Spinal or general anesthetic for C-section?

[ButterscotchBabe]

I'm having a C-section for twin pregnancy and need to decide whether to have a spinal or general anesthetic. I've spoken with an anaesthetist and gone through the pros and cons of both options but still struggling to decide.

Spinal
Pros - awake for the birth, calmer operation, doesn't affect the babies

Cons - risk of temp or perm nerve damage, risk of pain during the op if it doesn't work

General
Pros - no pain during the op (although they did say they use a lower dose for C-sections! 😬), no risk of nerve damage

Cons - neither myself or my husband can witness the birth, rushed operation to minimise anaesthetic effect on babies

If you've had a C-section could you share which option you chose and how you found it?

Please be reassured I had no differences in bonding with either of my DCs one was born by GA (placenta praevia) and the other spinal and the bonding was the same.

I was just grateful that Both my babies were in my arms and it didn’t matter who had seen them or held them first, I was just so happy dc had made it.

I understand not everyone feels the same but wanted to say it’s not always negative to have a GA.

I had 2 spinals and was fine with both. I have mild lordosis.

You’re wrong. You don’t get to choose a general

I'm definitely referring to an elective.

There was no time to site a spinal in my situation (cat 1, lost fetal heart times)

If you read one post on here OP, please make it GreyBeardy's, he (she?) is an anaesthetist and always takes sense. I was about to post as an ex-ODP who worked in obstetric theatres, but he's explained everything much better than I could.

Good luck.

You can indeed insist upon a general. It is the same with quite a lot of other procedures. Of course it tends to be the usual option to have this procedure carried out awake, but you can have it asleep. You need to specifically request it.

You’re the only other person I’ve ever heard of who still has a spot on their back that hurts. My second c-section was 20 years ago and I still have a spot on my spine that feels like it’s bruised if I press it. Been like that ever since I had my second child but when I mentioned it to GP years ago, they never seemed to want to follow it up. It doesn’t affect movement or hurt generally unless it’s pressed. I do pilates and have to use a small cushion when we do stuff that imprints the spine as that pushes my back down.
I can’t find anything online about it. How long ago was your section?

You’re wrong. You don’t get to choose a general

I had the choice. I had to see a consultant anesthetist first but she signed off on either method. Didn't have to choose until the time of the surgery.

I’m shocked you’ve been offered a GA. I’ve only known one person my whole life to have a chosen one when having a section and that was over 20 years ago .

I’d go for the spinal. They check it worked before they started! Don’t worry about that

Few thoughts based on ideas pp’s have raised that might be helpful (from an obs anaesthetist)….
-you really can’t compare the experience with an elective/cat 2/3 section and a cat 1 section (even when it’s a cat 1 under spinal….which isn’t that common). How things are post op is very much influenced by what the emergency was that meant the section was needed quickly rather than which anaesthetic was used.

-in an immediately life threatening scenario (which is what a cat 1 is) the aim is to have a decision to delivery time of less than 30mins as an absolute minimum (that includes the surgeon diagnosing the problem, explaining it and the management needed, transferring to theatre, getting the monitoring on, prepping & draping, doing the anaesthetic and getting the baby out)….often we can manage that in about 10mins and definitely should be aiming for better than 30mins as a rule. A GA is usually quicker than a spinal to perform so that’s why it’s usually the first choice in that scenario. Attempting a spinal is sometimes an option in a cat 1 but it will literally be just a single pass of the needle and if it doesn’t hit the spot then we convert to a GA (we’re more likely to try that if a GA is unusually high risk for the mother due to medical problems like significant obesity). A spinal injection in a cat 1 may be more difficult because there isn’t the luxury of being able to take time with getting the mum in a really good position (which is usually the most important thing in getting it in), going slowly with the local to the skin, ‘mapping’ the space out in our minds - it’s a quick pass of the needle and keep fingers crossed.
-you can’t compare GA for obstetrics with GA for non-obstetric surgery as easily as most people seem to imagine. Maternal physiology changes a lot in pregnancy and that can make GA hairier. Clearly is someone’s had a difficult GA before then that’d be worrying in an obs context, but having had a straightforward GA before doesn’t necessarily mean it’d be the same for a section. Thats why every decision is based on what the relative risks/benefits of the type of anaesthetic are at the point that the decision is being made. For the vast majority of elective scenarios a spinal is the safer option for the mother (and what’s safest for the mother is usually better for the baby too). There are a few maternal reasons why a spinal might be contraindicated from the start - the obstetricians are usually really good at noticing those and referring for an antenatal anaesthetist review so we can make a proper plan. The drugs used in obstetrics are often different to those used in a lot of ‘normal’ GAs too.
-pain can be trickier after a GA section because we usually put in additional long acting pain killer with the spinal injection and that helps even once the numbness is wearing off. We can do similar with an epidural too. With a GA though more intravenous painkillers are needed and then there’s a balance between giving good pain relief but trying not to make people too high on opioids to enjoy their baby once they’re awake. Most people aren’t in agony after GAs but they may not be as perky as someone who’s had a spinal.
-if someone does need a GA the the usual routine for reducing the dose of anaesthetic that the baby gets is for the woman to be prepped and draped before starting the anaesthetic - this is true in both elective and emergency scenarios. In an emergency where there’s fetal compromise that’s causing the need for the section they’ll often have the baby out within 2 mins of the GA starting. It may be a bit slower if it’s an elective GA but not much. In an emergency scenario it’s more likely that the original problem that meant the section was needed is more likely to be behind any neonatal compromise than a GA.
-back pain is fairly common postnatally whether or not you’ve had any anaesthetic. Spinals don’t cause long term back pain due to needle trauma. Both GA and spinal can be associated with post-natal backache due to the profound muscle relaxation that they cause.

-bottom lines are that in an elective scenario a spinal is most often safest for both mother and baby. Women can decline a spinal though, so long as they understand they may be choosing the higher-risk option. There are a few scenarios though where the opposite is true and a GA is better - in the elective scenario that is usually known about before the day though so they can plan for it. GA is always the back up plan whatever the starting point is and occasionally we still end up converting even on a straightforward elective list.

7 years ago now.

I also mentioned it to the anethetist for my 2nd section and they were unconvinced that the spinal would be the cause. But it was.

Mine is only when touched and bruised is the right way to describe it. It physically makes me recoil and do a sharp intake of breath.

@stackheadExactly the same for me. Same physical response. Sorry to say that being a few more years down the line (!) it’s probably going to stay like that.

Hi ButterscotchBabe,

Not sure if you have already had your twins yet. But I just would like to add some information, as I think its important to be able to make informed decisions.

I'm sure your care provider has already gone through these things, but also in case anyone else is reading this and not sure what to do.

I am a midwife that specialises in caesarean sections, I have spent 10 years plus in this role and also almost 20 years as a midwife and delivered singletons, twins, triplets etc.
The majority of the time this is completed using spinal anaesthetic or a combined spinal and epidural.

I run clinics every week where I talk through these kinds of concerns amongst many others with those having caesareans. Unfortunately I find that many people who are choosing to have a planned caesarean just are not getting all the information they need.

There is a link below to labour pains that discusses spinal anaesthetics and risks
https://www.rcoa.ac.uk/patients/patient-information-resources/anaesthesia-risk/spinal-risk-evidence

My concern as a midwife is the amount of time it takes to get the babies out if having a general aesthetic. General anaesthetic crosses the placenta, which will make baby sleepy, groggy require extra input from clinicians.

Having a planned caesarean section, with twins ( they are usually delivered before 39 weeks depending on type) will put babies at a little bit more risk of retaining fluid on their lungs.

A conversation I have regularly have, is around how planned section babies below 39 weeks often have a lot of fluid remaining on their chest.

They are not expecting to come out, they are not getting the hormones to say something is happening today or the squeezing to help push some of that fluid out.

One of the most common reasons planned caesarean birth baby's end up in SCBU is because of TTN or this remaining fluid on the lungs. If a General anaesthetic is then also introduced, as well as any medications you are taking due to health conditions - Gestational diabetic (insulin/metformin) Anxiety Depression medications (SSRIs). It can add more risk factors for baby needing to go to SCBU.
Most of the time that won't happen but it is worth being aware that its a possibility.

As a Midwife, I tend to see a General anaesthetic as 'this is now going to be an emergency section' due to the physiological impact on the baby and I prep for it in that way.
Having also seen people be intubated and difficulties with intubation that's far more scary to me than the stats for spinal anaesthetic.
Anaesthetist do an airway check, but its not until they actually intubate you that they might realise there is an issue deeper down your airway.

Apart from these things I have said above, I genuinely want the families I care for to be part of their babies very first moments.

I want this to be a core memory, you and your partner have so when the baby(s) turn 18 you can tell the story of how the passed urine all over the surgeon or pooped on the midwife!
I want the babies to have the benefits of all the little things we know gives them this great start, the optimal cord clamping, having your partner get a picture of them cutting the umbilical cord!
Getting baby's skin to skin as soon as we can to start that bonding process to help baby's settled, feel comfortable and reassured that this big scary world of bright lights and lots of noises, feels safe because they are with their parents, skin to skin.

If you have not already had babies you could ask to be referred for an anaesthetic appointment so that you have all the information you need so you feel fully informed and confident with whatever your choice is.

I hope you choose whatever feels right for you but also make sure that you have all the information, do your research and make sure you are fully informed before you make that choice.

I am 4ft 11 with hyperlordosis and had no issues with the epidural.

@HeartyHelper thank you for your detailed response, I haven't had the twins yet. They're planning to deliver them around 37 weeks, which will be early in the new year. I wasn't aware of the issue of fluid on the lungs, so thank you for sharing that. Even though this would still be the case with a GA, I understand the breathing difficulty would be compounded by the drowsiness and fluid. I am leaning more towards the spinal now

@Greybeardy thank you also for your response, I appreciate your detailed explanation of how it works. Knowing that with an elective they'll spend longer getting the needle in the right place, makes me feel more comfortable with a spinal. It's also reassuring to know they'll put in long acting pain relief

Had spinal for my twins elective C section 18 yrs ago, no problems, felt just the weird “rummaging” sensation but that was all during the op. Was lovely to “ be there” properly with their dad and all team were pleasant, friendly and professional. Did have pain soon after at C section site and had to really ask a lot for pain relief then, but sorted eventually with one shot of morphine. I was also worried about paralysis but had to just trust I was in v experienced hands in the end.

I’ve had two of each. I much preferred the GA. I was awake quickly after the births so fid not feel I missed out. I HATED the spinal. Hated the feeling of being numb, felt panicky in the births. Really not for me at all.