Caesarean section: A guide to anaesthesia

Over 1 in 3 babies are born by caesarean section and almost half of these are unexpected; you should therefore read this information even if you do not expect to have a caesarean yourself.

This guide explains your choices for anaesthesia for caesarean. You will be able to discuss them with your anaesthetist prior to your operation. Your anaesthetist is responsible for your wellbeing and safety during surgery. Anaesthetists are fully-qualified doctors who have had further training in anaesthesia and pain relief.

Your caesarean section may be planned in advance; this is called an elective caesarean section. This may be advisable have been advised if there is an increased chance of complications developing during a vaginal delivery or you may choose to have a planned caesarean.

In some cases a caesarean section may be recommended in a hurry, usually when you are already in labour. This is an emergency caesarean section. This may be recommended, for example, because of unsuccessful labour is not progressing in labour or because you or your baby’s condition becomes concerning.

Types of anaesthesia

There are two main types: you can either be awake or unconscious. Most caesareans sections are done with you awake under regional (spinal or epidural) anaesthesia, when the sensation from your lower body is numbed. It is usually safer for you and your baby and allows both you and your partner to experience the birth together.

Advantages of regional compared with general anaesthesia

• Spinals and epidurals are usually safer for you and your baby.
• They enable you and your partner to share in the birth.
• You will not be sleepy afterwards.
• They allow earlier feeding and contact with your baby.
• You will have good pain relief afterwards.
• Your baby will be born more alert.

Disadvantages of regional compared with general anaesthesia

• Spinals and epidurals can lower the blood pressure. This happens commonly after a spinal (1 in every 5 women), and occasionally after an epidural (1 in every 50). This is easily treated with the fluids given through your drip and by giving you drugs to raise your blood pressure.
• Regional anaesthesia can take longer to work than general anaesthesia.
• Occasionally they make you feel shaky.
• They normally work but sometimes a general anaesthetic is needed. This happens in about 1 in every 20 women following an epidural and in 1 in every 100 women following a spinal.

Side effects of spinal and epidural and epidural anaesthesia

• Itching during the operation from the morphine-like pain killer used.
• Local tenderness in your back for a few days.
• Headache in less than 1 in 100 following an epidural or 1 in 500 following a spinal (uncommon) – this can be treated, occasionally requiring another injection in your back.
• Rarely tingling down one leg, a residual numb patch on a leg or foot or a weak leg lasting for several weeks or months (in 1 in 1000) spinals/epidurals). Permanent nerve damage is even more rare, - it occurs in about 1 in 100,000.
• Infections (epidural abscess or meningitis) and epidural haematoma (a blood clot) are very rare.
• Severe injury, including being paralysed is extremely rare (1 in 250,000)

Spinals and epidurals do not cause chronic backache

Backache is common after childbirth, especially if backache occurred before or during pregnancy. Epidurals and spinals anaesthesia do not make it more common.

What happens when an elective caesarean section is planned?

Pre-operative assessment

Normally you will visit the hospital have a telephone “pre-op” appointment with a midwife the week before you come in for your an elective caesarean operation. The midwife will complete some essential assessments, explain what needs to happen before the surgery, discuss what to expect on the day and also confirm your birth preferences. The midwife will see you, You will be asked to attend Rosie phlebotomy take a for some blood and MRSA sample for tests and explain what to expect. You will also be given to collect your “pre-op pack” which includes some tablets you need to take prior to the surgery. These are to reduce the acid in your stomach and prevent sickness and; you will need to take one the night before the operation and one on the morning of the operation. The instructions are included with the medication.

It is important that you do not eat (including sweets or chewing gum) or drink anything containing milk for at least six hours before your operation. This is to ensure your stomach is empty and that if you were to vomit while under anaesthesia, you would not inhale food particles that could damage your lungs. In order to ensure your safety, your operation will be postponed if you do not follow these this instructions.

You may be allowed home, to return to hospital on the morning of your operation.

You should continue to drink water, dilute squash or non-carbonated isotonic sports drinks as needed until around 2 hours before your operation to ensure you stay hydrated. If you are coming in for surgery in the morning please do not drink after 6.30am; if you are coming for afternoon surgery please do not drink anything after 11am.

The anaesthetist’s visit

The anaesthetist will come and see you, normally on the morning of your operation. They will review your medical history and any previous anaesthetics and may need to examine you. The anaesthetist will also discuss the anaesthetic choices with you and answer your questions. The anaesthetist may also allow you to drink some more water while you are waiting and they will give you a time at which to stop drinking in order to make sure surgery can proceed safely.

Coming to theatre

You will normally walk to theatre with your birth partner and midwife. Before coming to theatre you will need to put on a hospital gown and wear a wrist and ankle identification band. You will also be asked to wear compression stockings, to reduce the chances of blood clots in your legs. Just before going to theatre you will be asked to remove your underwear as you will need to have a urinary catheter (a tube inserted into your urethra to keep your bladder empty).

Your birth partner will be shown where to change into theatre clothes (scrubs) and will be provided with shoe covers and a white hat to wear. They can bring a phone/camera into theatre to take photos of the baby and must keep valuables in their pocket. The rest of your belongings will be placed in the recovery area where you will be transferred to after the operation. While this is generally a secure area, your bags will be unattended so no valuables should be left in them.

There are a lot of people who work in the operating theatre including the anaesthetist and their assistant, obstetrician and their assistant, the scrub nurse, the theatre nurse, the midwife and in certain circumstances a neonatologist. Additionally there may be students present as this is a teaching hospital. Please let us know in advance if you do not wish to have any students involved in your care.

What to expect if you are having a regional anaesthetic

This is done in the operating theatre. One birth partner may stay with you throughout. Before the anaesthetic is started you will be asked to confirm your name, date of birth and the operation you are going to have.

A cannula (a small plastic tube inserted into a vein using a needle in order to give fluids and medication) will usually be placed in your hand or wrist using some local anaesthetic. Equipment to monitor your blood pressure and heart rate will be attached at this stage. An antibiotic is routinely given into your cannula to reduce the chance of a post-operative wound infection.

You will be asked to either sit or lie on your side, curling your back outwards. The anaesthetist will clean your back with sterilising solution. They will then find a suitable point between two of the bones in the middle of your back and inject local anaesthetic to numb the skin.

For a spinal, the next step is to pass a fine needle through this numb area and into the spinal fluid. Sometimes you might feel a tingling going down one leg as the needle goes in, like a small electric shock. You should mention this but it is important that you keep still. Next, the mixture of local anaesthetic and an opiate pain-relieving drug are injected. It usually takes just a few minutes, but if it is difficult to place the needle, it may take slightly longer.

For an epidural or a combined spinal-epidural, a larger needle is needed to allow the epidural catheter (tube) to be threaded into the epidural space but otherwise you will be positioned the same as for a spinal.

You will know the spinal or epidural is working when your legs begin to feel tingly, heavy and numb. Numbness will spread gradually up your body and reaches the middle of your chest before the operation. The anaesthetist will check with either a cold spray or by testing touch sensation that you are ready for the operation. Sometimes it is necessary to change your position to make sure the anaesthetic is working well. Your blood pressure will be checked frequently.

You will be lying on the theatre table with the table either tilted to the left or with a wedge placed under your right hip. This is to prevent your baby pressing on the blood vessels in your abdomen which can make your blood pressure drop.

If you feel sick at any point you should mention this to the anaesthetist. It is often caused by a drop in your blood pressure and the anaesthetist will be able to give you appropriate treatment.

The operation

A sterile drape will separate you and your partner from the surgeons. The anaesthetist will stay with you throughout to ensure you are comfortable and safe. Once you feel numb, a midwife will insert a tube (urinary catheter) into your bladder to keep it empty during the operation. This is usually removed the next morning.

Once the operation is underway you may feel pulling and pressure, but you should not feel pain. It has been described as being ‘like someone doing the washing-up in my stomach’. The anaesthetist will assess you throughout the operation and can give you more pain relief if required. Whilst it is unusual, it is sometimes necessary to give you a general anaesthetic.

From the start it takes about 10 to 15 minutes before your baby is born. It may take longer if you are having a repeat caesarean. Immediately afterwards, the obstetrician will pass your baby to the midwife, who will usually dry and quickly examine your baby and support you with skin-to-skin contact. A neonatologist may also be present.

Immediately after the birth, a synthetic version of the hormone oxytocin is given into your cannula to help your uterus contract and deliver the placenta. The obstetrician will take approximately another 30 minutes to complete the operation.

At the end of the operation a pain-relieving suppository may be given (this is inserted into the rectum – “back passage” while you are still numb). This gives good pain relief as the spinal/epidural wears off.

When the operation is over

You will be transferred onto your bed and then taken to the recovery area with your baby and partner. Here we monitor your blood pressure, heart rate, breathing rate and vaginal blood loss for at least two hours to ensure all is well.

The spinal anaesthetic will gradually wear off over the next few hours and you often feel tingling in your legs. Within a couple of hours you will be able to move them again and by 4 hours you should be able to lift your legs off the bed without assistance. When you feel ready to stand out of bed for the first time after the operation you should make sure that there is someone to assist you.

It is usual to be prescribed regular pain-relieving tablets (paracetamol and usually ibuprofen) four times a day. The midwives will be able to give you additional pain relief if required. Assuming your baby is born after 37 weeks and is healthy, all of these medicines are considered safe and will not affect your baby if you intend to breastfeed.

What to expect if you need a general anaesthetic

Your partner cannot be present in theatre but can wait in the recovery area ready to receive your baby. You should not eat or drink and will need to take tablets to reduce stomach acid as per the pre-operative assessment section above.

On arrival in the operating theatre, you will be given an antacid to drink. A cannula (a small plastic tube inserted into a vein using a needle in order to give fluids and medication) will usually be placed in your hand or wrist using some local anaesthetic. Equipment to monitor your blood pressure, oxygen levels and heart rate will be attached at this stage. An antibiotic is routinely given into your cannula to reduce the chance of a post-operative wound infection.

The anaesthetist will give you oxygen to breathe through a face mask for 3 minutes. Next, the anaesthetist will give the anaesthetic through the cannula and you will rapidly lose consciousness. Just before you lose consciousness we will press lightly on your neck. This is to prevent stomach contents getting into your lungs.

When you are unconscious a tube is placed into your windpipe to allow a machine to breathe for you and to prevent stomach contents from entering your lungs. The anaesthetist will continue to give you the anaesthetic throughout the operation and ensure your continued safety.

When your baby is born your midwife will dry and check your baby, place identity bands on your baby’s cord clamp and ankle and, if your baby is well, they will take your baby to your birth partner. If there are any concerns about your baby a neonatologist will assess your baby.

When you wake up your throat may feel uncomfortable from the tube, and you may feel sore from the operation. You will also feel sleepy for a couple of hours. You will be taken to the recovery area where you will meet up with your baby and birth partner. You may be given a patient-controlled analgesia (PCA) pump which allows you to inject a small amount of morphine painkiller into your drip at the press of a button when you feel pain.

Some reasons why you may need a general anaesthetic

• Your baby may need to be delivered so urgently that there is not time for regional anaesthesia to work.
• In certain conditions when blood cannot clot properly, regional anaesthesia is best avoided.
• A very abnormal back may make regional anaesthesia impossible.
• Occasionally spinal or epidural anaesthesia does not work properly. This happens in 1 in 20 following an epidural and 1 in 100 following a spinal.

Emergency caesarean section

It may become necessary to deliver your baby urgently by emergency caesarean section.

When possible this will be performed under regional anaesthesia. If you already have an epidural catheter for pain relief in labour, then this may be topped up with stronger local anaesthetic. This will normally give excellent anaesthesia for the operation. Alternatively a spinal anaesthetic may be performed.

General anaesthesia may be necessary if your baby needs to be delivered very urgently, when regional anaesthesia is inappropriate or the spinal or epidural has not been fully effective.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches), a current repeat prescription from your GP.

Laxatives and painkillers may be required after your hospital stay - ensure you have appropriate supplies at home.

Please tell the ward staff about all of the medicines you use. If you wish to take your medication yourself (self-medicate) during your stay then ask your nurse.