EMCS under GA - anyone with experience or knowledge?

[atrcts]

I've been told today that, if I go into labour early, I may have to have an EMCS under general anaesthetic. This is because I am taking a medication which means I can't have morphine (which is given in epidural and spine blocks), unless I have had a few days of stopping the medication I take.

There is a reasonable chance I could go into labour earlier than my anticipated elective CS date, because I have a dodgy cervix after having surgery on it in the past. Of course, if my cervix holds out until 39 weeks I can have stopped my medication and have a normal epidural with morphine, so no need for a general anaesthetic (fingers crossed!).

However, having been told this is a real possibility, it's raised a few questions for me and I wonder if anyone have any experience or knowledge about having an EMCS under general anaesthetic?

I am interested to know how long you're 'out' for, and how soon you get to hold the baby when you come round. What happens to the baby when you're still in theatre being put back together and then in recovery sleeping off the anaesthetic?

Also how soon it might be possible to feed the baby.

I'd appreciate anyone's insight!

I had an EmCS under GA with my first.
No idea how long out for but baby with midwife and daddy and had skin to skin with daddy!
Baby was given to me before I was fully awake so first memory is holding him supported by his daddy. Baby was dressed by then though so no immediate skin to skin with me. Latched on rugby ball within a few minutes of my waking ( midwife positioned baby for me) and never looked back with the breastfeeding...actually easier than feeding his brothers after normal delivery.

Personally I loved it ; had asked for an ELCS and been refused !

Baby was immediately given to my husband, can't remember exactly how long it took me to come round, but I did feel very sleepy and 'not quite with it' for a couple of hours. Make it clear who you want to tell you about the baby, my DH said he wanted to tell me himself (we had chosen not to know if it was a girl or boy - you may have made a different decision) but he was not with me when I woke up, the Doctor was obviously put on the spot as I think he had been told 'not to say anything' but as I was anxious he did break the news to me. So just be aware that might happen, it really didn't worry me, I just wanted to know. .

Establishing b/f was a bit tricky, and I subsequently found out that this can happen if you have an EMCS - but is absolutely not inevitable as Mahis has commented. Once I got home from the hospital I was able to b/f easily.

I had a crash CS under GA for DD2. She was given to her dad fairly swiftly.

I have no idea how long I was out for, but the birth was very quick so not long, I don't think.
Your partner will not be allowed to be in the theatre for the birth, but barring other complications, will be given the baby while you are out.

I didn't know her gender before she was born, but my first memory after the birth, I definitely knew she was a girl, so must have been told while not completely round. I clearly remember looking over and seeing my best friend dressing her in the first outfit I had chosen. It is a memory I treasure She was not out of my sight at all from that moment onwards, while i came round fully.

I fed her very shortly after that, and had no problems in the long term.

Good luck.

Thanks all! It's really nice to know Dad's can have the first snuggle - don't like the idea of a crying newborn in a cot by itself!

Good to hear also that breastfeeding wasn't impossible for any reason, though am surprised it was encouraged early as I assumed the GA drugs could be passed on through breast milk but maybe it's more short acting than I thought!

Hi OP, I'm an anaesthetist. I do wonder who told you that you can't have a spinal because of morphine issues. It's perfectly easy to do a spinal or epidural without opiates of any form, that's no reason to put you at the increased risk of a GA. It will affect postoperative pain relief though.

If you need a GA for other reasons, you'll go to sleep on the operating table and will be conscious enough to open your eyes to voice command within a few minutes of the end of the surgery. Some people have little recollection and feel very groggy for several hours afterwards, some are very awake and cuddling baby within half an hour. The drugs used to get you off to sleep can make baby a bit sleepy for a short time (less than an hour) afterwards, but you are almost always kept asleep with gas, which will not affect the baby.

HTH but I'd strongly suggest you ask to speak to a consultant anaesthetist for some specific advice. Very best of luck.

I asked my doctor if it would be possible for my DH to hold my baby to my breast after the birth if I am unconscious. She said that would be possible. I know it would be a shame to miss those first moments but baby doesn't have to wait to feel your skin and find your breast.

I also had what I thought was a dodgy cervix (had precancerous cells removed) and I carried my first baby to 40 weeks no problem. This time my baby is breech so I'm probably having an ELCS next week.

Best of luck!

Agree with HPsauce I tend to be quite sensitive to morphine and have worn a red band saying 'morphine allergy' for my two c-sections, one emcs.

I would get a second opinion or some clarification on the need for GA. I know that on the 4th attempt of getting the epidural in the anaesthetist mentioned having to use GA but thankfully he managed it. I had an appointment with the anaesthetist just to discuss the morphine 'allergy'. I'm sure it was agreed they'd use an alternative- could your midwife refer you to see an anaethetist maybe?

Unfortunately is was a consultant anaesthetist I saw - I had wondered if I could have a bupivicaine only epidural but they seemed to think that wouldn't do it, though not sure why as when I worked on a post op surgical ward morphine sensitive people would be offered that for their recovery. They did mention bilateral block for post op pain relief but seemed to think it would still need to be under a GA - the implied reason was for pain relief. There is no other reason I would need a GA.

I am not allergic to morphine but an taking LDN for multiple sclerosis, and because it's an opiate antagonist, no morphine would work for a few days, and would actually make me very sick (nausea etc). That's why they shrugged and said it would just be a straight GA if I had not been able to stop the LDN for a few days beforehand.

Hpsauce - any idea what other alternatives I could suggest instead of GA? As I mentioned, bupivicaine and NSAIDS were brushed off as unsuitable alternatives to a fentanyl epidural. It would be nice to go armed with some alternative ideas as obstetric medicine is not my forte!

Id be tempted to ask for a second opinion. A quick glance at the literature around naltrexone suggests there is little to no info regarding caesarian section planning. There is an outdated impression that spinal anaesthesia can worsen MS, but there is no direct evidence for this, only case report and anecdote see this article. I wonder if this is why they are suggesting GA. I have given many spinal anaesthetics to patients with MS and not had a problem, though i do not work in obstetrics anymore. GA in MS carries its own issues as you will know.

Personally, in your shoes, I would ask them to attempt a local anaesthetic only combined spinal epidural. this would almost certainly use levobupivicaine. There is a lower dose in the intrathecal space giving greater control through the epidural to raise the block high enough, without causing significant hypotension. The epidural could then be left in for 24hrs+ for postoperative pain relief. Neither the spinal nor epidural should have any opiates in (fentanyl, morphine or diamorphine). If they are worried it won't work, and there's no evidence to suggest it won't, you can always have GA as a plan B.

Without a postop epidural, paracetamol and NSAIDs would have to be the mainstay of your analgesia, so I can't understand why they are against their use.

The acute pain consultants in the hospital (anaesthetists with special interest in pain) would be worth a chat with. They should certainly be involved in your care as will have good background knowledge regarding naltrexone in the postoperative period.

Of course, if you're happy to have a GA then that's fine! I don't mean to suggest that a GA is dreadful, just really wouldn't be my choice in your shoes.

Good luck.

Thanks for all of that. I really don't want a GA, as having a GA for an emergency appendicectomy 18 months ago left my MS temporarily unbearable (extreme nausea and vertigo exacerbated by cerebellum lesion), and I would rather avoid that! Not to mention the psychological aspect of wanting to be 'present' at the birth if I can.

I've had a spinal before - in my last birth - when I needed forceps and episiotomy, and there were no ill effects from it that I am aware of. I put the post partum relapse (where I developed spinal cord lesions) down to being hormonal changes which are known to place someone with ms at a higher risk of relapse for 3 months, rather than linked to having had a spinal analgesia.

I really appreciate your input, I must admit I was really surprised to be told it has to be a GA so am grateful for your confirmation of this and will see if I can explore a second opinion. It's so awkward though, as I used to work although alongside this anaesthetist, however I realise I probably have to choose between the birth thats right for me or the professional pride of an ex colleague.