Chapter 47: Neuraxial Anesthesia for Cesarean Delivery

BACKGROUND

Cesarean delivery (CD) ranks among the most common surgical procedures in the world. Yet, too many women die during childbirth. Regional anesthesia had been used in obstetrics since 1940s.¹ Evolving knowledge and clinical advances in obstetric anesthesiology made significant contributions in the field of neuraxial anesthesia. Today, regional anesthesia is safer and more effective than ever because of countless contributions of researchers around the world.

Contributing factors to improving maternal satisfaction, patient safety, and decreases in anesthesia-related maternal mortality and morbidity in Obstetric Anesthesia include:

• Increased use of neuraxial anesthesia and decreased use of general anesthesia^2,3

• High-quality and preservative-free (PF) medications

• Use of neuraxial morphine for long duration of postoperative analgesia

• Test dose for epidural catheters to identify intrathecal and intravascular catheter, and incremental dosing of epidural medications

• Advances in the design of epidural catheter

• Advances in the design of epidural and spinal needles to decrease the incidence of postdural puncture headache and nerve injury

ADVANTAGES OF NEURAXIAL ANESTHESIA FOR CESAREAN DELIVERY

• Avoid general anesthesia and potential difficult airway.

• Lower risk of aspiration.

• Less blood loss, possible due to lower mean blood pressure and lack of effect of uterine atony from inhalational agents.

• Minimal placental drug transfer.

• No inhalational agents needed and less pollution.

• Ability to install neuraxial morphine for much better postoperative analgesia.

• Awake mother is allowed to experience childbirth.

CONTRAINDICATIONS FOR NEURAXIAL ANESTHESIA

• Patient refusal

• Allergy to local anesthetics (true allergy to amides is extremely rare)

• Coagulopathy and severe thrombocytopenia

• Local infection at the insertion site

• Uncorrected hypovolemia

• Lack of monitoring or resuscitative equipment

Relative contraindications:

• Increased intracranial pressure (avoid dural puncture)

• Uncooperative patient

• Obstructive cardiac lesion (avoid spinal anesthesia)

• Systemic or remote infection

POTENTIAL RISKS AND SIDE EFFECTS

• Failed spinal: Usually it is a technical failure; rarely it is because of anatomical variation^4,5

• Failure conversion of labor epidural to epidural anesthesia for CD (Chapter 49, “Conversion of Labor Epidural for Cesarean Delivery”)

• Postdural puncture headache (Chapter 64, “Postdural Puncture Headache)

• Severe nerve injury (Chapter 62, “Peripartum Neurological Complications”)

• High spinal or total spinal (Chapter 60, “High Spinal”)

• Hypotension (Chapter 50, “Hypotension After Spinal Anesthesia”)

• Nausea, vomiting, and pruritus (Chapter 57, “Side Effects of Neuraxial Opioids”)

CLINICAL POINTS

• Spinal injection should be below the L2 vertebra to avoid potential contact with the spinal cord. Ultrasound confirmation in patients with morbid obesity and/or scoliosis may be helpful.

• Aseptic technique is a must—always wear a mask and a cap for neuraxial procedures.

• Spinal injection is a HIGH-RISK procedure. Two sets of eyes should verify the medications before injection.

• A T4 sensory blockage is appropriate for CD under neuraxial anesthesia. The sensory afferent ...