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Anesthesia for Cesarean Section

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REGIONAL ANESTHESIA
Regional anesthesia includes both spinal anesthesia and epidural anesthesia. They are very similar in terms of how they are performed, the location they are placed, how they work, etc. Both involve the placement of medications near the spinal cord by means of a needle in your back. They both result in the lower portion of your body becoming anesthetized (or "numb") so that the surgery can be completed without any pain. This is why they are called regional anesthesia - they affect only a region of your body. The fact that the mother can remain awake, see the baby and interact with the baby as soon as it is born and does not require a breathing tube are all advantages.

Generally a spinal is faster and simpler to place, works slightly faster and is less technically complicated. It involves a single injection in the back that produces anesthesia (lack of sensation) from approximately the mid-chest down.

An epidural takes a little longer to place, a little longer to start working and is slightly more technically involved. Instead of a single injection, a plastic catheter is placed in the back. This allows medication to be given repeatedly or continuously - useful if careful control of anesthetic level is needed or if the length of the surgery is unknown. In some cases, it is necessary for anesthesia to be administered gradually - an epidural allows this versus the "single shot" of a spinal.

In most cases, cesarean sections take a known amount of time and a spinal anesthetic is more than enough for this to be completed. Some anesthesiologists, however, appreciate the additional flexibility and control an epidural gives them and they may prefer this technique. This is a perfectly acceptable choice as well. Of course, if you already have an epidural catheter in place for labor analgesia then it makes sense to utilize that catheter to give you anesthesia for a subsequent cesarean section. To reiterate, either technique is a good choice for cesarean section.

There is one benefit to utilizing an epidural for cesarean section that you might want to consider...the epidural can be utilized both for the operation itself as well as for pain relief after the operation. Many patients think that with an epidural the pain of labor is bypassed - and while this is true in a way, you must remember that there will be issues of pain after the surgery is done.

POSTOPERATIVE PAIN RELIEF
Many patients incorrectly assume that it would be better (or easier) to have a cesarean section because, since anesthesia is given for cesarean section, there is "no pain involved". This is simply not true. Whereas with a vaginal delivery there is the pain of labor and delivery with relief once the child is delivered, with a cesarean section there is the pain of the surgical incision after the surgery that may last for a few days or longer.

Of course, as anesthesiologists, our goal is to control and treat this pain as well. As I mentioned above, general anesthesia is probably the worst option in terms of postoperative pain control because it wears off relatively quickly after the surgery is done. When the patient requires pain medication at that point, either intravenous or intramuscular shots or narcotics are usually utilized to control pain. The common side effects of these narcotics include drowsiness, nausea and vomiting, itching, constipation, etc. Sometimes the pain relief from these medications is incomplete but the fact that they suppress normal breathing means that more cannot be given (or at least must be given very cautiously).

If an epidural is utilized for the surgery, it can be utilized to control postoperative pain as well. This is usually done with a continuous infusion of local anesthetics, narcotics or a combination of the two. This allows very good pain relief with minimal sedation and much lower doses of narcotics. Side effects, while they can still occur, are minimized in this way.

If a spinal is utilized, the anesthesia will persist for some time after the surgery. Initially the complete numbness utilized for the surgery will persist (up to a few hours or so). After that, depending on what medications were injected at the time of the spinal, there may be little to no pain for quite some time. Duramorph is one of these medications often given to the patient who gets a spinal for the treatment of postoperative pain. Basically, it is morphine (a narcotic) which is effective in a very low dose due to its placement near the spinal cord. Once given, it results in pain relief for 18-24 hours after the operation. The side effects are similar to narcotics given by other means (nausea, vomiting, itching, etc.) but are usually minimal due to the much lower dose and are usually easily treated.

CONCLUSION
To summarize, general anesthesia should be utilized only for a true emergency when the situation will not allow any other options. Regional anesthesia (either spinal or epidural) offers an effective means of anesthesia for cesarean section while allowing the mother to remain awake and avoid a "breathing tube". The regional techniques also offer some advantages for the control of pain after the operation. As with any anesthetic, make sure you discuss the options, risks and benefits with a anesthesiologist who know your individual condition and situation.

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