When a good anesthetic goes bad – anesthetic failure during c-section

Someone (thank you Mona Lisa) sent me a link to an article about a nightmare c-section where a woman felt the entire surgery and asked these questions:

Why does this happen?  Can it be fixed mid surgery, or does the anesthesiologist have their hands tied?  Several mothers have commented on Navel Gazing Midwife saying this has happened to them, or they know someone it’s happened to.  How common is this?  What sort of disciplinary action should the anesthesiologist face?  Or is this just an accepted risk of the procedure?

We are talking about neuraxial block failure – ie a spinal or epidural block that is inadequate for the surgery.  First we need to understand what neuraxial blocks are and the difference between the different types.  A neuraxial block is an injection of local anesthetic and narcotic into the intrathecal space (a spinal, the medication goes into the fluid or CSF that surrounds the spinal cord) or the epidural space (an epidural, the medication goes into a fat-filled space outside of the membranes that surround the spinal cord and spinal fluid).  A spinal interrupts nerve transmission in the spinal cord itself, an epidural interrupts nerve transmission in the nerve roots as they exit from the spinal column through the epidural space.  A spinal requires less volume of drug because the interthecal space is smaller.  It also has a faster onset compared to an epidural.  For an epidural to work for a c-section, many levels of nerve roots need to be frozen.  The medication has to spread up and down in the epidural space and enough volume has to be injected for it reach all the nerve roots that carry sensation to the surgical site.  Although the incision for a c-section is usually confined to a small area, the freezing has to work on the entire peritoneum (the membrane lining the abdominal cavity, not the perineum which is the skin and muscle located between your vagina and anus).

 Above: an epidural catheter in the epidural (above the dura) space.  The dura is not punctured.

A spinal/ intrathecal injection.  The dura is punctured and the injection is into the CSF.

Different neuraxial blocks have gone in and out of fashion over the years due to complications and availability of different medications.  It was discovered (before my time) that certain preparations of lidocaine, when injected into the interthecal space, were causing neurological irritation and damage in a small proportion of patients (http://www.jcafulltextonline.com/article/S0952-8180(00)00186-0/abstract).  This could be prevented by using an epidural injection to keep the lidocaine outside of the interthecal space.  Epidurals became more popular compared to spinals for a short time.  There were also some thoughts about an epidural being beneficial because you could titrate the block through a catheter rather than just placing a single shot injection which theoretically gives the anesthesiologist greater control with fewer side effects.  However, bupivacaine came out, then ropivacaine and both could be used in the interthecal space without causing problems with transient neurologic syndrome and cauda equina…and since a spinal injection is simpler, now spinals are used for most elective or planned c-sections as well as for urgent c-sections in labouring women who don’t have an epidural.  It is also possible to do a combined spinal-epidural or CSE where an epidural catheter is inserted just after an interthecal injection.  This allows a spinal block to be extended with an injection through the epidural catheter if the surgery lasts longer than the spinal.

Neuraxial blocks are preferred over general anesthesia for most c-sections (except the super super emergent) because we recognize that birth is a special moment for the family and that most women would prefer to be awake for the birth of their child.  An awake mom also allows the presence of a support person so generally the child’s other parent gets to be present for the birth too.  Secondly, general anesthetic agents are transferred to the fetus and can cause some depression, although, to be honest, with modern agents and techniques, this doesn’t appear to be much of a problem.  A neuraxial anesthetic allows us to avoid having to instrument the pregnant airway – briefly, putting a breathing tube down the larynx of a pregnant woman and getting it out safely at the end of the procedure is not straightforward as there is a higher incidence of failed intubation, hypoxia, airway obstruction and serious morbidity and mortality due to that compared to non-pregnant women.  Maternal mortality is lower after a c-section under neuraxial compared to general as is morbidity.  There is less blood loss, earlier mobilization, breastfeeding and return of gut function after neuraxial compared to general.

The failure rate of a spinal injection for c/s is 0.5-4% while the failure rate for an epidural is a bit higher at 4-13% (Pan et all, Int J Obstet Anesth 2004; 13:227-33).  The failure rate for epidurals is higher because they are often placed during labour and may migrate out of the epidural space.  The failure rate for an epidural placed in the OR in a controlled fashion just prior to the c-section is probably less than the above quoted rate.  Neuraxial blocks take away pain and temperature sensations and may take away motor control.  However, they do not take away the sensations of pushing and pulling that occur during the surgery and that is completely normal and does not mean that the block is not working.

When a neuraxial block fails to provide adequate anesthesia for a c-section there are several possibilities.  Maybe there are anatomical abnormalities that prevent spread.  Maybe the drug wasn’t injected into the right anatomical space – the techniques are “blind”.  Maybe a dosing error was made and not enough drug was injected.  Maybe a drug error was made and the wrong drug was injected.  Maybe the drug was a bad batch.  We’ve had some troubles with 0.5% bupivacaine that we use in the spinals for major joint replacements.  Turns out trucking it across Canada without climate control caused some breakdown of the drug.  Maybe it was working but the block has regressed faster than anticipated or the surgery has lasted longer.  Maybe the block is working perfectly but my patient is having a panic attack.

Maybe we will never know why it didn’t work.

The first step that you should expect and insist on as a patient is that when you voice your concerns about inadequate anesthesia, that you are listened to and your discomfort is acknowledged.  Then some steps should be taken to fix the problem.  These steps depend on the urgency of the c-section and the stage of the surgery.  If the surgeon hasn’t begun and your baby is happy, then perhaps a little more time will allow the block to develop more or maybe it would be a good idea to repeat the injection, or put in an epidural to extend an inadequate spinal…A second intrathecal injection puts you at risk of getting a really high spinal which might compromise your breathing or even cause unconsciousness so your anesthesiologist may not feel it is safe.  Sometimes, if it’s truely elective, we can wait for a partial spinal to regress before we repeat it.  If your epidural doesn’t work perfectly for labour (ie lots of top-ups and lots of medication required, unilateral or patchy), I personally usually don’t bother trying to top it up for a c-section…I pull it out and put in a spinal because it is more reliable.  Putting in a spinal due to inadequate anesthesia after topping up an epidural also might increase the risk of a high spinal as the swollen epidural space “squishes” the interthecal space.

If the surgeon has begun the operation, then we can’t sit you up or roll you over to repeat a neuraxial injection because that compromises the sterility of the surgical site.  The choice then is a general anesthetic, or if your discomfort isn’t severe and something you can live with, then perhaps some local anesthetic injected by the surgeon, an alteration in the surgical technique (less tugging, no exteriorization of the uterus) and/or a small amount of sedatives and narcotics via the IV will get you through the experience.  If you chose the latter, be aware you can change your mind and request a switch to a general anesthetic.

Maybe if things are pretty scary and your baby has to come out right away, conversion to general anesthesia is the only way to go.

In the third world where anesthesia services are not available, C-sections are truly heroic life-saving procedures and frequently done with local anesthetic alone.

In terms of disciplinary action for an epidural or spinal that doesn’t work…all physicians, anesthesiologists not accepted, are required to treat their patients with dignity and compassion, to do no harm and to respect their patient’s autonomy.  Behaviour to the contrary can be addressed directly with the physician, through the patient complaint department at the hospital, via the provincial college of physicians and surgeons in Canada (or I suppose the state licensing authority in the US) or via legal channels.

When I discuss anesthetic options with my patients and we are discussion a spinal or epidural block, I always mention the possibility of block failure as well as methods to address it such as conversion to general anesthesia.  When a block fails, there is a human tendency to dismiss it…oh, well, the patient is just nervous, or, well, it’s not that bad, right?  Clearly she’s just feeling tugging, not pain and tugging is normal.  But that doesn’t do either myself or the patient any service.  They will get increasingly distressed and I’m just putting off the inevitable.  We need to face our failures head on and deal with them and fixing the problem of a neuraxial block that doesn’t provide adequate anesthesia for a c-section requires time – time for a discussion to occur with the patient regarding options and preferences, and time to repeat the injection or set up for and establish a safe general anesthetic.  Best to fix the problem as soon as it is identified.

19 comments

  1. miriam · · Reply

    I felt the popping of fat with the bovie. It is amazing how much you can feel without feeling pain! But nothing hurt… which is a tricky distinction to get through to someone who is nervous already and doesn’t know what to expect. I spent the first 5 minutes of every c/s I did during residency terrified that the spinal wouldn’t work…

  2. My sister ended up with an “epidural headache” after birth and needed a blood patch. From what was explained to her it sounds like the epidural needle went through the dura–is that right?

    What about general anesthesia failure, where the patient is aware of everything? I had thought that was an urban myth, but I know of a case where a patient complained to her surgeon after surgery that she felt everything. The doc thought she was full of it and was dismissive. The patient then proceeded to list all the songs played during surgery, and recounted the conversations that took place, including one about her breasts.

    1. A post-dural puncture headache/ spinal headache or epidural headache occurs after 1-2% of epidurals for labour. Even if the dura is not overtly punctured, sometimes the headache develops. If the dura is accidentally punctured, the risk of PDPH is much greater, around 52%.

      Failure of general anesthesia, as you point out, occurs also. Awareness under GA is rare but more common during emergency c-section, trauma surgery, cardiac surgery and in patients who have significant organ dysfunction. For an emergency c-section under GA, awareness occurs in roughly 1% of cases.

      When awareness occurs under anesthesia it may or may not be accompanied by anxiety and distress and it may or may not be accompanied by pain. General anesthesia is a cocktail of medications for amnesia, for pain, for anxiolysis so if one component isn’t high enough, the others generally still function.

  3. Snorkel · · Reply

    When I had a spinal for my cs, the anaesthesiologist was very careful to check the block worked correctly before letting work commence. He tilted the bed head-down to get better coverage and checked my feeling with a sharp plastic thing. All the way through surgery, he kept asking if I was ok, comfortable etc.

  4. Amanda · · Reply

    I had epidural failure during my first c-section, and while I feel the anesthesiologist and nurse-anesthetist handled it well with comforting words and some ketamine, I still felt terrified thinking back on it for years. I felt really brushed off when I brought it up with my OB later. However, I had a spinal-epidural with my second baby and it provided the dense coverage I desired. The anesthesiologist was a no-nonsense type but she listened respectfully to my concerns and was absolutely wonderful. It really diffused the last of the fears I had going into the OR again. Great article.

  5. J and K's mum · · Reply

    In my last C-section, which was a planned RCS, I had a resident start my spinal. It took 5 tries and each time I felt a searing, horrible pain just above my left hip. He was audibly mumbling about my spine being weird, but then the actual anaesthesiologist took over, said, “I don’t think so,” and I went instantly, wonderfully numb. Could the resident have been hitting a nerve or something? Is this very common? I will never let a student or resident touch my spine with a needle again.

  6. I wish you’d been my anesthesiologist for my C/S. I only barely remember seeing my son because I was yelling repeatedly, “I AM STILL EXPERIENCING PAIN IN THE UPPER LEFT QUADRANT OF MY ABDOMEN!” The anesthesiologist was very rude the whole surgery. Further I was already in a full blown panic attack. He was annoyed and at some point I was just knocked out. I am pretty sure it was sedatives but my memories of the OR are spotty at best.

    1. That sounds pretty terrible. I might not have been able to do anything better than your anesthesiologist did for you in that situation, but I hope I would have at least been nicer about it.

      1. No, I don’t think that you could have magicked the pain away – although it sounds like you would have handled it differently anyway (i.e. inadequate multiple-top-up epi). But I am 100% sure you would not have rolled your eyes and been irritable with me as I gasped “is he okay? Is he okay?” and “Am I going to die?” (although I’m not positive I actually said it out loud – by then I was in a blur.”

        I’m betting you would have told me if I was going to be knocked out.

        I’m betting you wouldn’t have laughed at me and teased me when they wanted to show me the baby and I was yelling about pain.

        Shit, I’m betting you would even have heard me gasping “Somebody text my mother we’re okay” right after the birth. She still complains about how nobody told her anything for hours. Not that it’s your job, but you write with enough empathy that I think you’d at least ask if SOMEBODY would. Maybe that’s assuming too much because of the false intimacy of internetz, but still.

        I’m betting you would have treated me like a person and not an irritatingly frightened talking uterus.

        1. Yeah, you’re right…its not just teh false intimacy of the internet.

          That sounds aweful. I’m so sorry that you had such a horrible experience. And yes, I would have totally texted your mother. I would have even texted her a picture of the baby.

  7. Maile · · Reply

    This happened to me. I was mostly numb, but could definitely feel a lot more than just “a lot of pressure”, which is what I had been told I would feel. The anesthesiologist was wonderful. He gave me additional meds (I forget what), and when I was still saying that it hurt, he said, “there’s one more thing I could give you, but you might not remember the surgery”. I said, “go for it” and I think I was out after that.

    The most confusing part was after the surgery because I wasn’t sure if I had imagined the whole thing. This really bothered me, and I asked the nurse if I could speak with a hospital social worker. Re-telling the surgery wasn’t easy, but it was helpful, and the social worker had one of the head anesthesiologists speak with me the next day. He explained that, yes, this really happened, and why it happened (his explanation was similar to your post). This made me feel a thousand times better and allowed me to process the whole experience. I had a birth experience that some would describe as terrible (30+ hours including four hours of pushing, followed by this crazy c-section), BUT because the hospital staff was so amazing during the whole thing, I feel like, overall, I had a very positive experience.

  8. [...] epidural only took on one side. Like most issues in my pregnancy, this is a very rare complication (less than 4% chance). But our girl could not wait, and putting me fully under would make the great battle Lydia had in [...]

  9. N. Mitchell · · Reply

    Tomorrow it will be 36 years ago. My spinal failed during my second C-section and why I found this website page. I still wonder about it. The doctors would never answer my questions — wouldn’t tell me that spinals fail. My husband and mother had only been told that I’d “had a rough time,” but that I was fine.

    When I was wheeled past them after surgery, I could barely speak but told my them, “They tried to kill me in there.”

    I’d felt the pin prick test. I felt it when they catheterized me. No one seemed concerned except me. I asked the student anesthesiologist why I was feeling those things. He told me that it would take effect before they started.

    It was a dreadful experience, painful beyond description. I broke free of my crucifixion pose, and clobbered anyone close by. So much mayhem when all I wanted was someone to hold my hand as I died.

    I was given gas and calmed down till the pain hit me like another grenade explosion and when the mask was put on my face the second time, I couldn’t suck the gas fast or deep enough.

    After the birth no one would square with me. Not the woman operating on me, or the guy doing his residency in anesthesiology. He’d come sit with me mornings though, for five days post operative, he came and sat with me. He came even after I told him it was odd to wake up and see him every morning. I knew he felt guilty, but he never told me the spinal failed. Period. Sorry.

    Thank you for sharing this information, it was good to find a simple explanation after almost all these years.

    1. Grenades exploding in your. Abdomen. Yes, that is what it felt like for me many years ago. I suffered post- traumatic stress disorder and suffered depression and severe anxiety after. There are no words to describe that pain of a failed., completely ineffective epidural. Sorry for anyone who had this

  10. Christine · · Reply

    These look like old posts but maybe writing will make me feel better. I sit here and I cry. My first was breech (they tried to turn her around but it failed. I also don’t recommend this procedure). Scheduled C-section. Spinal block. Cotton test. Felt hot slice of my abdomen. Screamed. Second hot slice. Screamed again. Husband rushed out of room. General Anesthesia. :( I see a lot of people have had similar experiences (and worse) but I wonder and I wonder if any of their children have ended up disabled. My daughter is 15. No diagnosis but has been labeled mentally retarded after many doctors, mri’s tests etc.. as well as leg and back issues (no prior family history) I gave up. She’s great and love her to death but she will never grow up like a normal teenager. She will never get married and never have children. It’s been 15 years and I can’t help wondering if it has something to do with my awful delivery. Hospital claims Apgar was high, so it ends there. I also wonder why is it so important and such an emergency to get me under general anesthesia after starting surgery. It was so URGENT, doctors, nurses rushing etc….I recently asked an Anesthesiologist (during a procedure my husband was having) how often the spinal failure happens like that and he said never. Maybe in his experience. OK, so do I feel better, for the time being. Thanks to whomever is paying attention. I feel haunted my the unknown. Christine

    1. I”m not writing much anymore but I’m still here and I do read all the comments. I’m sorry for your horrible experience. Spinal anesthetics do have a small but real failure rate. Depending on the institution, a conversion to GA can be an experience like you had – with lots of “running” and “rushing” or it can be more relaxed, a lot of that is cultural and depends on the experience of the OR team involved. Without reviewing your medical records, I can’t really comment on any relation to your daughter’s outcome beyond saying either a spinal or a general anesthetic is not associated with a higher degree of developmental delay. If you haven’t already, you could ask for a copy so that you could get an independent opinion (i.e. not from the hospital involved). Closure is an important thing, I think, and you might find it helpful, particularly as you are still hurting.

      1. Christine · · Reply

        Thank you!!!!!!!!!!!!!!! It was so nice of you to respond. Very helpful…… :)

  11. Debbie Duffy · · Reply

    I’m also writing late. My second c section was 7 weeks ago now and thank god, both my children are very healthy so I don’t think the traumatic birth affected my new baby. I’m still in a blur about the whole thing. My ob/gyn didn’t want me to go more than 10 days overdue so I didn’t get the vbac I was hoping for. On the morning of the section, I was nervous but calm as although my previous c section was an emergency, it was very successful and pain free. There was pressure but nothing more. This time, a registrar applied the spinal, and hit a nerve a few times while I was getting the spinal. It felt like a bolt of electricity down my right thigh. When I lay down, I could still move my leg quite easily. I could feel the cold spray quite low down on my abdomen. I told them and they waited to see if it would take better. They also tilted back the bed/table, to no effect. Feeling apprehensive, I asked them to be careful if I needed to go under general anaesthetic as I’m a singer and feared damaging my vocal chords. I didn’t feel the incision thank god, but I felt everything else. I could feel my organs moving about and the birth was terrible. My baby (9lbs5oz) was huge and I could feel the width of the incision as he was pulled out. I saw him in the distance and heard him cry so I knew he was okay. Then, I completely lost focus. The pain got much worse. My memory of what else happened is very patchy, but my husband remembers most if it. I could feel the stitches and the consultant anaesthetist tried to increase meds and mop my brow as I turned bright red and came into a cold sweat. They apparently asked me if I wanted general anaesthetic but I said I didn’t know. Then they sedated me.

    I woke in recovery some time later, confused, as if the whole thing had been a dream. No baby near me, no husband, no one. But I was in terrible pain. I told a passing nurse who gave me one oxy norm pill. That had no effect. When I got back to the ward I told the midwives I was in pain. I ould barely talk with the pain. I persevered with breastfeeding through the pain. The midwives fought my corner and after about 2 hours I finally was given a morphine pca. By then I was so tense with pain I couldn’t allow my body to relax. A very kind doctor helped me with some guided meditation and I drifted off to sleep.

    I spoke to a few different doctors while I was in hospital about my experience, and for the most part they were sympathetic and apologetic (though not all). I even met a couple of anaesthetists but I was in such a tizzy I can’t remember much of what they said. I hope to have at least one more baby sometime in the future but am terrified of birth now. My husband is pretty traumatised too and can’t even talk about it.

    I don’t know what to do… If anything.

    I hope you get this message.

    Debbie (from Ireland)

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 97 other followers

%d bloggers like this: