HISHEN A/L KRISHNAMOORTHY

MBBS 1809-9647

Advantage of regional anaesthesia for Lower Segment Caesarean Section

Regional anaesthesia by definition is anaesthesia of only a specific part of the body, such as a
limb or the lower half of the body with the consciousness remaining intact.

The general advantages of regional anaesthesia includes reduced post-operative

nausea and vomiting (PONV), reduced incidence of deep venous thrombosis and pulmonary
embolism. Reduced perioperative blood loss hence reduced rate of blood transfusion which
will avoid the complications that arise from blood transfusion such as hemolytic reactions,
transfusion related lung injury, circulatory overload and air embolism which could be life
threatening in pregnancy. On top of that, regional anaesthesia also avoids polypharmacy,
early return of bowel function secondary to reduced ileus (early oral intake which is crucial
for the breastfeeding mother). RA also provides extended analgesia (with presence of
catheter). It also reduced the risk of allergic reactions post-operatively. RA is indicated as a
non-GA option for malignant hyperthermia.

Neuraxial block as known as central neural blockade where local anaesthethic agent is
administered into either spinal or epidural or in some cases may be both space from posterior
part of the trunk through the inter-vertebral space. This technique is a single shot bolus and
can be used for procedures or surgeries involving the lower abdomen, pelvis and lower ribs
which is expected to last than 3 hours. The dynamicity of CSF in the spinal space allows the
LA agent to act directly on the spinal nerve roots and spinal cord which gives the immediate
onset of block property. Their principle advantages are fast to perform and has rapid and
immediate onset (within 3-5 minutes). It has a dense block (better quality of sensory and
motor blockade compared to epidural). Opioids (fentanyl or morphine) may be added as an
adjuvant to the LA agent in order to prolong and intensify the quality of block (despite its
lower dose, side effects of opioids can still be encountered).
 Epidural anaesthesia is more dynamic as it can be done at the level of lumbar (most
common), sacral (caudal) or thoracic intervertebral space. LA agent act nerve roots as they
pass through the anterolateral epidural space and produces slower onset (approximately 15-20
minutes) and less intense blockade. Principle advantages of epidural anaesthesia is able to
provide intraoperative anaesthesia that lasts more than 3 hours (achieved by giving LA agent
titration boluses through an indwelling catheter). Able to provide postoperative analgesia
(achieved by infusing continuous diluted LA and opioid mixture through an indwelling
catheter. Epidural anaesthesia provides excellent analgesic effect without disrupting the
motor function or diminishing the sensory function (touch, temperature, proprioception). In
this way, there will be less post-spinal puncture headache and less systemic hypotension.

In addition, combined spinal epidural anaesthesia is done by initially locating the

epidural space, performing spinal anaesthesia followed by epidural catheter insertion hence
using both Tuohy and spinal needle. Spinal anaesthesia is performed by a ‘needle-through-
needle’ technique whereby the spinal needle will be inserted through the Tuohy needle. This
allows combination of both technique advantages during intra and postoperative anaesthesia
which are speed of onset and density of blockade and the ability to extend the intraoperative
anaesthesia and postoperative analgesia.

In the case of lower segment caesarean section, any types of regional anaesthesia
mentioned above can be performed but in the hospital setting it is usually either spinal or
epidural anaesthesia. Regional analgesia may benefit the mother in other ways beyond
relieving pain and anxiety. In recent studies, pain may cause maternal hypertension and
reduced uterine blood flow. Epidural analgesia blunts the increase in maternal cardiac output,
heart rate, and blood pressure that occur with painful uterine contractions and “bearing-
down” efforts. By reducing the maternal secretion of catecholamines, epidural analgesia may
convert a previously dysfunctional labor pattern to a normal one. Regional analgesia can
benefit the foetus by eliminating maternal hyperventilation with pain, which often leads to a
reduced foetal arterial oxygen tension owing to a leftward shift of the maternal oxygen–
haemoglobin dissociation curve.

A C-section may be performed as an urgent procedure when complications have

developed during pregnancy or labour or as an elective procedure, where the surgery has
been planned in advance. When a C-section is carried out, anesthesia may be local, where the
mother is awake but sensation in the lower body is numbed, or general, where the mother is
unconscious during the delivery. A C-section may be required when the labour has not
progressed naturally, when there is a history of two or more caesarean sections, when the
baby is in the breech or bottom first position, when there is a complication called praevia,
where the placenta lies inside the lower segment of the womb and when the mother is
expecting twins or triplets. In these kinds of cases regional anaesthesia is preferred compared
to general anaesthesia due to its advantages.
References

1. Choi, J. Obstetric regional anesthesia. NYSORA. Retrieved November 11, 2021,

from https://www.nysora.com/foundations-of-regional-anesthesia/sub-
specialties/obstetric/obstetric-regional-anesthesia/ . (April 23, 2020).

2. Ishak, N. H. (2015). Basic anaesthesia handbook. UiTM Press.

3. Yeoh, S. B., Leong, S. B., & Tiong Heng, A. S. Anaesthesia for lower-segment
caesarean section: Changing perspectives. Indian Journal of Anaesthesia, 54(5), 409.
https://doi.org/10.4103/0019-5049.71037. (2010).