Spinal Block for C-Section Surgery
What is Cesarean Section?
A cesarean section is the surgical removal of an infant through an abdominal incision. It may be called an "operative delivery" or "surgical delivery". Often, the name is shortened to C-section by doctors and patients, alike. The practice of removing a fetus in this manner goes back into antiquity. But despite popular belief, Julius Cesar was most likely NOT delivered this way. It's unclear if that is the origin of the name of the procedure, since that is a common legend. It is also thought that perhaps a relative of his was delivered this way, but there is no good evidence for this, either.
Prepping the Abdomen for a C-Section
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Anesthesia for Cesarean Section Surgery
Regional anesthesia is usually used for cesarean sections. Regional anesthesia includes spinal blocks, epidurals and combined spinal epidurals. Over 95 percent of C-sections are done with regional anesthesia.
General anesthesia is sometimes needed for cesarean sections. Usually, this is due to unforeseen failure of, or inability to place regional anesthesia. General anesthesia will more often be given in cases of emergency or "crash" c-sections where the baby, mother or both are at risk of impending death or severe complications. It usually takes longer to place a spinal or epidural than it does to rush the mother off to sleep in these dire cases. Many anesthesiologists also feel that it is easier to control the blood pressure and other vital signs with general anesthesia under these circumstances.
Epidurals are often used in women who have been laboring and already have them in place. They can be "dosed up" to be used during surgery. The medicine that is used during labor is not strong enough, doesn't usually reach high enough and isn't 'dense' enough for surgical anesthesia. So different medication will be bloused into the epidural catheter to make the block adequate for surgery. If the epidural isn't adequate (the doctors will test it before starting the surgery), then spinal or general anesthesia may be required as a backup plan.
Combined spinal-epidural techniques can also be used. Usually, the spinal portion was already done when the epidural was placed, and the epidural was already in place for labor.
A spinal block is the most utilized technique for elective cesarean section. Spinal anesthesia (not to be confused with a spinal tap-they are different) provides dense, reliable and safe anesthesia for most women undergoing c-section surgery.
Spinal Anesthesia for C-Sections
A spinal block is performed by injecting numbing medicine into the spinal fluid in the lower part of the spinal column. In humans, the spinal cord runs down the back from the base of the brain to the lower back. The spinal cord ends in area of the low back. For its whole length, the cord is surrounded by layers of protective membranes, the outer of which is called the dura mater. This tough membrane forms a sac around the cord that contains the CSF- the cerebrospinal fluid.
Spinals may be called sub-dural anesthetics, which just means below the dura. An intra-thecal anesthetic also refers to a spinal since the sac holding the spinal fluid is also called the thecal sac.
Before you get your spinal, you should have a chance to talk to your anesthesiologist and ask any questions that you may have. Make sure you give him or her as much accurate information as possible. Include information about medical problems you have and any medications you take, including herbals and over-the-counter remedies. Let him or her know if you have been sick recently. They will want information about your allergies and past reactions to anesthesia. It can be helpful if you can express any particular concerns or fears that you have. Also, be honest about the last time you had anything to eat or drink.
Spinal Anesthesia Procedure for C-Section
Sometimes, the worst thing about a procedure is the anticipation or the fear of the unknown. Most of the time, patients will report after spinal anesthesia that it wasn't nearly as bad as they had imagined. The needle that is used is quite thin. The injection of the numbing medicine for the skin is often the most uncomfortable part.
Position: For the spinal, you will either be sitting or lying on your side. I prefer sitting as I find it easier to keep the back aligned. Other anesthesiologists prefer the lying position. There is no right or wrong position and all providers have done both. Once in position, you will be instructed to round out your low back toward the anesthesiologist. This is the opposite of arching your back. Push your low back out. I always say curl around your baby or push your back like a halloween cat. This opens the spaces between the backbones and makes the rest of the procedure easier for everyone.
Palpation: Once you seem to be in good position, your anesthesiologist will feel your backbones and perhaps the top of your hips. This helps the anesthesia doc find an appropriate space for spinal placement.
Skin Numbing: After this, you may feel his or her finger on your back. You should then get a warning that you will feel a 'pinch and burn' in that little spot. This is the numbing medicine (usually lidocaine) for the skin and tissues below the skin. We try to inject this slowly so it doesn't hurt any more than necessary. Some people barely feel this, some feel a pinch and some think it burns quite a bit. (Personal note: As a patient, I did not feel any burning, just a tiny pinprick-not bad).
Spinal needle (top) and introducer hub (below)
Needle Placement: After this a short "introducer needle" may be placed into the skin. This hollow needle acts as a guide for the very skinny and more flexible spinal needle. The introducer only goes a short way into the numb skin. It should feel like pressure or pushing on that spot in your back and you should not feel sharp pain. After that is done, the spinal needle is placed through the introducer. It then passes layers of skin, fat, ligaments and the epidural space. Finally, the skinny spinal needle pierces or separates the fibers of the dura. The anesthesiologist can feel the 'pop' of the needle go through this layer (but you usually won't). When he or she feels this, spinal fluid will drip back out of the end of the needle.
Confirmation of Correct Placement: Return of CSF (spinal fluid) is confirmation that the needle is indeed in the spinal space (also called subdural, subarachnoid or intrathecal space).
Injection of Medication: A carefully selected medication, or combination of medicines, is injected slowly into the spinal fluid. Often, we will pull back on the syringe to make sure we still have CSF return and that the medicine is still going into the spinal fluid.
Monitoring of Vital Signs: Once the med is all placed, you will be helped into position for surgery. You will lie on your back and have a bump or wedge placed under your right hip to tilt your uterus and baby so they are not compressing the big blood vessels in the abdomen. Your arms will be extended out away from your body and allowed to rest on special armrests. It's important that you keep them there so you don't interfere with the sterile area or the surgery.
Treatment of Side Effects: The most common side effect right after placement of the spinal is nausea and sometimes vomiting. While you will be numb up to about mid-chest level, the spinal affects different parts of your nervous system. Low blood pressure is fairly common after spinal placement and nausea is often the first sign, sometimes occurring before the blood pressure cuff has even had a chance to show it. If you feel nauseous when laying back down after getting your spinal, tell the anesthesiologist. This is usually pretty easily treated. Other side effects may require reassurance. Because the chest wall gets numb, you may feel like you aren't breathing well, but the monitors will show that you are. If you feel this and especially, if it makes you feel anxious, tell the doctor so they can reassure you and increase your oxygen if necessary. Itching is another common effect of some of the medicines that can be used in a spinal. If it is bothersome, tell the doc so they can treat it (although they may wait until after the baby is delivered)
Test: Before the surgeons start the operation, the anesthesiologists and then the surgeons, will test to make sure your abdomen up to your chest is numb. You must be numb much higher than where the actual incision goes because of the way the nerves communicate with each other.
During Surgery: Your anesthesiologist will stay with you for the entire surgery until you go to the recovery room. He or she is carefully monitoring your vital signs on a continual basis. Even if they don't say much, they are there making sure you stay safe.
Spinal Anesthesia Video - Watch the administration of a spinal block for cesarean section.
Spinal Block Recovery
As the spinal wears off, you will be able to feel and move your toes first. It may start to wear off from the top down, too. The area of the incision will hopefully stay numb for as long as possible! Most spinals are mostly worn off in about 3 hours, but can take up to 6 hours or more to be completely gone. You may get a 'pins and needles' feeling as it wears off. This is normal.
Spinal Anesthesia - Effect on Your Baby
Because the medication used in spinal anesthesia is deposited into the spinal fluid and not into the bloodstream, less is absorbed by the body and passed to your baby.
There may be some medication that reaches the baby before delivery, but it is minimized by this technique. A local anesthetic is used in the spinal. Sometimes narcotic pain medication is added to the numbing to help with pain relief after surgery.