Hello everyone! I’m Ben, Hannah’s husband; I’m an Anaesthetic doctor working in the NHS and I’m taking over this month’s medical post to try and give you some insights into a key part of my job: epidurals and caesarean sections. I know that many women would prefer to have minimal or no medical intervention when it comes to their childbirth experience, but as I am sure you all know, sometimes things don’t go to plan, and if that does happen, I think it really helps with the fear-factor if you know what to expect. I hope to dispel a few myths and leave you with greater understanding so that you might feel more empowered, should you ever face these situations.
I thought it would be useful to walk through what happens on the day when someone comes for a planned (elective) caesarean section.The process is essentially exactly the same as an emergency caesarean section, but as this usually happens to avoid potential harm occurring to either mother or baby, things tend to move a bit more quickly. Most women I meet are understandably nervous at the prospect of a caesarean, and a major part of my role is to guide them through the process, and look after them until they are safely in the recovery area with their family and new baby. I have often found that the most important thing in mitigating some of the fears of surgery and the anaesthetic is knowledge and understanding of what is going on, and why. Do remember that we all want you to have the best experience possible; I know that people can have quite different desires but whatever they are, we want to work with you – it is your big day after all!
On the day of your C-section usually you will come to one of the wards near to the labour ward/delivery suite, and will likely be given some paperwork to fill out. You should have already been given advice about when and what not to eat and drink depending on the local policies and the timings on the day. You will meet your anaesthetist and your obstetric surgeon, and be asked a lot of the same questions again and again, but please, bear with us, we are just making sure everything is safe. We will check things like any past medical history and medications, check your blood tests and generally make sure there is nothing unexpected for when we get into theatre. This is of course a good opportunity for you to ask us any questions you might have, although if you have major concerns you should bring them up with your midwife before the morning of surgery and they can help arrange for you to see an anaesthetist in a pre-op clinic.
For me, the most important part of this morning meeting is to try and get to know you and your birth partner a little; we are about to embark on one of the most memorable (and sometimes scary) experiences in life, and I want to help to look after you as best as possible. If you want distracting, we’ve got plenty of chatter, if you want to be left to yourself a bit more that is fine also; if you want to know everything that happens, or nothing that happens, just let us know! Usually, elective surgery happens on time, but of course if there is an emergency case that needs the delivery theatre then this would take priority. It is not unknown for surgery to be delayed or even cancelled and women brought back the next day, which may be inevitable, but is all the same understandably frustrating.
When theatres and the team are ready, you will be brought to the anaesthetic room, but in some smaller hospitals you will go straight into theatre. We will all be there ready, anaesthetists and assistants, midwife and assistants, obstetrician and assistants, sometimes there will be additional students or trainees – sometimes patients are quite alarmed to see the number of people present; this is all normal! We will introduce ourselves again and start our pre-theatre checks; name, date of birth, NHS number, etc. We routinely do a verbal check of all this basic information, just as a team of airline personnel check their pre-flight checks for safety.
Next, you will have monitoring attached: sticky ECG dots, a blood pressure cuff and an oxygen saturation peg on your finger. We will place an intravenous cannula into a vein in your hand/arm (with some local anaesthetic to numb the skin) and connect this to some IV fluids. Now, for a spinal anaesthetic or an epidural we will often ask you to sit up on the bed with your legs over the side and curled forward over a pillow to expose your lower back. It can be done with you lying on your side but this can be more difficult. The anaesthetist will dress in sterile gown, mask and gloves, and sterile drapes will be placed over your back; we also use an antiseptic spray on your skin that feels very cold when applied – sorry about this! It makes everyone jump! For the sake of sterility we often ask partners to wait outside of the room until the spinal anaesthetic is done.
The spinal anaesthetic involves a single injection of local anaesthetic solution into the fluid that bathes the nerves in the back, below where the spinal cord ends. It takes about 10 minutes to take full effect and lasts about 1.5 hours for operative anaesthetic, though weak legs and numbness can persist for around 8 hours. You will be awake, but numb from the chest down, you might feel pins and needles, warmth, pushing and pulling but shouldn’t feel pain. Often, a strong painkiller is added to the mix to give good post operative analgesia for about 24 hours, it can give you a really itchy nose and make you feel a bit sick, but it is usually well tolerated.
An epidural is similar, but slightly different to a “spinal”. It involves using a needle to place a small plastic tube into the epidural space – a layer just outside of the spinal cord membranes. Local anaesthetic in put down the tube and into the epidural space, where it blocks the nerves as they leave the spine. It takes a bit longer to put in place and for the effects to work; 30 minutes or so, plus it can be a bit less predictable than a spinal, sometimes leaving patches of skin that aren’t totally numb. It has the advantage that with the plastic tube, we can give more anaesthetic, or strong pain killers to “top it up” if we need. Epidurals used for analgesia in labour are the same principle but use a weak strength of local anaesthetic to try and find a balance of pain relief with mum still able to move and also help push. If we need to go to theatre but already have a good working epidural for labour pain relief, we can “top it up” but putting down some stronger medicines. Occasionally we combine the benefits of spinal (fast and reliable) with those of an epidural (can be topped up, more controlled) by doing both.
Once done, we help lie you down and position you with a tilt to the left to take some of the weight of your bump off your blood vessels. When ready, we test the anaesthetic with a very cold spray. The nerve fibres that carry cold sensation are the same as those that carry pain – so if you are numb to cold, you will be numb to pain. Some people can still feel something often described as “wet” or “like air” from the spray, this can be true for the surgery itself, it can be normal to feel dull touching sensations.
General anaesthesia (GA) means giving powerful drugs to put people off to sleep, plus putting a breathing tube to take over breathing and to protect the lungs from gastric acid. It is accepted to be the fastest and most reliable option but carries the biggest risks. It is usually reserved for emergency situations, where spinal or epidural has failed or cannot be used and occasionally at maternal request. Remember, it is what we, as the anaesthetic team, do day in, day out for lots of different types of surgery; we’ve got lots of training, equipment, and protocols to make it safe.
The most common way to have a caesarean section today is under a single shot spinal anaesthetic, it minimises any drugs passing through your circulation and into your baby, you are awake through the procedure so can hold your baby straight away and you have no hangover afterwards so recovery is much faster. That said, a general anaesthetic when needed is not something to be scared of; babies can be a little more drowsy immediately afterwards but this wears off very quickly and there is no evidence of them being harmed in any way. In fact, because of speed and the reduced effects on blood flow that we can see with a spinal, a general anaesthetic is still considered by some to be the best anaesthetic for your baby.
I won’t go into great detail on the actual surgical procedure, it’s not my particular area of expertise but also it’s not something you can actually see on the day. It can be done very quickly when needed, but for an elective C-section it usually takes 10-20 minutes before your baby is born and another 20 – 30 to stitch everything back neatly afterwards. Generally, once the baby is out safe and in your arms, most women don’t even notice this time passing, and once cleaned and dressed we will help get you into you hospital bed and back out into the recovery area.
I am personally a big advocate for skin-to-skin and as natural a birth as possible; yes the bright lights and number of people are not usually what people think of as relaxing, but even with a C-section birth you can still hold your baby straight away and share in this moment with your partner just like anyone else. If this is something you want, say so – often the baby is whisked away to ensure they don’t need any support with breathing, but then get dried, weighed and wrapped in blankets, rather than having immediate skin-to-skin with you. You can even have your own CD on if you want, just ask so we can work with you as best as possible!
Finally, to quote my obstetric anaesthesia consultant: “The best form of pain relief is a supportive partner.” If you’re pregnant and have found this helpful, get your partner to read it too, so you’re not having to reassure them on the day!
I hope that you found this post to be useful, please do leave me a comment and I’ll do my best to answer any questions below! I’ve also left a few links to some good additional information online.
This is the Epidural information card we give out to all mothers, it includes some of the complications and risks that can be associated.
This site has loads of reliable information written by doctors, midwives and mothers on labour analgesia and anaesthesia options.