SPINAL ANAESTHESIA FOR CAESAREAN SECTION

In the vast majority of cases, planned caesarean sections are performed with the mother awake, under spinal anaesthesia. Indeed, in many emergency sections also take place with a spinal anaesthetic, or if an epidural is already being used for pain relief in labour, this may be “topped up” to provide a similar effect.
In this article I will outline the pros and cons of being awake, and explain what you are likely to experience.

What are the benefits of staying awake?
There are several advantages, both physical and psychological, to staying awake.
Firstly, it’s safer for the mother than a general anaesthetic. One of the most serious risks of general anaesthesia is that of vomiting under anaesthesia, with inhalation of vomit into the lungs. This is very rare, but is much less likely in a conscious person.
Other serious complications such as post operative chest infections and blood clots in the leg veins are also less common, as are less serious complications like post operative nausea and vomiting. In fact most mums who have stayed awake report that they generally feel better and recover more quickly than those who have had a general anaesthetic
It’s also better for baby. Some of the drugs used in a general anaesthetic cross the placenta and make baby a little sleepy too. This will soon wear off, but can sometimes make baby a little slow to feed etc. The drugs used in a spinal anaesthetic don’t do this.
Psychologically, most mums feel happier about being awake. The idea of being awake and participating in the delivery is often very reassuring. It is often possible for mum to hold baby very soon after birth, and the drowsiness and disorientation that may occur after a general anaesthetic is absent. This helps mum get to know her baby and may make establishing breastfeeding easier. Also baby’s father or another supporter can join mum for delivery if wished, helping the delivery to be a proper family affair!

Can everyone stay awake?
Whilst this is a suitable anaesthetic technique for most people there are a few circumstances when it’s not possible and a general anaesthetic is preferable. These may be related to the mother’s medical condition or to the baby’s needs.
For instance, spinal anaesthesia may be dangerous if mum has certain heart complaints, or blood clotting disorders. It’s also inadvisable if mum is bleeding heavily or heavy bleeding is anticipated during surgery. Because it takes longer than a general anaesthetic to establish, spinal anaesthesia may not be possible if a very rapid delivery is needed, for example if the baby is severely distressed.
Previous back surgery or injury may make the procedure more difficult, though this is not always the case.
Your anaesthetist and obstetrician will discuss this if any of these circumstances apply to you.

What happens?
Prior to your section you will be seen by an anaesthetist and obstetrician, who will speak to you about the proposed procedures and ask you to sign a consent form. You will be asked some questions about your medical history, your heart and lungs will be examined and some blood tests taken. If you don’t understand anything or have any questions don’t be afraid to ask for more information. This may occur the day before your surgery if your section is planned, or immediately beforehand in more urgent circumstances. Some hospitals run pre –operative assessment clinics and you may be asked to come in to be seen some time in advance.
On the morning of surgery you will be given a tablet to help neutralize stomach acid. Sometimes this is also given the night before. You will be asked to have nothing to eat or drink for about 6 hours prior to surgery if your section is planned. Prior to theatre you will need to change into the gown you will wear during the section.
A midwife will usually accompany you to the operating theatre and introduce you to the anaesthetic assistant. He or she will check your details and take you into theatre, whilst your partner gets changed into theatre clothes. Some monitoring devices will be attached to help the anaesthetist care for you – usually sticky dots on your chest to monitor your heartbeat, an automatic blood pressure cuff and a peg on your finger, which monitors your blood oxygen levels. You will also be given a small cup of anti acid medicine to drink.
The next step is the setting up of a drip – the anaesthetist will insert a plastic cannula into the back of your hand or arm, and attach it to a bag of fluid. Next the anaesthetist will wash his hands and put on a pair of sterile gloves and a gown, whilst the assistant helps you to get into the right position for the anaesthetic to be given. This may be lying on your side, curled into a ball, or sitting up with your feet on a stool. Your back will be washed with an antiseptic solution (feels cold!) and most of your back covered with sterile towels. The anaesthetist will feel your back to find the best location, and then inject some local anaesthetic (stings a bit). Then he will gently pass a fine needle between two of the bones of your back. Sometimes this only takes a few seconds, but other times it takes a little longer to locate exactly the right spot. You can help the anaesthetist by listening carefully to the instructions of how to position yourself and trying to sit as still as possible. The injection is not usually particularly painful, but can be a little uncomfortable. If you find it too sore, ask the anaesthetist to inject some more local anaesthetic. Once the injection is done, you will start to feel numb. This may start as a warm feeling in your bottom, and takes a few minutes to become fully effective. Your legs will feel heavy and you will not be able to move around without help. You may be asked to lie in different positions for a while, such as on your side, to help the anaesthetic spread around. The anaesthetist will check that all the vital areas are numb before surgery commences. The numbness will extend to the top of your tummy, or part way up your chest.
Before surgery begins, a catheter will be passed into your bladder. This keeps the bladder empty during the operation, reducing the risk of damage, and also allows the midwives to check on the amount of urine you are making after the operation.
The operating table will be tilted to the left to take the weight of your womb off the big blood vessels in your tummy, as this may cause your blood pressure to fall. You will be given some oxygen to breathe from a light, clear plastic mask. Your tummy will be washed with some antiseptic, and sterile towels placed over you. A barrier will be placed so that you cannot see the operation actually taking place, and you will then be ready to have your baby!
During surgery, you will feel some pushing and pulling, which is a bit odd, but not painful. The staff will explain what is happening and your anaesthetist will be with you throughout. If anything bothers you, be sure to tell him.
Your partner will be sitting beside you too. Although many men are at first apprehensive, most find it a happy experience. If your partner does feel faint or funny though, he mustn’t feel embarrassed and should tell the staff as soon as possible!
Once surgery begins, it isn’t very long before the baby is delivered, maybe 10 – 15 minutes. It takes rather longer to “put everything back together again” but everything is usually finished within about an hour. Whilst this is happening, you and your partner are often able to hold and cuddle your baby.
When everything is finished, you will be transferred back into your bed and moved into a recovery area for a while before you are ready to go back to the post natal ward.
The numbness will wear off gradually – this may take a few hours. As the feeling comes back, you may get some funny sensations, a bit like when a local anaesthetic from the dentist is wearing off. You will also start to need some pain relief – I have discussed this in a separate article.

What are the disadvantages?
The commonest side effect of spinal anaesthesia is a fall in blood pressure. This happens because the anaesthetic also affects some of the nerves that control your blood pressure, and this is why your blood pressure will be carefully monitored throughout. This may make you feel light headed or sickly, but can generally easily be treated with extra fluids and a drug called ephedrine injected into your drip.
Rarely a severe headache may occur after this type of anaesthetic. This happens to less than 1 in 100 people, and a variety of treatments are available if this happens.
Some people may develop itching of the skin. Drugs can be given to treat this if needed, but it will go away on its own fairly soon. You may feel cold or shivery for a short time, but this will also go away soon.
The injection site may feel a little sore for a while, but there is no scientific evidence to suggest that this type of anaesthetic causes long-term back problems.
Many people worry about possible long-term nerve damage, but don’t worry – this is extremely rare indeed.
Another common concern is that the numbness will wear off too soon, or the anaesthetic will not work. This is rare, but occasionally does occur. The anaesthetist will check how numb you are before the surgery begins, and alternative techniques offered if it is not satisfactory or if the anaesthetist has been unable to site the injection. (Also rare) If you find the procedure uncomfortable there are various choices available, including breathing gas and air, or having painkillers injected into your drip. And you always have the option to be put to sleep if necessary.
Over all, most people believe that the advantages far outweigh the disadvantages of this technique.

Some personal tips
Having a caesarean section can be a positive experience, and there are some things, which you can do to make it more special.
Often you can take your own music into theatre with you. Why not make a special CD or tape for the occasion?
Don’t forget your camera. Photography is allowed in many hospitals – just check with your midwife to be sure. Theatre staff are often happy to help with photos.
You could ask for the staff not to tell you the sex of your baby then you and your partner can discover this together when the baby is first handed to you.

Finally….
The idea of being conscious through surgery is scary for many people, but it is unusual to find a mother who has done this who then asks for a general anaesthetic in the future. Fear is reduced by knowledge. I can only outline the general points here, but if you have questions, don’t be afraid to ask your doctors and midwives.

General Anaesthesia For Caesarean Section

The majority of both planned and unplanned caesarean sections are now performed with the mother awake, and there are many advantages to this. However, there are still some circumstances when it may be in your, or your baby’s interest for a general anaesthetic to be performed. In this article I will attempt to explain why a general anaesthetic may be needed, and what to expect if you have one.

Who needs general anaesthesia?
Sometimes a mother may be suffering from a medical condition, which makes a spinal anaesthetic potentially dangerous. These include disorders of blood clotting and certain heart conditions. Also, if heavy bleeding is expected during surgery, or the mother is already bleeding heavily a general anaesthetic may be the safest option.
If the baby needs to be delivered quickly, for instance if severely distressed, general anaesthesia may be the best option, as it is usually quicker.
Occasionally, despite the best efforts of your anaesthetist, it is impossible to site a spinal or epidural, or the numbness is inadequate for surgery. Don’t worry too much about this though; it is uncommon.

Is it safe?
Although it is true to say that there are more risks with general than spinal anaesthesia for c/sections, the vast majority of women will have no serious problems. If you are having a c/section, you will usually be encouraged to remain awake if possible, but general anaesthesia does provide a safe alternative when it is needed. There are some special factors that the anaesthetist needs to take into consideration so you may find the procedure slightly different to other general anaesthetics you have had. More of that later.
Of course, there are also the risks that apply to any general anaesthetic, such as allergy to one of the drugs, but these are also rare.

What will happen?
As with any other anaesthetic, you will see the anaesthetist preoperatively and s/he will ask you some questions about your medical history and explain what will happen. Obviously the time available for this will vary enormously depending on the urgency of the situation.
If time allows, you will be given a tablet to reduce acid in your stomach. This is important because in pregnancy the stomach does not empty efficiently and the valve mechanism at the top of the stomach becomes inefficient. (That’s why you get heartburn) One of the most serious risks of general anaesthesia is the possibility that stomach contents may spill into your lungs as you drift of to sleep, and your anaesthetist will take a series of steps to prevent this happening. In an emergency you are likely to be given this same anti acid drug as an injection. You will also be given a small glass of antacid liquid to drink just before you go to sleep. Tastes horrid – but very important.
The anaesthetic assistant will attach some monitoring equipment to help keep you safe during the
surgery – your heartbeat, pulse blood pressure and oxygen levels will be monitored throughout.
The anaesthetist will put a drip up in your hand or arm and then ask you to breathe some oxygen for
a few minutes from a facemask. This is an important safety measure, so try to put up with it even if
you don’t like masks! The anaesthetist will then inject a drug into your drip and you will go to
sleep very quickly, often getting a taste of onion or garlic just as you drift off. Just as you go to
sleep, you may be aware of the anaesthetic assistant applying pressure to the front of your throat.
You are not being strangled – this manoeuvre closes your gullet and helps keep any remaining
stomach contents in their right place. Once you are asleep, the anaesthetist will insert a breathing
tube into your windpipe. You will breathe through this during the operation and it also helps
prevent stomach contents entering your lungs. Passing this tube may be trickier in pregnant
women. The anaesthetist will have special equipment to help if this is the case.
The few minutes before you go to sleep may seem a bit chaotic as the staff will be checking all the equipment and preparing as you arrive. You may also have a catheter inserted and a bikini shave before you go to sleep. It may seem that there are too many people in the room, but it does take quite a big team of people to care for you. If you do not wish students to be present you are able to request this.
Once you are asleep, your anaesthetist will remain with you, administering further drugs and fluids as needed. You will be carefully monitored throughout and the anaesthetist will not leave you until the operation is finished and you have woken up. Then you will be moved into a recovery area and a midwife or theatre nurse will look after you until you are ready to be transferred to the post natal ward. It is very common not to be able to remember clearly what happens immediately after surgery, so your memories of this time may be hazy.

Will I really be asleep?
You may have heard stories of people being awake but unable to tell anyone during a c/section, and many women are scared of this, but embarrassed to say so. This can happen, because if too much anaesthetic is given, the baby may be at some risk. In the past, anaesthetists used to err on the side of caution in choosing drug doses, for fear of harming the baby. However, nowadays the drugs used are much better and monitoring a lot more sophisticated, so general anaesthesia is both safer and more effective than in the past. This problem is now extremely rare.

How will I feel afterwards?
As with any surgery, you will of course be sore and need painkillers. I have prepared a separate article on this subject.
You may also feel sickly and a variety of treatments are available for this. Be sure to let someone know if you feel sick.
The drug used to relax your muscles so that the anaesthetist can pass the breathing tube may unfortunately cause muscle pains in the first day or two. This can be unpleasant but your painkillers will help and it will soon go away. The breathing tube may also cause a sore throat, but this also usually settles in a day or two.
You will also feel sleepy to start with, but with modern anaesthetic drugs this feeling doesn’t last as long as in the past. If you have been in labour for a long time prior to your section you will feel more tired for longer than if you have not.

Personal Hints
Not many women would choose to have their baby by caesarean section under general anaesthesia, and for many it is the worst-case scenario. But it can be life saving. Many of us don’t really think of this as a possibility and so are totally unprepared if it happens. I think it is helpful to have considered what you might wish in these circumstances, as you still have choices. It’s particularly important that your birth partner knows how you feel as you might not be able to express yourself terribly well at the time. Here are a few of my ideas.
Don’t forget your camera. Depending on the circumstances one of the staff may be able to take some photos of your baby’s first minutes. Also ensure that you get plenty of pictures of you and baby in the recovery area, as your memories of this time may be hazy.
It will usually be at least an hour after your baby’s birth before you are able to hold him. This upsets many women, as they feel that the world and its wife have seen baby before mum has. You are perfectly within your rights to ask, for instance, that only your partner sees baby before you. Unless you are not going to be reunited for a considerable period of time, there should be no immediate need for anyone else to feed baby before you are awake either. If you are going to breastfeed you could ask the midwife in recovery to latch baby on for you, even if you are still drowsy. Make sure your partner knows to ask.
You may be disappointed that you can’t have skin-to-skin contact with baby immediately. Ask your partner to get his shirt off and do it instead and then you have your turn as soon as possible. You might also want baby to be cuddled in an item of your clothing so he gets to smell that lovely mummy smell straightaway, even though you cant hold him immediately.
Also, think how you would like to learn the sex of your baby. Do you want the staff to tell you as soon as you wake, your partner to tell you in recovery or would you rather wait and look for yourself?

In Conclusion….
If you have a choice, I would recommend that you stay awake for your caesarean section, but if you NEED a general anaesthetic, try not to worry too much. It is the safety of you and baby that comes first. I would suggest that everyone ought think a little about this possibility, as being prepared better can help make the experience less traumatic.

PAIN RELIEF AFTER CAESAREAN SECTION

Good pain relief is important! Not only is pain unpleasant, but also research has repeatedly shown that patients who do get adequate pain relief after surgery recover more quickly than those who don’t. Caesarean section is no exception and you should not be afraid to ask for painkillers if you need them.
Pain relief may be delivered in slightly different ways in different hospitals, but the basic principles are the same. Usually a combination of painkillers is used and I will look at these in turn.

Opioids
These are strong pain killing drugs. Drugs in this group include morphine, pethidine and diamorphine. Morphine is probably the most commonly used painkiller in the first day or two after surgery. Later in your recovery you may instead be given codeine, a similar but “weaker”opioid.
Morphine and the other strong opioids can be given in several ways. They may be injected into your drip, into a muscle or just under the skin surface. Some hospitals use a system called patient controlled analgesia – PCA. In this system, you are given the control button, which you can use to deliver your own pain relief. When you press the button a small dose of painkiller, usually morphine, is delivered directly into a vein via a plastic cannula. For safety, the machine is pre programmed by your anaesthetist and limits are set determining how much morphine you may have and how often. Only you may press the button, and you should only do so when you have pain. This is a safe and effective form of pain relief, but occasionally you may need help with the technique or the doses may need to be changed. If you are unsure about anything ask the midwives on the ward.
Although opioids are good painkillers they do have side effects. You may feel sick, dizzy or sleepy. Some people may feel itchy and constipation can occur. Let your midwife know if you have any of these problems. Rarely these drugs may cause the breathing to slow, the blood pressure to fall or the heart rate to fall, so these will be monitored whilst you are receiving the drug.
All these drugs have similar side effects, but sometimes one drug does suit an individual person better than another. If you get a lot of side effects with one, it may be worth asking to try another. All the side effects tend to be worse with bigger doses of the drug.

Non Steroidal Anti Inflammatory Drugs (NSAIDs)
This group of drugs, related to aspirin, includes ibuprofen (brufen, nurofen) and diclofenac (voltarol). They are usually given by mouth or as suppositories. In the first day or two suppositories are usually used so that you still get the benefit of the drug even if you are sickly. These drugs provide pain relief without drowsiness, but are not enough on their own after major surgery. By taking these together with morphine, the overall dose of morphine you need will be reduced, so you get better pain relief with fewer side effects.
NSAIDs do have their own side effects, the commonest being stomach irritation. Let staff know if you have any stomach irritation or your stools become black. You should not take these if you have had a stomach ulcer in the past or if you are known to be allergic to aspirin. Sometimes they are unsuitable for asthma sufferers, but this is not always the case – talk to your anaesthetist.

Paracetemol
It may seem unlikely that the humble paracetemol can help after major surgery, but research has shown that taking regular paracetemol can significantly reduce the amount of morphine that is needed. Paracetemol may be given as a suppository as well as by mouth.

Next Steps
After a day or two you will probably feel well enough to take your pain relief in tablet form. It is common to be given a combined painkiller containing codeine and paracetemol eg Tylex, Kapake, CoCodamol, and a separate NSAID. As time goes on, you may feel that you need less codeine, in which case you can ask for your codeine and paracetemol to be prescribed separately. Alternatively you can take one of the combined tablets with a normal paracetemol, when you had previously been taking 2 combined tablets. Just be sure that you don’t take more than 4g of paracetemol and or more than 240mg of codeine in 24 hours.

A word about constipation!
This is very common after a c-section, due to a combination of the surgery, hormonal factors and painkillers, especially codeine. If you are affected there are a few things you can do to help. Make sure you drink plenty – water especially. Get up and about as soon as you feel able, as gentle exercise will help get things moving again. Consider reducing your codeine intake as described above, but don’t go without pain relief that you need. Ask your midwife or doctor about a gentle laxative – lactulose is good and is safe during breastfeeding.

Other things.
You will need to be careful how you move and be sure you don’t lift any heavy weights. You may need extra help with your baby at first. Supporting your scar with your hands when you cough, laugh or sneeze is helpful. A special breastfeeding pillow can be useful to help you position baby without pressure on your wound, as may trying different feeding positions. Ask your midwife for help.

Summary
Pain relief is very important, so don’t be afraid of it. By combining a number of drugs and adjusting their doses side effects can be reduced, whilst maintaining good pain relief. Most painkillers, including all those described here can be used whilst breastfeeding. If in doubt – ask!
And as ever, if you have concerns, ask your midwife or doctor for more information.

Hope yr having a good new yr

((hugs))

Brit
xxxx

Thank you. found it very helpful.

Emmaxxxxxxxxxxxxxxxxxx