Epidurals and hypotension

MommyLauraRN · Sep 28, 2004

Epidural or spinal anesthesia is usually preferred over general anesthesia for C/S unless it is a true emergency C/S and there is no time to do a spinal. (General anesthesia depresses the baby and once it's administered they have to get the baby out quickly) A lot of healthy pregnant woman have low blood pressures just like your daughter. Anesthesiologists can give IV meds to increase blood pressures that become dangerously low such as ephedrine. It's good to be thinking of the "what ifs" because you can never predict labor/delivery but I'll cross my fingers that your daughter has a nice lady partsl delivery at the birth center!

bam_bam · Sep 28, 2004

epidural/spinal in my opinion is the only way to go. Like she said above meds can be given to increase b/p. Also usually patients are given a iv fluid bolus prior to epidural to prevent a significant drop in b/p. The only reason to do general is if it is emergent c/s (even then, our anesthesiologists do spinals. Their rationale is that the can get a spinal in just as quick as a general and takes effect very quickly) or if a spinal is attempted but unable to get in due to patient size, back problems, etc. I have seen too many depressed babies from general. When I am discussing anesthesia with someone who is unsure about having a spinal/epidural I tell them that it is less risky for both babe and mom to have regional. Also they don't get to hear there baby's first cries when they are put under. Also in our facility and others that I have worked at, if the mom is under general, the dad or significant other is not allowed to be present at the c/s.

Good luck and enjoy that baby!

jwk · Sep 28, 2004

My daughter is currently 32 weeks pregnant and at her next antenatal appointment will start to draw up her birth plan. As she is booked into a birth centre, the primary purpose of the birth plan is to record her wishes should something go wrong during labour and delivery which requires her being transferred to the labour and delivery unit. One of the issues to be considered is whether she would prefer epidural or general anaesthesia should a caesarian section become necessary for the well-being of herself or her baby.
My daughter's blood pressure tends to be on the low side at the best of times (it's extremely rare for it to ever go as high as 100/70 and most of the time it hovers around 80/60), and during this pregnancy it's been even lower more often than not (at most antenatal visits, it's been around 80-90/40). I'm aware that epidurals often cause a further reduction in maternal blood pressure and wonder epidural anaesthesia is an option which should even be considered should my daughter require a caesarian or whether it would be much safer to go with a general.
Ideas?

Any reliable CRNA or MD would probably refuse to offer you an elective general anesthetic for a C-Section. C/S is one of the few operations where a regional anesthetic is clearly the proper way to go. The leading cause of anesthetic death during C-Sections is aspiration during a general anesthetic. In addition, neonatal depression often occurs due to the drugs used to induce and maintain a general anesthetic. General anesthesia is appropriate in only a very few circumstances, including true emergency C-Sections (fetal bradycardias, placental abruption, prolapsed cord, amniotic fluid embolism) or when there are clotting abnormalities that would make epidurals or spinals risky due to the chance of a hematoma around the spinal cord which could result in paralysis. Simply put, a general anesthetic as an elective choice for a C/S is NEVER appropriate. In our facility, we would simply tell the patient that a general anesthetic would not be available to them. Since most competent surgeons can have the baby out in less than 10 minutes after incision (many do it in less than 3 minutes even on a non-emergent C/S with regional anesthesia), we will give IV narcotics and/or sedation after the cord was clamped as needed if the mother is still too "uptight".

Hypotension from regional anesthesia can often be avoided by adequate IV fluid loading prior to starting the regional. Should it occur, which is not uncommon, it is easily treated with IV ephedrine, and is really not a major concern since it is so easily treated.

BittyBabyGrower, MSN, RN · Sep 28, 2004

My blood pressure was always very low when I was pregnant and I had an epidural..they just gave me extra fluid and it was fine :)

reprise · Sep 28, 2004

Epidural or spinal anesthesia is usually preferred over general anesthesia for C/S unless it is a true emergency C/S and there is no time to do a spinal. (General anesthesia depresses the baby and once it's administered they have to get the baby out quickly)

This is really the situation which we are being asked to consider - mostly because if something has gone wrong enough for my daughter to be transferred to L&D for a caesarian there isn't likely to be a whole lot of time available for discussion and decision-making.

jwk · Sep 28, 2004

This is really the situation which we are being asked to consider - mostly because if something has gone wrong enough for my daughter to be transferred to L&D for a caesarian there isn't likely to be a whole lot of time available for discussion and decision-making.

I get the impression you are in the UK - if that's true, it may be that things are done differently there. Most patients in the US would already be in L&D for their labor.

Regardless, if she needs an emergent C-Section, she won't have much of a choice in the matter anyway. If there is enough time to place an epidural or spinal, they will do that. If not, they'll do a general. At this point, birthing plans pretty much get tossed out the window and what's best for the mother and baby takes priority.

reprise · Sep 28, 2004

I get the impression you are in the UK - if that's true, it may be that things are done differently there. Most patients in the US would already be in L&D for their labor.

I think that the different "standard" procedures may have something to do with it. Although the birth centre is part of the standard birthing unit (literally across an ten foot hallway), the L&D suites contain equipment which the birth centre rooms do not. In the normal course of events, a birth centre mother would only be transferred to L&D if that equipment was needed or if she requested an epidural. As the birthing unit as a whole is pretty much midwife managed, I can see that by the time an obstetrician has come to the unit and made an assessment, a woman has been prepared for theatre, and the anaesthetist has arrived, a general may be the fastest option available.

It may also be that the birth centre and the birthing unit as a whole has had complaints from women who anticipated that if they needed a caesarian it would be done under epidural anaesthesia only to be disappointed in their birth experience when they were given a general and that the raising of the issue by birth centre staff is more of a CYA thing. Certainly the design of their birthplan as a whole seems to be aimed at getting women to consider the choices they would make in unanticipated circumstances (something which a lot of "do it yourself" birthplans often ignore completely). Birth plans are drawn up for all women who receive their antenatal care at either the midwives clinic or the birth centre (and from, from what I gather, also for those who attend the doctor's clinic due to medical reasons). The choices the women are free to make might be more apparent than real - especially in those who are high risk - but I have little doubt that the "forewarned and forearmed" policy probably leads to a higher level of overall "customer satisfaction" and women feeling that they have had more input into and control of the labour and delivery process.

MommyLauraRN · Sep 28, 2004

There are several reasons why your daughter could end up needing a C-Section that wouldn't necessarily mean "emergency or stat C-Section". CPD for instance (which could present as not dilating completely, hours of pushing with no real progress etc.) In these cases the baby isn't usually crashing but isn't going to come out lady partslly. There is time to place regional anesthesia and let it take effect while still monitoring the baby. We even had a cord prolapse with a woman at 4cm and our docs monitored her baby, placed a spinal with her on her side, with a doctor having a hand in her lady parts keeping the baby's head off the cord instead of going with general. Another patient who would have been hard to do a quick spinal on (she was a very obese lady) had a continous spinal placed (constant infusion like an epidural) in case she needed a stat section. She wasn't a great candidate for general because she had other health problems related to her obesity anyway. I've been on L&D for a few months and I've seen one C-section done under general (26 week primip, came in complete, double footling breech, bulging bag of waters). Your daughter could ask to meet with an anesthesiologist to discuss her concerns and have her questions answered in case the need for a c-section arises she will feel more prepared.