Caesarean birth: 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 birth yourself.

This guide explains your choices for anaesthesia during a caesarean birth. You will be able to discuss them with your anaesthetist on the day. 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 birth may be planned in advance; this is called a planned caesarean birth (also known as an elective caesarean section). In some cases a caesarean birth may be recommended in a hurry, often when you are already in labour. This is an unplanned caesarean birth (also known as an emergency caesarean section).

Types of anaesthesia

There are two main types: you can either be awake or asleep (unconscious). Most caesarean births are done with you awake under regional (spinal or epidural) anaesthesia, when the sensation in the lower part of your body is numbed. It is usually safer for you and your baby and enables both you and your partner to experience the birth together. Your recovery is from this will also be easier. The type of anaesthesia where you are asleep is called a general anaesthetic. If you are having an unplanned caesarean birth, 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.

On the day of your planned caesarean or in the event of an unplanned caesarean you will meet with an anaesthetist. To help inform your decision and discussion of your anaesthetic options they will need to know about:

• Your general health, including previous and current health problems
• Whether you or anyone in your family has had problems with anaesthetic medications
• Any medicines or drugs you use
• Whether you smoke
• Whether you have had any abnormal reactions to any medications or have any other allergies
• Your teeth – whether you wear dentures, or have caps or crowns

Your anaesthetist may ask to listen to your heart and lungs, ask you to open your mouth and to move your neck. They will also review your test results. They will answer any questions you have and make a plan with you for your birth anaesthesia.

Potential risks and complications of anaesthesia

A useful guide to the frequency of a risk occurring

• 1 in 1 to 10 people = very common (like a person in the family)
• 1 in 11-99 people = common (like a person in the street)
• 1 in 100 to 999 people = uncommon (like a person in a village)
• 1 in 1,000 to 9,999 people = rare (like a person in a small town)
• 1 in 10,000 to 249,999 people = very rare (like a person in a large town)
• 1 in 250,000 people or more = extremely rare (like a person in a city)

Risks and complications of epidural or spinal anaesthesia

The following information is based on Obstetric Anaesthetists’ Association data, available at the labour pains website (opens in a new tab). The risk or complication is the same for spinal and epidural unless specifically indicated.

• Itching skin and feeling/being sick during and after the birth due to the morphine-like pain medication used: this is a common side effect (no figures available).
• Tenderness around the place where the needle is inserted into your back during the procedure and discomfort during the procedure: this is a common side effect (no figures available).
• Significant drop in blood pressure: 1 in 50 (this can be corrected and is temporary)
• Regional anaesthesia not working well enough for a caesarean birth so you need to have a general anaesthetic: 1 in 20 (epidural) / 1 in 50 (spinal)
• Severe headache: 1 in 100 (epidural) / 1 in 100-200 (spinal)
• Numb patch on a leg or foot, or having a weak leg (nerve damage): 1 in 1,000 (temporary) / 1 in 13,000 (lasting more than 6 months – permanent)
• Infection where the epidural was inserted (abscess): 1 in 50,000
• Serious infection of the brain or spinal cord (meningitis): 1 in 100,000
• Blood clot forming around where the epidural was (epidural haematoma): 1 in 170,000
• Severe injury, including being paralysed: 1 in 250,000

Risks and complications of general anaesthesia

• Sore throat: 1 in 10
• Feeling and being sick: 1 in 10
• Minor chest infection: 1 in 100
• Muscle pains: 1 in 100
• Severe chest infection or breathing problems leading to low blood oxygen levels: 1 in 300
• Corneal abrasion (scratch on the eye), damage to teeth, or awareness under general anaesthesia: 1 in 1,000
• Severe allergic reaction: 1 in 10,000
• Brain damage or death: 1 in 100,000

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.

Eating and drinking before your planned caesarean birth

It is important to follow the below instructions or we may have to postpone your operation.

For 7am arrival time you must not to eat any ‘solids’ after 2am the morning of your caesarean birth; for 11am arrival time you must not to eat any ‘solids’ after 7am the morning of your caesarean birth. You can drink still (non-carbonated), clear fluids until 2 hours before the operation. After this you should be ‘nil-by-mouth’ and may only have a sip of water if you need to take medication.

‘Clear fluids’ are: water, pulp-free juice, non-fizzy sports drinks and black tea/ coffee. Clear fluids are those through which newsprint can be read.

‘Solids’ includes all food, milk, milky drinks, chocolate and sweets.

What to expect if you are having a regional anaesthetic

This is done in the operating theatre. Before the birth the anaesthetist will start your pain relief (see information above about anaesthesia). First they will ask to place a tube into a vein (cannula), usually in your hand, wrist or arm. They will also attach some sticky tabs to monitor your heart rate, oxygen levels and blood pressure.

You will then be asked to either sit or lie on your side, curling your back outwards. The anaesthetist will clean your back with sterilising solution. Once this has dried they will 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. All of this usually takes 5-10 minutes, but if it is difficult to place the needle, it may take longer and more than one attempt may be needed.

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. If it is difficult to place the needle, it may take more than one attempt and take longer than 5-10 minutes.

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 until it reaches the middle of your chest. The anaesthetist will check that you are ready for the operation with either a cold spray and by touch sensation. Sometimes it is necessary to change your position to make sure the anaesthetic is working well. Your blood pressure will be checked frequently in case it starts to drop. We can correct this with fluids and medication through the tube in your vein (cannula).

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.

After the birth

If you have had an epidural or spinal anaesthetic, immediate pain relief (analgesia) is provided by this anaesthetic. At the end of the surgery you will be given oral tablets or a suppository (inserted into your back passage while you are still numb) to provide pain relief while your spinal or epidural wears off. If you have a general anaesthetic you may require stronger pain relief such as morphine, usually this is given as a “patient controlled analgesia” where you press a button as and when you need pain relief which then releases a morphine-based medication into your vein through a tube (cannula).

The anaesthetic will gradually wear off over the next few hours. It is normal to 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 straight without assistance. Please tell us if you can’t. 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. Your catheter will be left in position for 12 to 24 hours, until you are more mobile.

It is usual to be prescribed regular pain-relieving tablets (paracetamol and usually ibuprofen) four times a day. Please let your doctor or midwife know that if you have asthma or a gastric ulcer. You will be given these medications in hospital but make sure you have some available at home. 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 or chestfeed.

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. 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, wrist or arm. They will also attach some sticky tabs to monitor your heart rate, oxygen levels and blood pressure.

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 asleep 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 medications throughout the operation and will ensure your continued safety. Before the surgery your midwife will also insert a tube (catheter) into your bladder to keep it empty during the birth.

When your baby is born your midwife will dry and check your baby on a warming platform, this will include checking your baby’s temperature, heart rate and breathing rate. They will place identity bands on your baby’s cord clamp and ankle, wrap your baby in towels and blankets and place a hat on them. If your baby is well, they will take your baby to your birth partner in recovery. If there are any concerns about your baby a neonatologist will assess your baby and your partner will be updated.

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 through your cannula at the press of a button when you feel pain.

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 insulin injection, inhalers, injections, creams, drops (eye, ear, nose) and skin (transdermal 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 and any allergies you have. If you wish to take your medication yourself (self-medicate) during your stay then ask your midwife.

Further useful information

• Enhanced recovery pathway after planned caesarean birth
• Headache after epidural analgesia or a spinal
• RCOG - Information for parents in hospital on what to expect in the first six hours after birth (opens in a new tab)
• Pain relief during pregnancy and after birth
• Self-administration of Medicines (SAM) in the Rosie Hospital Maternity Wards
• Labour pains - Caesarean birth (opens in a new tab)
• Receiving a Blood Transfusion (opens in a new tab)