Obstetrical Surgery

Providing anesthesia to women in labor allows us to participate in the miracle of childbirth, and Metro-west Anesthesia offers a wide breadth of services in labor and delivery.
Good prenatal care before the birth of your baby can mean the world of a difference in the experience that you have during this momentous event. When you meet with your obstetrician before your labor and deliver, please make sure to tell that doctor about your entire medical and surgical history. Please tell them about any allergies as well.
Your complete medical and surgical history is important, and there are certain items that are of particular interest to anesthesiologists:

Any issues with a previous labor and delivery
Any issues with a previous spinal or epidural that was placed for any reason
Any issues related to your back, including previous back surgery or a history of scoliosis
Any medications that you take that may cause you to bleed more easily, such as warfarin (Coumadin), clopidogrel (Plavix), or apixaban (Eliquis).
Any history of blood clots in the legs or the lungs
Any issues with pain medication, which includes chronic use of pain medications or a history of pain medication abuse.
The use of pain medication blockers, such as naloxone or naltrexone
All of your allergies
Any history of neuromuscular disorders, which are medical problems that make you weak in your muscles.
A history of seizures
A history of a bleeding disorder
Any heart or lung problems
Any history of a stroke
Any liver or kidney problems

It is often preferred to deliver a patient vaginally to avoid a surgery, but there are many reasons for a woman to need a cesarean section. Regardless, a cesarean section is also a very safe procedure with multiple options for anesthesia.

Anesthesia for Vaginal Delivery

If you are planning to have a vaginal delivery, there are options for pain management during this particular event. An epidural catheter is a popular choice. Other options include a combined spinal epidural, intravenous (IV) medications, or a natural delivery.

Epidural Anesthesia

When you have an epidural catheter placed, a small flexible catheter made of plastic is placed in a special area of your back. Numbing medication and pain medication are injected in to this catheter and cause numbness and pain relief in the area where you are feeling contractions. Your epidural may be placed by an anesthesiologist or a certified registered nurse anesthetist (CRNA). Make sure to tell your anesthesia provider if you are on a medications that make you bleed or if you have back problems.
If you are planning on having an epidural, then you may expect the following steps:

We will perform something called a “Time Out,” where we verify your medical information before we place your epidural.
You will be sitting on the hospital bed. A nurse or a person of your choosing may be sitting in front of you to coach you through the process.
The anesthesia provider will clean off your lower back with a cleaning solution, and a drape will be placed on your back afterwards.
Your back may be palpated to feel for the bony landmarks of your back.
Some numbing medication may be injected into the skin and soft tissues of your back.
A separate needle will be used to find a special area of your back called the epidural space.
When we get into that space, a small flexible catheter made of plastic will be advanced into that space. You may feel a funny feeling like numbness, tingling, or pain in your leg, and let your anesthesia provider know if this happens.
Then, we will test the catheter by doing a “test dose.” We will ask you to let us know if you have and ringing in your ears, funny taste in your mouth, funny feeling in your legs.
We will then tape the catheter to your back.
We may give additional medication through the epidural to control your pain.
A medication pump will be hooked up to your epidural to inject a constant infusion of medications through your epidural. There will also be a button to press for additional medications. You may experience additional pain as your labor progresses. You can press this button for additional pain relief. You do not have to worry about overdosing your epidural, since the infusion pump controls for that.

An epidural is a very safe option that has been used for countless women in labor. Scientific literature has shown that the epidural does not significantly slow the progress labor. There can be a little bit of a slowing of certain stages of labor, but it is generally thought that this difference is not clinically significant. There are rare complications of the epidural that would include infection, bleeding, nerve damage, nerve irritation, or a headache.
A combined spinal epidural is very similar to an epidural. However, before the flexible catheter is placed, a separate injection is made to offer additional pain relief. It is to the discretion of the anesthesia provider to perform this procedure.
Intravenous medications can be used for labor pain relief. However, they can often be sedating to the mother, which makes it difficult to participate in the delivery when the time comes. Additionally, there can be some effects to the baby that are undesirable.

Anesthesia for Cesarean Section

Your obstetrician may decide that you need a cesarean section for a number of reasons. This may be decided before the day that you present to the labor suite or it may be decided on the day of your delivery. The decision to have your cesarean section on the day of your delivery may be declared an emergency, meaning that the baby must come out as soon as possible. On the other hand, you may also need an urgent cesarean section, which means that the baby must come out soon, but there is some time that we can wait beforehand.
If you already have a labor epidural, then this epidural may be used as the surgical anesthetic for your cesarean section.
If you don’t have a labor epidural, and there is a little time before the baby needs to come out, then a spinal may be performed as the surgical anesthetic.
If you are having a spinal, you will sit on the operating room table. Monitors will be placed to monitor your vital signs. A time out will be performed to verify your medical information. Your lower back will be cleaned off by your anesthesia provider. A small amount of numbing medication will be placed in the skin and soft tissues of your back. A separate needle will be used to find a special area in your back. Numbing medication and pain medication will be used to numb up the area that you are having the surgery. A spinal is a very safe way to have a cesarean section, since the baby and mother are not too heavily sedated. Like an epidural, there is a small risk of infection, bleeding, nerve damage, nerve irritation, or a headache with a spinal.
If you are having an emergency cesarean section or if your spinal or epidural are not working, then the decision may be made to do your cesarean section under general anesthesia. If you are having general anesthesia, you will be taken to the operating room. Monitors will be placed to monitor your vital signs. Oxygen will be delivered through a mask. Medications will be placed in your IV line to make you fall asleep. Once you are asleep, a breathing tube will be placed. At the end of your surgery, the breathing tube will be removed once you are breathing on your own. General anesthesia is usually very safe, but there is a risk of sore throat, hoarse voice, injury to the mouth or teeth. Sometimes, general anesthesia can contribute to bleeding and sedation of the baby and mother. General anesthesia will only be performed if the benefit outweighs the risks.

Labor Epidural FAQ

What is an epidural?

An epidural is a regional anesthetic block that helps diminish the pain associated with labor and delivery. You will be sitting or lying on your side. An anesthesia provider will numb a small area of skin between two backbones of the lower back. The block is administered below the level of the spinal cord. A needle will be placed until the epidural space is identified. The epidural space is the area located around the envelope, which surrounds the spinal cord, called the “dura”. A small flexible tube called an epidural catheter is inserted through the needle into this epidural space, then the needle is removed and the catheter is taped in place. Local anesthetic is given through the catheter continuously by a computerized pump. Fetal monitoring is routine before, during, and after the procedure. After the epidural is in place, you will notice a brief increase in the frequency of your blood pressure measurements.

How long does it take for the epidural to take effect and how long will it work?

What does it feel like when it is working?

What are the risks of an epidural block?

The most common complications of an epidural are minor and easily treated.

These are:
· A drop in blood pressure, which may also cause nausea and vomiting, is usually treated by intravenous fluids (fluid given into a vein).
· A headache can occur about a day after the epidural is placed. This is a rare occurrence which happens in only 0.5% to 2% of cases. It is treated by lying flat, taking oral fluids, and very rarely will require extra treatment by an anesthesia provider.
· Rarely, some of the local anesthetic can enter the spinal space or a vein. This can lead to temporary side effects such as headache, ringing in the ears, tingling around the mouth and very rarely seizures. Infection and spinal cord compression
are even more rare complications. These have never occurred at our institutions, however, be aware that we are extremely qualified to treat any of these untoward effects.
· Back pain can occur where the epidural was placed.
· Shivering may occur, and in fact, is very common.
· Although extremely rare, transient or permanent nerve damage can occur.

Will the epidural block affect my baby?

Will it slow down my labor?

Can any patient in labor have an epidural?

What If I need to have a C-section?

If an epidural was already placed earlier for labor, it can be used as the anesthetic for the delivery by adding stronger local anesthetic. Time permitting, one can also be placed in the C-section room for the patient who does not already have an epidural. A spinal block can also be used for a Cesarean delivery. This is placed very similarly to an epidural but a smaller amount of anesthetic is injected into the dura (the envelope surrounding the spinal cord) instead of outside the dura. The onset of numbness is more rapid. General anesthesia is also a possibility for C-section. It is used when an epidural or spinal is not possible or safe.