Spinal Anaesthesia in Lower Segment Caesarean Section

PART ONE

The spinal anaesthesia is referred to the neuraxial regional anaesthesia that includes injecting local anaesthesia into the subarachnoid space that initiates from the foramen magnum and extends to the s2 in adults (Gratz et al., 2020). The use of 3.5 inches needle is used in this process which by passing the skin followed by subcutaneous tissue, supraspinous ligament, interspinous ligament and ligamentum flavum reaches the duramater in the spinal cord to initiate its effect (Gratz et al., 2020). The use of spinal anaesthesia is common among multiparous women who are undergoing lower segment caesarean section (LCS) as in this process minimum amount of anaesthetic is administered to the patient. Moreover, this process leads to cause minimum pain to the individual and ensures immediate pain relief after surgery (Johnson, 2017). Thus, the process is beneficial to be used for the 33year-old multiparous woman who is undergoing LCS as the person would require reduced need of painkiller or emotional turmoil due to increased pain after the caesarean section.

The administration of spinal anaesthesia for LCS causes the small and unmyleinated sympathetic fibers to be blocked initially followed by blockage of the myelinated fibers that are sensory and motor fibres in the lower spinal region. The sympathetic nervous block caused by the anaesthesia is able to exceed motor or the sensory fibers by two dermatomes (Šklebar, Bujas & Habek, 2019). The spinal anaesthesia causes minimum impact on the ventilation efficiency, but higher spinals has the ability to cause negative impact on the intercostal muscles which leads the individual develop breathing problem and cough (Šklebar, Bujas & Habek, 2019). The spinal anaesthesia causes less blood flow from the surgical wounds as it facilitates occurrence of vasodilation in the arteries, vein and arterioles. This creates reduced mean blood pressure in the arteries in turn cause less oozing out of blood from the surgical wounds (Šklebar, Bujas & Habek, 2019).

One of the potential side-effect of spinal anaesthesia to be faced by the 33-year-old multiparious women is that she may feel pain during the injection of the anaesthesia. This is because the different layers in the spinal area to be perforated by the needle in reaching the duramater to administer the anaesthetic medication (Ortiz-Gómez et al., 2017). The negative impact on the cardiovascular system by the spinal anaesthesia initially depends on the rostral extent of sympathetic block and secondarily on the sedation degree. Therefore, the occurrence of hypotension is mainly dependent the thoracolumbar sympathectomy which has been induced by the aesthesia. The occurrence of the hypotension increases in spinal anaesthesia if increase in the rostral extent of sensory analgesia occurs between the sympathetic and sensory blocks in the process (Sreekanth & Totawar, 2018). Another side-effect to the faced by the 33-year old woman during the spinal anaesthesia is presence of extended headache. The headache in individuals with spinal anaesthesia mainly occurs as a result of leakage of spinal fluid from the spinal cord during injection for administering the anaesthesia which leads to lower pressure of the spinal fluid in the brain making individuals to develop headaches (Ortiz-Gómez et al., 2017). The other side-effect that could be faced by the woman includes difficulty in passing out of urine, backache and itching. The urinary difficulty mainly occurs after spinal anaesthesia is due to impact of the anaesthetic drug which hinders the functioning of the neural circuit that manages the muscle and nerves for urinary process (Sreekanth & Totawar, 2018).

PART TWO

The spinal anaesthesia-induced hypotension is the condition in which the blood pressure is seen to be intentionally reduced for surgery for lowering the loss of blood so that reduced need for blood transfusion occurs in the patients (O'Sullivan & Cockerham, 2016). The increased drop of blood pressure in the induced hypotension for spinal anaesthesia is to be resolved or it may lead to cause shock to the body. The shock hinders the functioning of organs in the body as reduced blood pressure cause low amount of oxygen to be delivered to the organs for their functioning (O'Sullivan & Cockerham, 2016). The symptoms of spinal anaesthesia-induced hypotension include light headiness, nausea, fatigue and blurred vision. The nausea that occurs after the spinal anaesthesia acts as the key alert for the possibility of high hypotension which is severe enough in causing stroke (Shahzadi, Hanif & Afridi, 2016). Thus, the anaesthetist is required to ask the women after administration of spinal anaesthesia if the individual is feeling increased nausea or fatigue as it could be an indication of severe hypotension for which immediate action can be taken to protect the women after facing stroke that may be fatal.

The anaesthetist to treat induced hypotension in spinal anaesthesia is to avoid administering vasopressor after the extensive reduction of blood pressure has already occurred and considered prophylactically administering the vasopressor infusion. The preferred vasoconstrictor implemented in this process is phenylephrine. The advantage of using it is that the medication causes reduced incidence of maternal nausea, foetal acidosis and prevent vomiting along with occurrence of hypotension in pregnant women (Kee, 2017). Thus, the prophylactic administration of the medication would be effective for the 33-year-old woman to avoid facing any complication regarding induced hypotension and other side-effects such as nausea and vomiting along with foetal damage. The administration of the phenylephrine in managing induced hypotension needs the anaesthetist to titrate the medication depending on the level of blood pressure every two minutes along with pulse rate to avoid increased and inappropriate administration of dosage of the medication which may create risk of extensive blood pressure anomaly in the body (Heesen et al., 2019). However, one the risk related with administration of phenylephrine is that it may cause bradycardia which is though rare, due to which consideration of administration of norepinephrine is considered as alternative but it is not scientifically proved (Šklebar, Bujas & Habek, 2019).

The treatment used by anaesthetist for preventing induced hypotension in spinal anaesthesia includes administration of 500-1500 ml of crystalloid and colloid preloading. However, the limitation of the technique is that the crystalloids are quickly redistributed and thus the coloading technique was implemented which is the quick administration of crystalloids in simultaneous manner with induction of spinal anaesthesia that was somewhat effective in lowering the limitation (Okonkwo, 2017). The other technique implemented in reducing the amount of crystalloid in preload condition is wrapping the lower limbs of the patient with bandages or compression stockings. This is because it leads to enhance the systematic blood pressure in the body and reduce symptoms of induced hypotension (Šklebar, Bujas & Habek, 2019). However, the methods are unable to provide enhanced satisfactory level of impact and therefore the administration of phenylephrine is considered by the anaesthetist in case of pregnant women.

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References

• Gratz, I., Baruch, M., Takla, M., Seaman, J., Allen, I., McEniry, B. & Deal, E., 2020. The application of a neural network to predict hypotension and vasopressor requirements non-invasively in obstetric patients having spinal anesthesia for elective cesarean section (C/S). BMC anesthesiology, 20, 1-15. Retrieved on 29 October from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195764/
• Johnson, E. (2017). ‘Advances in understanding and management in obstetric anaesthesia’: The great myth of our times. Indian journal of anaesthesia, 61(4), 285. Retrieved on 29 October from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5416716/
• Kee, W.D.N., (2017). The use of vasopressors during spinal anaesthesia for caesarean section. Current Opinion in Anesthesiology, 30(3), 319-325. Retrieved on 29 October from: http://adaarc.org.ar/wp-content/uploads/2017/05/VASOPRESORES-Y-CESAREA.pdf
• Ortiz-Gómez, J. R., Palacio-Abizanda, F. J., Morillas-Ramirez, F., Fornet-Ruiz, I., Lorenzo-Jiménez, A., & Bermejo-Albares, M. L. (2017). Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine-a double-blind, randomized, placebo controlled trial. Saudi journal of anaesthesia, 11(4), 408. Retrieved on 29 October from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637416/
• Shahzadi, I., Hanif, S., & Afridi, Y. (2016). Role Of Ephedrine Infusion In Spinal Anaesthesia Induced Hypotension. Pakistan Journal of Physiology, 12(4), 12-15. Retrieved on 29 October from: http://www.pps.org.pk/PJP/12-4/Iram.pdf