Anesthesia

Core Concepts

Epidural analgesia and anesthesia

An epidural involves placing a small catheter into the epidural space (outside the dura) in the lower back, through which local anesthetics and often opioids are infused or dosed. During labor it provides dense pain relief — many people feel contractions as pressure rather than pain — while the person stays awake and usually retains some ability to move and push (the degree of motor block varies with the drug regimen). An epidural placed for labor can also be "dosed up" to provide surgical anesthesia for a cesarean if one becomes necessary, which makes it flexible as well as effective.

During placement, the nurse's jobs include: verifying consent and pre-anesthesia information per policy (allergies, relevant history, recent intake, lab work if ordered), positioning the person (sitting or side-lying, curled forward to open the spaces between the vertebrae), providing physical and emotional support, and monitoring maternal blood pressure and fetal heart rate. After placement, ongoing care includes frequent blood pressure checks and fetal monitoring, assessment of pain relief and block level, and observation for complications.

Combined spinal–epidural (CSE) and spinal anesthesia

The combined spinal–epidural gives a small spinal dose for rapid onset of pain relief, then places an epidural catheter for ongoing dosing — "fast start, long finish." The spinal (subarachnoid) block is a single injection of anesthetic into the cerebrospinal fluid; it produces a rapid, dense, profound block, making it ideal for cesarean birth but less flexible for long labors. A high or total spinal — the anesthetic spreading upward and suppressing breathing — is a rare but serious complication that anesthesia providers manage and nurses help recognize.

Blocks for vaginal birth: pudendal and local

For the second stage and for perineal repair after birth, providers may use a pudendal block (anesthetic injected near the pudendal nerve, numbing much of the lower vagina and perineum) or local infiltration (anesthetic injected directly into the perineal tissue before an episiotomy repair or laceration repair). These do not relieve uterine contraction pain — they numb the birth canal for stretching and repair.

General anesthesia

General anesthesia — unconsciousness with airway support — is used when a cesarean must happen immediately (e.g., an emergency where there is no time for a regional block) or when regional anesthesia is contraindicated. Because the pregnant person is treated as having a full stomach, a rapid sequence induction is used to secure the airway quickly and reduce aspiration risk, and the airway itself can be more difficult to manage in pregnancy. The nurse's role includes preparing the person and equipment, assisting the team, and being ready for the newborn's transition, since the anesthetic crosses the placenta to some degree.

Complications: what the nurse watches for

• Maternal hypotension is the most common complication after neuraxial placement: the block dilates blood vessels below the block, and the supine uterus can compress the vena cava on top of that. Blood pressure is checked frequently per policy after placement, the person is positioned (lateral tilt or side-lying) to relieve aortocaval compression, and IV fluids are given per order. Untreated hypotension reduces uterine blood flow — which is why the fetal tracing is watched alongside the blood pressure cuff.
• Inadequate or one-sided block — pain persists or only one side is numb. The nurse reports it; the anesthesia provider adjusts or replaces the catheter.
• High block — anesthetic spreads upward, causing weakness of the arms, difficulty breathing, or slurred speech. This is an emergency: the nurse recognizes it, calls for help, and assists per protocol.
• Local anesthetic systemic toxicity (LAST) — anesthetic entering the bloodstream can cause neurologic or cardiac effects. Rare, but nurses are trained to recognize early signs and activate the response per the institution's protocol.
• Postdural puncture headache — a positional headache that can follow an accidental dural puncture, usually managed by the anesthesia team.
• Other common effects: pruritus (itching) from epidural opioids, nausea, urinary retention (the person may need a catheter or frequent voiding checks per policy), and sometimes a rise in maternal temperature that the team assesses and manages. Fetal effects are largely indirect — via maternal blood pressure and position — and the tracing is monitored continuously after placement.

The nursing care bundle around anesthesia

Pre-placement: informed consent verified, baseline vital signs and fetal status, IV access per policy, and positioning support. Post-placement: frequent blood pressure and fetal heart rate checks per policy, assessment of pain and block level, bladder care, and safety measures — the person often has reduced sensation and mobility in the legs, so bedrest per policy, call bell, assistance with position changes, and fall precautions are standard. Education: the person needs to know what to expect (numbness, when to call, what the pump alarms mean, that they will still feel pressure with contractions). Documentation covers the entire arc: baseline, placement, monitoring, complications, and response. Scope note: nurses do not place neuraxial blocks or choose anesthetic drugs; candidacy (including contraindications such as bleeding disorders or infection at the site — examples only) is determined by the anesthesia provider, and all monitoring parameters follow institutional policy.

Common Confusions