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Anesthesia for cesarean delivery

INTRODUCTION

Either regional or general anesthesia is an acceptable approach to providing anesthesia for cesarean delivery.

CHOICE OF ANESTHETIC APPROACH

The anesthetic plan for cesarean delivery should take into account the well-being of two patients: the mother and the fetus. Regional anesthesia is the most common method of anesthesia for delivery because it allows the mother to be awake and immediately interact with her baby. It is also safer for the mother than general anesthesia: a population based study of anesthesia related maternal deaths in the United States reported that maternal mortality associated with regional and general anesthesia was 2 and 32 per million cases, respectively [1].

Regional anesthesia is used for 95 percent of planned cesarean deliveries in the United States. The three main regional anesthetic techniques are spinal, epidural, and combined spinal epidural (CSE) [2]. Spinal and CSE anesthesia are the most common regional anesthetic choices for planned cesarean delivery. Many practitioners prefer these techniques over epidural because they have a rapid onset and lower incidence of failed block. Their use for cesarean birth was facilitated by the popularization of pencil-point needles, which dramatically reduced the incidence of postdural puncture headache.

Regional anesthesia for cesarean delivery differs from analgesia for labor and vaginal delivery in two major ways:

  • Operative anesthesia requires a more intense block because the nociceptive stimulus of surgery is more intense than the pain of labor. Relatively dilute concentrations of local anesthetics are administered for labor analgesia in order to avoid motor and minimize interference with second stage pushing efforts. However, motor block is desirable during cesarean birth to obtain abdominal muscle relaxation. A more intense block is achieved by administering a high concentration of local anesthetic.
  • The dermatomal level of anesthesia required for cesarean delivery is higher than that required for labor analgesia. A sensory block to the 10th thoracic dermatome is sufficient to achieve analgesia for labor, but for cesarean, the anesthetic level must be extended cephalad to at least the fourth thoracic dermatome to prevent nociceptive input from the peritoneal manipulation.
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