Anaesthesia for Caesarean Section.
Medical authorities such as the American Society of Anesthesiologists advise the use of spinal or epidural anaesthesia for caesarean section (http://www.asahq.org/news/asanews040207.htm). The use of general anesthesia for caesarean section in pregnant women can cause difficulty in airway management which might result in serious harm. The use of general anaesthesia is thus recommended to be reserved for caesareans associated with major bleeding or other complexities.
In most cases I would plan to use spinal anaesthesia with a fine non-cutting needle which minimises the risk of a spinal fluid leak which causes headache. If there are other factors or complexities, epidural or combined spinal anaesthesia might be used because an epidural enables reinforcement or prolongation of anaesthesia. If you have been already laboring with an epidural, the epidural would usually be reinforced with a strong dose and used for the caesarean.
After you arrive in the operating room, I place an intravenous drip in the hand or forearm. You will usually be asked to sit and curl over for the spinal injection. Your backed is thoroughly wiped with disinfectant and I scrub my hands and don a mask and sterile gown and gloves. A small injection of local anaesthetic in the skin is done before the spinal injection. The local anaesthetic can sting but the rest of the procedure is usually painless. The injection is done in the lower back between vertebral bones. It usually takes about half a minute, but can take longer in some people if the passage between the vertebral bones is difficult to find. Once the space and spinal fluid is found the injection is done and you lie down on your back with a tilt to the left. The anaesthetic block takes 10 – 15 minutes to take effect and during this time the theatre staff prepare things for the caearean.
I check the level of block: alteration of sensation should begin over the breasts to predict a good block for caesarean. This takes time to develop; sometimes another injection is needed to achieve that level of block. Blood pressure can fall with the onset of anaesthesia so you blood pressure is taken very frequently and medication is given into the drip to keep the blood pressure up.
You are still awake and will be aware of you body being moved, pushed and stretched. The weight of the baby and uterus may feel quite heavy and uncomfortable for the short time before delivery. If you wish, you can see your baby be delivered. Rarely, pain may be experienced but this can be treated with intravenous painkillers. Very rarely, general anaesthesia may be needed.
Delivery usually occurs about 10 minutes after starting surgery. After delivery you will usually receive an antibiotic (to reduce the risk of wound and uterus infection), anti-nausea drugs and oxytocin (to contract the uterus). It usually takes another 30 minutes for surgery to be completed and you will spend much of this time holding your baby. You are cleaned, and fresh linen is placed underneath you and you are taken to the recovery area for another 30 – 45 minutes of close observation before going to your hospital room. It usually takes 2-3 hours after the injection for the spinal to wear off. Pain Control after Caesarean
Most Melbourne hospitals use a “multimodal” oral regimen for pain control after caesarean. This is with tablets of oxycodone (“endone”), diclofenac (“voltaren”) and paracetamol. Recent studies confirm that such oral regimens provide good pain control after most caesareans (http://www.medscape.com/viewarticle/530952). You will usually be given the painkillers before the spinal wears off and will be offered them regularly for the first 24 hours. The oxycodone tablets can be taken as frequently as two-hourly. If this is not enough, a “rescue” dose of morphine can be injected under the skin.
Sometimes I offer a small dose of morphine with the spinal. This dose gives pain control 12 hours or more after the anaesthetic wears off but can cause a troublesome itch over the body or excessive sedation. I usually offer it if the patient has not tolerated oral painkillers in the past, or if the caesarean might be more complex with potentially more pain than usual.
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