Failed Epidural: Drama in the Operating Room

What really happens if you feel pain during a C-section?

In this episode of Gyno Info: Frank Talk with Dr. Burki, I answer a listener’s question about a traumatic emergency C-section complicated by preeclampsia, where the epidural didn’t provide adequate pain control and general anesthesia was required.

I explain:
 • What preeclampsia is and why delivery is the cure
 • How epidurals and spinal anesthesia work during C-sections
 • Why epidurals don’t usually “fail” mid-surgery
 • How emergency timing changes anesthesia decisions
 • Why partners may be asked to leave the OR
 • What likely happened in this case

If you’ve experienced birth trauma or have concerns about C-section anesthesia, this episode will help you understand what may have happened — and why.

My goal is always education without fear.

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You can write to us at Questions@GynoInfo.net

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Transcript

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Welcome to Gyno Info, Frank Talk with Dr. Berkey, the podcast dedicated to teaching everyday women what they need to know about their body and how it works to successfully deal with the healthcare system and communicate with their doctors. Each week, I'll provide you with new information and practical tips about gynecology and women's health care. I want to prepare you for your doctor's appointments by teaching you what to expect, what information your doctor will need to know from you, and what questions you will need and should ask her so you can be confident and make the most out of every visit. GynoInfo will give you the knowledge you need to take charge of your health and do this in a clear and frank way that you can understand without having a medical degree. One episode at a time. So now let's begin. Hello. Welcome back to Gyno Info, the podcast about women's health in normal, everyday language that normal, everyday people can understand. No special medical words, no doctor speak. A special welcome to those who just discovered us and are listening for the first time. And please take a moment to subscribe to GynoInfo so you can get back to this episode in case you have to interrupt in the middle and would like to finish the podcast later on. You cannot count on the internet algorithm to send it to you anytime soon. So this week, I'm again going to answer some questions that a listener sent to me at questions at gynoinfo.net, where you too can send in any questions you have, as long as they have something to do with gynecology or women's health or medicine in general. When I don't know the answer to your question, I will always research it carefully and give you the answer in a more understandable forum. Then the medical textbooks and scientific articles that I studied to find the answer were written in. I promise you that I will always do my very best to get to all your questions. Please keep listening for them. To answer some of the questions, like the one I'm answering today, I may need a whole podcast. First a notice about today's podcast right up front. This podcast does contain slides. You might want to watch it on YouTube rather than just listen to it wherever you usually listen to your podcast, so you get the most out of it. Now here's today's question. It's actually several questions in one. A colleague of mine had to have a C-section after failed induction because of pre-eclampsia. During the C-section, she started to feel the cutting and screamed. They converted the case to general anesthesia and put her to sleep. Her husband was taken out of the operating room. She was intubated and the baby was successfully delivered by cesarean section. Mother and baby are doing fine. My question is, how common is it for an epidural to fail mid-C-section? I never heard of something like that happening. Did pre-eclampsia make this more likely to happen? First, just for our listeners who do not know much about pregnancy complication, a little translating. Pre-eclampsia is a serious problem in pregnancy that usually starts with high blood pressure and can lead to kidney and liver failure, seizures, stroke, and death if it's not treated. So it's really serious. The most effective treatment for pre-eclamcia is delivering the baby and ending a pregnancy. This is generally done by inducing labor, starting labor with medications. Sometimes it works, and sometimes, like the questioner writes, it does not. That is then called a failed induction. Labor just never progresses to the point where the baby can be delivered naturally through the vagina. But the baby needed to be delivered as soon as possible because the mom was seriously ill with pre-eclampsia, which can kill the mom if it goes on long enough. This is why the doctors had no other choice than to do a cesarean section and deliver the baby by surgery to save the mom's and actually the baby's life. Obstetrics can get quite dramatic sometimes and get the doctor's ignorance adrenaline pumping. Caesarean sections or C-sections or cesareans used to always be done under general anesthesia, with the mom put to sleep for the duration of the surgery. In those days, it was usually a race against time to get the baby out before the medications that were used to put the mom to sleep reached the baby and put the baby to sleep as well. You wouldn't want to deliver a sleeping baby. It would make it harder for that baby to start breathing once they were outside, were born. Nowadays, instead of general anesthesia, doctors use spinal or epidural anesthesia, where only the lower part of the mom's body is numb. She's numb from the waist down. She can be fully awake while the baby's taken out of her belly, and there is no danger for the baby to fall asleep either. In most hospitals, when the C-section is done with the mom awake, the dad gets to be in the room and see his child be born, which is very special. But of course, dad or whichever support person the mom chooses will have to be dressed in all the right operating room clothes, wear head and shoe covers, and a mask. They also have to be sitting still and out of the way of the operating team. This way, as soon as the baby has been taken out of the belly and checked out and wrapped in a baby blanket, the dad gets to be the first one to hold the baby until the mom's belly is sewed up and she can also hold the baby. It is a very wonderful and moving experience. In the case of our listener's colleague, something went wrong with the epidural. And when the surgeon began to cut through the skin of the mom's belly to get into the uterus, she felt everything, and naturally she started screaming. What they had to do then is put the mom to sleep immediately so they could continue the surgery and deliver the baby. In that situation, there is no time to fix the epidural anesthesia. You cannot just stop a surgery once you have made the first incision and started cutting. Things get generally pretty hectic in the operating room if something like this happens. The last thing the operating team needs in that situation is a freaked-out dad asking questions about why the mom is screaming. It is important that only people who are trained and know exactly what needs to be done are in the room in that situation. A panic dad will be of no use at all, and there will be no one available to calm him down and explain to him what is actually going on. So the dad is handed to someone outside the room to take care of him and let him know what is happening inside. Apparently, all went well in the end, and thankfully, everyone is okay, and dad will have an exciting story to tell for the rest of his life. The mom, who felt it all, might not find it as entertaining. Which leaves us to the two actual questions the listener asked. The first one is, how common is it for epidural anesthesia to fail mid-C-section? The epidural in this case did not fail mid-C-section. It probably did not work right from the beginning. But the surgeons only noticed it, and the patient noticed it, when they started cutting. All the procedures before, like desinfecting the skin and putting on the surgical drapes, covering everything up except the part of the belly where the cut was to be made, would not have been painful. Nobody could have really known that the woman was not numb enough in the area where the cut was to be made. Let me just explain a little bit about epidural anesthesia and spinal anesthesia. With an epidural, a very thin tube is put through the skin in the middle of the back into the space around the spinal cord. Through that thin tube, numbing medicine is then injected in a way that the body below the level of where the tube is placed becomes numb. You want that level to be high enough that the area where the surgeon cuts and operates is numb, but not so high that the person can no longer move their chest and breathe. It is pretty tricky to get that level just right. Anesthesia doctors called anesthesiologists or anesthetists in other places spend several years training for it. For the placing of the epidural catheter or the tube, the patient has to sit up and lean forward. So the bones in the back move apart a little bit, and the epidural catheter can be slid between the vertebral bones into the right place. On this slide here, you can see how this is done. The pinkish areas on the right side of the pictures are bone, and the light grayish areas where you can see the needle passing through are ligaments, the fibrous tissues that hold the bones together. Through that area, an epidural catheter tube is slowly and carefully slid through a tiny hole in the skin until it reaches the so-called epidural space. That space is right next, but just outside the spinal cord. The space where the spinal cord, here in the slide, it's the yellow strip, is located. That is why this procedure is called epidural anesthesia. You can see this in the top half of the picture. Through this epidural catheter tube, the numbing medicine, the anesthetic, is injected. It takes a few minutes for the medication to make its way into the spinal canal where the spinal cord is located and numb the spinal cord and all the nerves connected to it. Next, the anesthesiologist checks how high up the patient can still feel things, and if necessary, gives a little more numbing medicine through that epidural catheter tube. Under calm and collected circumstances, epidural anesthesia almost always works very well. Only rarely might there be a small area where the numbing medicine did not quite work well enough. Before I go on with this traumatic story, just a quick word about the bottom half of the slide. This shows a spinal needle being put in place. It goes all the way into the space where the spinal cord runs. So again, that yellow stripe. This is the way a spinal anesthesia is placed. Spinal anesthesia works faster because the numbing medicine is placed direct by the spinal cord, but it is a one-time shot only. You inject whatever amount of medication you decide to put in and then draw the needle back out. When that amount of the medication is used up, the nurse begins to wake up and the patient begins to feel the cutting and sewing of tissues by the surgeon. Spinal anesthesia is much cheaper, works faster, does not require a lot of fancy and expensive tubes like epidural anesthesia. But it cannot be topped off if the surgery takes longer, or it is not possible to add more medication if a certain spot did not go numb. I used to do surgery in Nicaragua under spinal anesthesia many moons ago. They did not have a lot of anesthesia gas and used what they had for surgeries that could not be done under spinal anesthesia. Surgery on the lower part of the body. I always found it incredibly nerve-wracking to have to race against time be done before the patient started moaning in pain, to make sure I was done with my hysterectomy or a cesarean or a bladder surgery before the spinal anesthesia wore off. I guess it trained me to become very fast and very good. But now back to epidural anesthesia and the type of anesthesia used in our story. I just explained how it is done slowly and carefully and checked if the level is just right before a regular surgery, let's say to take out the uterus through the vagina or operate on someone's hemorrhoid is started. But now imagine doing this tricky and difficult procedure on a woman who cannot really lean forward because her belly is in the way, who's having contractions every couple minutes and can really not hold still, even if she tries her very best. Add to that difficulty that pregnant women are often very much overweight. That makes it almost impossible to feel the bones in their spines well and makes everything even more difficult. On top of that, there is a time pressure because the baby is not doing well and the surgeon wants to start operating right now. This makes it a hundred times harder, and I always found it absolutely amazing that the anesthesia doctors managed to do it at all when I was still practicing obstetrics and doing C-sections. But they miraculously do manage almost all the time. I don't have exact statistics, but happily it is not at all common for epidural anesthesia not to work. It's not something that you worry about as a surgeon. The second question the listener asks is whether pre-eclampsia had anything to do with it. The answer to that is yes and no. Pre-eclampsia itself does not make epidurals work less well. But the circumstances that pre-eclampsia lead to, where an epidural has to be placed in a great hurry and under very difficult circumstances without having time to carefully check the level of numbness before the surgery starts, definitely have something to do with it. Under these conditions, it takes a highly skilled doctor, an experienced doctor, to be able to do it as fast as needed, and failed epidurals become slightly more frequent, but amazingly enough, are still rare. And then there is a second possible scenario, a different way this all could have happened. The listener really did not give me enough details to know for sure. It could also be possible that the patient already had an epidural catheter placed during her induced labor to help her with the pain. That is often done. In fact, this is the only way I would myself ever have been able to endure my own labor pains with an epidural anesthesia. Because the epidural catheter that remains near the spinal cord for the whole time the epidural anesthesia is needed, it can be changed to very little, so you can even still walk and still feel your contractions for the less sharp pain. That would be called a walking epidural. The anesthesia is then increased as needed as the delivery draws nearer when the contractions and the pain get more intense. If it turns out that a C-section becomes necessary, the epidural can be topped off even more to make sure the woman is completely numb from the waist down. Because the listener's colleague could already have had an epidural in place when she arrived in the operating room, it is therefore also possible that something went wrong during the rushing of the patient from the labor room to the operating table. Either the epidural tube was displaced and the numbing medicine could no longer flow to the right spot on the spine, or they simply forgot to top it off during all that excitement of the emergency. Either is possible. It is hard to know what really happened, but the most important part is still the happy ending. Mom and baby are well, and dad has a story to tell. This was such a long question that I don't really have time for another one today. And we are now at the end of this episode. If you have any further questions about epidurals or pre-eclampsia or c-sections, or any other topic having to do with women's health, please don't hesitate to send them to me at questions at gynoinfo.net. Again, that's questions at gynoinfo.net. And if you like this episode, please give us a lot of likes and share it around. Again, it'd also be super nice if you could subscribe to GynoInfo. It makes it easier for other women to find us and also helps Josh and me to keep this podcast going. Thank you. Until next time, thank you for listening. And remember that you and your health are super important and deserve your full attention. Don't ever put off contacting your doctor because you're scared or embarrassed when something feels wrong about your body. Doctors are here to help you, not to judge you. And also, regular well-woman visits are always a good idea that you should make time for. You deserve it, and you owe it to yourself, and you owe it to your body and your health. This podcast is part of Pride House Media, hosted by me, Dr. Burke, produced and edited by Josh Rosenzweig. Original music composed by Nell Balaban. If you enjoyed this episode, please subscribe wherever you listen to podcasts. And while you're there, leave us a rating and a review. It really helps others discover the show. Stay connected and join the conversation by following me on Instagram and Facebook at GyNOINfo and on LinkedIn at gynoinfo podcast.