Pain Management for C-Sections
If you are going to give birth by Cesarean section (or C-section) and are concerned about the anesthesia, you should know that the procedure is safer than ever before. Anesthesiologists do everything possible to make sure you're comfortable during delivery and that you and your baby are safe.
According to the Centers for Disease Control and Prevention, in 2021 C-sections account for just over 32% of all deliveries—about one out of every three births—in the United States. It’s the most common surgery in the U.S., with around 1.3 million C-sections performed every year.
A C-section is a surgical procedure for delivering a baby through an incision in the abdomen. They may be planned or performed as an emergency surgery if problems occur during labor.
People who undergo a C-section have a few pain management options, including regional anesthesia—a spinal, epidural, or a combination of the two—that blocks pain in the lower body while allowing the mother to stay awake for the birth, and general anesthesia, in which the mother is unconscious during the procedure. Most C-sections in the United States are performed using regional anesthesia. It’s estimated that general anesthesia is used in only about 6% of all C-section deliveries in the U.S.
“Yale Medicine has dedicated, highly skilled obstetric anesthesiologists caring 24/7 for our obstetric patients through both planned and emergency C-sections,” says Yale Medicine obstetric anesthesiologist Aymen Alian, MBChB. “The Society of Obstetrics and Perinatology (SOAP) has recognized the obstetric anesthesia division at Yale New Haven Hospital as a Center of Excellence for care of our obstetric patients.”
What anesthesia is given for a C-section?
Mothers who have a C-section will be given one of two types of anesthesia: regional or general.
Regional anesthesia. This type of anesthesia involves using local anesthetics to block pain sensations from part of the body, and anesthesiologists use it for C-sections whenever possible.
Regional anesthesia numbs a woman’s midsection and legs so she won’t feel any pain from the surgical incision or delivery.
Prior to delivery, pain medication—typically a combination of a local anesthetic and an opioid—is injected in or near the spine in the lower back in one of three ways:
- Spinal anesthesia: A woman whose C-section is planned will typically receive spinal anesthesia, also known as a “spinal” or “subarachnoid” block. The anesthesiologist injects medication into the cerebrospinal fluid that bathes the nerves and spinal cord. Usually, this procedure involves a single shot of anesthesia, but in rare cases, a catheter may be inserted to give medication continuously. Spinal anesthesia allows the pain medication to quickly reach the nerve receptors that transmit pain signals, providing rapid pain relief lasting up to two hours. Only a small amount of local anesthetic is needed for a spinal block which lowers the risk of complications from the medication for both mother and baby.
- Epidural anesthesia: A labor epidural involves placing a catheter (a thin plastic tube) in the patient’s lower back. The catheter sits near the nerves that carry pain signals to the spinal cord but is placed below the spinal cord. It takes around 10 minutes to set up and place an epidural. Once it’s in place and medications are administered, it can take another 5-20 minutes to get good pain relief. Because the catheter remains in place, epidurals allow for continuous anesthetic administration. It also typically requires higher doses of drugs than spinal anesthesia.
- Combined Spinal Epidural (CSE) Sometimes, spinal and epidural anesthesia are used in tandem. In this procedure, the anesthesia provider first administers a dose of spinal anesthesia, then places the epidural. This allows the anesthesiologist to provide rapid pain relief via the “spinal,” while allowing the option of continuously administering more anesthesia using an epidural catheter, if necessary.
General anesthesia. In some cases, general anesthesia is used for Cesarean delivery for the following reasons:
- There is not enough time to administer spinal or epidural anesthesia.
- The spinal or epidural anesthesia is not working properly.
- The surgery is complex, or the woman is at risk for hemorrhage (bleeding).
- The mother has health conditions for which spinal or epidural anesthesia would not be recommended.
- Personal preference. Some women may choose to have a C-section under general anesthesia.
When general anesthesia is used, the mother will not be conscious during the C-section. While general anesthesia is safe for pregnant women, it’s not usually the first choice (in part because many women wish to be awake for the birth of their child) unless it’s medically necessary.
What should a patient getting a spinal or epidural for a C-section expect?
Mothers receiving an epidural during a C-section should expect the following:
- A mother preparing for a C-section will be asked to sit in a slouched position with her back curved in a “C” shape. Some patients might lie on their sides instead. Then, a local anesthetic will be injected into the skin before an anesthetic is injected in or near the spine.
- Epidural anesthesia may take 20 minutes to fully take effect. Spinal anesthesia, on the other hand, acts almost immediately. Both procedures numb the legs and abdominal area. Women who receive spinal anesthesia may be unable to move their legs until the medication wears off.
- A mother given regional anesthesia for a Cesarean section will typically feel some pressure and be aware of the health care providers working on her but will experience no pain.
What should a patient getting general anesthesia for a C-section expect?
Mothers receiving general anesthesia during a C-section should expect the following:
- General anesthesia is delivered intravenously. The patient will not be conscious when the incision is made, while the baby is being delivered, or while the incision is being closed.
- Side effects from general anesthesia can include a sore throat; injury to gums, teeth, or lips; and nausea and vomiting. This is from the breathing tube that is inserted during the procedure.
- The anesthesiologist tries to limit the time between administering general anesthesia and delivery to minimize the baby’s exposure to the drugs used to anesthetize the mother.
How is Yale Medicine’s approach unique for pain management for a C-section?
At Yale New Haven Hospital, we are implementing an enhanced recovery after Cesarean delivery (ERAC) protocol that aims to standardize the perioperative care of peripartum patients to improve maternal outcomes, functional recovery, maternal-fetal bonding, the patient experience, and quality of care, as well as minimize opioid consumption (and the potential for addiction), explains Dr. Alian. “It will also help to address racial disparities. ERAC involves multidisciplinary efforts from experts in Anesthesiology, Obstetrics & Gynecology, and Nursing,” he says.
The ERAC protocol utilizes non-opioid intravenous and oral analgesics, such as Tylenol and ibuprofen, and the transverse abdominis plane (TAP) block postoperatively for Cesarean deliveries, if appropriate. The TAP block provides analgesia to the incision site.
We have experienced, well-qualified anesthesia staff working 24/7 to provide care, adds Dr. Alian.
“Our anesthesia team is always proactive. We interview our patient once she is admitted to the floor to discuss perioperative analgesia options, and we have a weekly high-risk anesthesia clinic every Friday where we discuss the anesthetic plan with our high-risk patients and discuss their expectations during the day of delivery,” says Dr. Alian.