tube is required to breathe and it cannot be placed correctly, there is great risk to the mother.

The second risk is that the mother may aspirate during the placement of this tube. Aspiration means that some of the contents of the stomach end up in the lungs. The contents of the stomach are usually quite acidic and do not belong in the lungs - this can result in a serious pneumonia which can be life threatening as well. The reason that this occurs is that the mother is unconscious and has lost the normal reflexes for protecting the lungs from the stomach contents.

Anesthesiologists spend a great deal of time and effort to prevent these problems from occurring. There are a number of special techniques and devices that are utilized to decrease the risk of these events. Therefore, they happen fairly infrequently - but they are significant and dangerous risks that are minimized or eliminated if regional anesthesia is used instead of general anesthesia. This is why most anesthesiologists prefer to utilize regional anesthesia when the surgery is not an emergency.

Lastly, general anesthesia does affect the newborn - at least a small amount. When giving the mother general anesthesia for cesarean section, the obstetrician will try to deliver the baby as quickly as possible to minimize the amount of anesthesia that the baby receives. The anesthesia that the baby receives does wear off fairly quickly - but initially the baby might be sleepy, less active, etc.

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