Regional Anesthesia (Vaginal birth and caesarean section)
The spine is formed by a series of bones successively standing on the top of another (vertebra) and having bone processes backwards referred as spina. Spinal cord and nerves are located inside the spinal column and this structure provides nerve equipment to the body. Spinal cord is located inside a sac consisting fluid. The fluid surrounding the spinal cord is named as spinal fluid and the space is referred as spinal space or spinal gap. The space surrounding the spinal sac from outside is the epidural space. When anesthetics are applied to these spaces, regional blocks occur. For epidural anesthesia, an epidural needle or the catheter is inserted into the epidural space; for spinal anesthesia, the spinal needle or the catheter is inserted into the spinal space. Nerves are desensitized by injecting local anesthetics into those spaces. Spinal and epidural anesthesia have the same effect (a wide region of the body becomes numb), because nerves are anesthetized at the branching site in both techniques. Because spinal injection is applied more directly (closer to the nerves), its effects start immediately. In combined spinal-epidural anesthesia, spinal injection is followed by the placement of epidural catheter. Effects start immediately and the anesthesia is maintained using the epidural catheter.
Side Effects and Complications of Regional Anesthesia
Although anesthetists take several measures in order to prevent complications of the anesthesia, side effects can still be seen.
Low blood pressure (Hypotension)
The incidence (occurrence rate) is 10-15% in vaginal births and 25% in caesarean sections. It is easily treated with ephedrine and intravenous fluids. Nausea can be seen due to rapid decrease of the blood pressure.
It is a common reaction. Sometimes, it can be seen without use of the anesthetics as well. Warming the concerning subject helps to reduce shivering. Itching: This condition occurs due to the narcotics used in epidural and spinal anesthesia It is generally well tolerated. If itching could not be well tolerated, then local anesthetics can be given in single administration.
Local anesthetic reaction
Although local anesthetic reaction is rarely seen, it can be serious. Respiratory problems: In rare cases, anesthetic drugs may affect chest muscles and cause difficulty in breathing. Oxygen can be given in order to aid breathing.
In pregnancy, veins located in the epidural space dilate. There is a risk with regards the injection of anesthetics into these vessels. Your anesthetist administers a test dose at first in order to help prevention of resultant adverse reactions.
Inability to relieve pain in some regions
Epidural anesthesia may not work well in 10% of the cases. Sometimes, anesthetic drug cannot reach a specific region and there may be an area sensing the pain. In some cases, epidural catheter has to be removed and placed again. Low back pain: You may experience a localized pain in low back due to the placement of the needle and it lasts approximately for one day. In addition, you may have a generalized low back pain but it is not necessarily due to epidural administration. Frequency of low back pain increases depending on changes in the connective tissue resulting as a result of the pregnancy. This incidence of this complaint is 50-75%. It is seen whether epidural analgesia is applied or not It generally lasts days or weeks.
Paresthesia (feeling the neural sensations) There is a tendency to link the postpartum nerve problems to the epidural anesthesia because epidural anesthesia is performed via lumbar catheterization. However, the most neural problems, which occure following labor and birth, develop due to the babyls movements in the vaginal canal resulting with the influence on nerves and rarely due to the regional anesthesia If weakness or other nervous problems occur in legs, anesthetist must assess the condition and carry out the appropriate follow up. When the epidural catheter touches the nerves in the epidural space during placement, a temporary inerve sensation/electric shocki may develop. Although such sensation is frequently experienced during epidural injections, permanent nerve damage is very rare. The rate of nerve injury is less than 1/10000.
The headache occurring after labor and birth which has no relation with the epidural anesthesia may have several reasons. However, ad-lough t is rare, headache may develop following the epidural block (<% 1). This condition develops due to pinhole of the needle on the spinal sac during epidural process. Spinal fluid leaking into the epidural space may lead to the headache. Headache generally develops within 24 hours following the epidural block Typically, the headache increases at sitting position and decreases at lying position. This head and neck problem which may last for a few days can be reduced or eliminated using simple methods such as lying drinking fluid and taking painkillers. If the headache persists or problems are experienced along with headache such as nausea, difficulty in looking at light and hearing strange sounds, additional treatment may be required. Headache can be very effectively eliminated by epidural blood patch. Pain in shoulders: Pain spreading to the chest and shoulders can be seen in 5% of the patients. It results from the stimulation of the diaphragm by blood or amniotic fluid. It can be relieved by lying in a position where the head is 5-10 degree upwards and by roughly rubbing the shoulder girdle. Epidural hematoma, abscess and death: They are seen very rare (less than I / I 00000). Your anesthetist will assist you in evaluating the problem and for an appropriate follow up.
Regional anesthesia is preferred as much as possible because it minimizes respiratory complications. General anesthesia is applied in cases that regional anesthesia is not the most appropriate option based on medical or other reasons. For example, when immediate caesarean section is required, there may not be enough time for regional anesthesia Use of regional block is also not appropriate under some bleeding conditions. The underlying reason is that small bleedings resulting from perforations or injuries, which can occur in epidural veins while epidural catheter is placed, may not be stopped by coagulation (clotting) system of the body. The blood mass (hematoma) can compress the nerves and surgical intervention may be needed. In addition, when regional anesthesia cannot be adequately accomplished or when catheter cannot be placed, the procedure is deemed as failure and the general anesthesia can be performed. Besides these, the fear of regional anesthesia or the preference of the general anesthesia by the mother may be other reasons. In the general anesthesia, the drugs are used, which are safe for your baby. Selection of the anesthesia method is determined according to your clinical and medical conditions.
FREQUENTLY ASKED QUESTIONS
Is anesthesia harmful for the baby?
Both general and regional anesthesias are safe and have no significant effect on baby. Anesthetics, which pass through the placental barrier at minimum level and will not harm the baby, are preferred. Although undesired risks are almost equal in both methods, the regional anesthesia is more advantageous. During both regional and general anesthesia, safety monitors are used in orderto monitor vital functions of the mother and to ensure that they are within the necessary ranges with regards the babyls health.
Is fasting necessary for caesarean section?
Regardless of the anesthesia method used, 8 hours of fasting is necessary before any elective surgery. Additionally, a gastro-protective and anti-nausea drug can be intravenously given. One of the most important concems during the general anesthesia is whether any food or liquid is present in mothen's stomach. When consciousness is lost, aspiration (gastric contents are aspirated to the lungs) may occur. When this happens, pneumonia or respiratory problems may develop. Therefore, if the mother is not at fasting condition, additional measures are taken to protect lungs.
How are spinal and epidural anesthesia felt?
Most women define spinal anesthesia as feelings of warming and tingling which immediately start in legs (I -2 minutes) and spread to the body.
Afterwards, numbness and heaviness are felt in legs. After spinal anesthesia is employed, anesthetist determines anesthesia level in order to assess distribution of the numbness. it is common to feel numbness throughout the body ranging from lower level of the chest to the feet In the epidural anesthesia, these feelings start more slowly (5-15 minutes); numbness in legs, loss of sensation and paralytic states are as intense as in the spinal anesthesia In general, the feeling of touch and deep sensation remain. Under the spinal and the epidural anesthesia, pain is not felt during the surgery. However, surgical interventions to lower parts of the body are discerned. Particularly, feelings of ipulling and hanging can be experienced when the surgeon moves abdominal muscles and tissues. Furthermore, surgeon may apply pressure on abdomen in order to facilitate the birth. This can be felt as pressure on the chest.
Can epidural catheter, which is placed for painless birth, be used in the epidural caesarean section?
Birth may begin in the form of normal vaginal delivery and then it may turn into caesarean section as a result of urgent or non-urgent new occurrences. If epidural catheter has been already placed and it is still operable, anesthetists prefer to give additional drugs through the catheter for ensuring the state of numbness at a sufficient level for the surgery.
What are the advantages of the combined spinal-epidural anesthesia?
The combined spinal-epidural anesthesia (CSE) combines the advantages of both techniques. Effects of anesthetics start immediately, pain is suppressed more effectively, and negligible amounts of drugs are released to other systems of the body and to the baby, since lower doses of drugs are used. As a result, better satisfaction of the mother is the primary advantage.
Does combined spinal-epidural method have any risk different from that of epidural one?
This method does not have any risks different from the epidural anesthesia Although there are several techniques, needle-through-needle technique is the most common approach in CSE. In approximately 4-5% of the cases, spinal space cannot be accessed due to the technical difficulties and only epidural catheter is placed.
Do general anesthesia medications cause any damage in the baby?
Drugs used for starting and maintaining the sleeping state are not harmful forthe baby, because the type of anesthetic drugs and the dose reaching to the brain are not enough to make the baby sleep. Here, the most important barrier (the structure preventing the passage of drugs) is the placenta. For this reason, babies are active and they cry immediately after the birth, while mothers are still sleeping.