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Anesthesia

Anesthesia and Childbirth

04/22/2009

Question:

I am preparing to have my second child and am concerned about a possible problem with my reaction to anesthesia. When delivering my first child, the 2 epidurals I had did not work. When I was finally sent in for the cesarean and given multiple anesthetics that also did not work, they used gas to knock me out. I have never had a problem with gas to knock me out. I have had 3 surgeries in those cases and all went well. The doctor couldn`t understand why I couldn`t feel her pinching me but I could feel the knife. I tried explaining to her that my skin was numb but beyond that was not. I have also had similar experiences at the dentist when getting a filling. The original injection was not felt and my outer gums were numb, but when the dentist started drilling deep in the tooth, I could feel everything. He attempted over 6 injections before I finally decided to just deal with the pain. My question is whether I do have a resistance to certain anesthesia and what my options would be for my next delivery? I am concerned with the effects on the baby. I have heard that the gas may slow the breathing when the child is delivered. My doctor has told me that a cesarean is very highly recommended in my case. Thank you for any advice.

Answer:

Thanks for your question and for the carefully described account of your problems with anesthesia. There are several technical and pharmacological reasons why a local anesthetic injection, such as an epidural, or a nerve block for dental procedures, might not work. It is hard to explain however why multiple procedures, probably with at least two different local anesthetics, and presumably administered by several different practitioners, failed to take full effect. Medical science is beginning to explore in some detail the genetic variants of receptors and other vital proteins in the body and how they relate to the way anesthetics work. Local anesthetic agents are thought to attach to receptors called sodium channels which exist in different forms on nerve and muscle cells.

I am tempted to speculate that you may have some sort of genetic variant that reduces your sensitivity to local anesthetic effects. Unfortunately, clarifying whether you do have some sort of condition along these lines would involve very specialized investigation available in only a few centres in the world, and is unlikely to solve your immediate problem. You should try to get as much documentation of the various anesthetics you have had, particularly what was given, and in what dosages. This may provide your next anesthesiologist with some ideas about alternative agents and/or doses to try.

Spinal anesthesia usually achieves a more "dense" form of anesthesia than epidural, so for your next cesarean section this might be a good option instead of the epidural. In view of your past history however, your anesthesiologist would need to be prepared to administer general anesthesia if the spinal fails to "take". There is no need for an elective cesarean section to begin before the anesthesia has been tested and you are assessed to be pain-free in response to a surgery. Although spinal and epidural anesthesia are the preferred forms of anesthesia for cesarean section today, general anesthesia continues to be administered where necessary, and with minimal adverse effects on mother and baby.

You should feel confident that if your anesthesia and surgical team recommend general anesthesia that you and your baby are very unlikely to be harmed. If your baby is a little slower to breathe immediately after delivery this should not be a big concern because treatment is simple and highly effective. I will ask a colleague with expertise in this area for any additional suggestions, so please watch this space.

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Response by:

Gareth S Kantor, MD Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University