Epidural Anesthesia for Cesarean Sections

Introduction

Cesarean surgery is for childbirth when the baby delivers through an incision given in the lower abdomen and womb. This surgery requires specialized anesthesia to perform and reduce the pain. The anesthesia used mainly is epidural anesthesia. Pain during childbirth or labor is very intolerable and affects the mother and the baby. All women experience different levels of pain. However, it is not similar for everyone. Therefore, anesthesia is required to control the pain in women. The doctor uses regional anesthesia commonly. Epidurals are regional anesthesia.

What Are Cesarean Sections?

Cesarean is required when the baby fails to be born through a vaginal path because of the position of the baby or placenta position or when the mother or baby is at risk. So, the cesarean is the plan to extract the baby from the womb by giving cuts to the lower abdomen and womb. There are few possibilities for having confirmed cesarean surgery. They are:

• Labor pain fails to occur naturally.

• Previous history of cesarean cases.

• The baby presents in an odd position, making him unable to use the vaginal path.

• The placenta is attached to the lower uterus.

• Mother with twin case.

How Is Cesarean Surgery Performed?

The doctor starts the cesarean surgery after the anesthesia starts working. The patient has numbness in the leg and lower abdomen area. The doctor gives a horizontal incision (cut) about 4 to 6 inches in the abdomen near the pubic hairline. The incision goes from deep skin to fascia to the uterus walls, and the baby delivers through the cut. It takes an hour to complete the surgery. The baby takes 10 to 15 minutes, even less in an emergency. After baby delivery, the stitchings of the uterus wall and fascia are done. Again, the stitchings take time, more than the baby’s delivery.

What Is the Anesthesia Given in Cesareans?

Anesthesia used in cesarean can be epidurals, spinal or general anesthesia. Depending upon the case, the anesthesia is decided. It includes:

• Epidurals - Epidurals are the most commonly used regional anesthesia in cesareans. Before going for surgery, epidurals are given on the back of the patient, in the epidural spaces just outside the spinal sac by injection or by some specialized catheter, relieving the patient from pain.

• Spinal Blocks - Spinal blocks are used along with epidurals in cesareans. Spinal blocks are given at the back of the spinal sac by injection or by a tiny catheter. It numbs from the abdomen to the legs and relieves the pain. It lasts for about three hours.

• General Anesthesia - It relieves the pain but loses the patient's consciousness. General anesthesia exposes the baby to some medication. It is ideally not the doctor's first choice, but in cases like a mother bleeding or being unstable to cooperate during surgery, make a doctor use general anesthesia.

How Is Epidural Anesthesia Administered?

Epidural anesthesia is administered to the patient by laying the patient on one side or making the patient sit. The skin is cleaned with an antiseptic solution. Local anesthesia is applied to lower the pain of the needle used. A specialized catheter with a needle containing an exact appropriate dose of medicine is inserted in the epidural space just outside the spinal sac.

After maintaining a proper position, the catheter remains even after removing the needle. The catheter remained to provide medicine for pain relief post-surgery. The epidural takes 10 to 15 minutes to work. It lasts for about three hours.

There are a few guidelines for the administration of epidural anesthesia. They are:

• An anesthesiologist should conduct an evaluation and should have informed consent.

• Emergency equipment should be present to handle the complication during the surgery.

• Always disinfect the skin with two percent Chlorhexidine.

• Monitoring fetal blood pressure and maternal blood pressure is essential.

• The infusion rate of anesthesia needs to adjust to minimize the effects and complications.

• Monitor the respiratory rate.

• After the delivery, remove the catheter.

What Are the Drugs Used in Epidural Anesthesia?

The drugs used in the epidurals are the same as in local anesthesia. Some factors to consider in selecting the most appropriate amount of anesthesia are surgery duration, surgery requirement, and duration of anesthesia. Chloroprocaine, Lidocaine, Mepivacaine, Bupivacaine, and Ropivacaine are used in epidural anesthesia. Epidural anesthesia should have preservation-free solutions. Epinephrine is also used in epidural drugs to increase the effectiveness of the block by reducing toxicity and bleeding.

What Are the Complications Related to Epidural Anesthesia?

Anesthesia during surgery does have some complications. It includes:

• The most common complication doctor faces the post-dural puncture headache occurring due to the puncture of the dura with a needle. And the headache is usually caused by leakage in a cerebrospinal fluid resulting in lowering intracranial pressure. The doctor often resolves the headache with an epidural blood patch.

• Postpartum urinary retention can also occur but can be controlled by avoiding sensory blocks.

• Hypertonic uterine contractions are also seen but managed by Nitroglycerin or Terbutaline.

• Maternal hypotension is present in 80 percent of the patients. If a decrease in blood pressure occurs, it can cause less blood flow to the fetus. So, before epidurals, the doctor gives an isotonic electrolyte solution to the patient.

• Some rare but serious complications are epidural hematoma (when blood gets collected in the epidural area), epidural abscess (when fluid gets collected in the epidural space and can cause swelling and pain), or neurologic injury.

• Even a high dosage of anesthesia can cause respiratory and cardiac arrest.

What Are the Contraindications for Epidural Anesthesia?

Contraindications to epidural anesthesia during labor include:

• Patient refusal.

• Maternal hemorrhage.

• Infections.

• Signs of coagulopathy.

• Septicemia (blood poisoning by bacteria and its toxins).

Conclusion

Epidural anesthesia is a very effective way to go through cesarean surgery by reducing the intolerable pain of the patient (mother). The doctor can combine the epidurals and spinal blocks. For combined epidural-spinal cesarean sections, spinal anesthesia is initially delivered, followed by epidural anesthesia with a catheter. The catheter is removed at the end of the surgery. It takes nearly 15 minutes to work and lasts for about three hours. Then, the cesarean surgery starts with a horizontal cut on the lower abdomen. Unfortunately, epidural anesthesia shows complications of maternal hypotension and post-dural headaches. Some cases even have urinary retention as a complication of epidural anesthesia. Complete management to overcome the difficulty makes a success in surgery.