Beth Ann Clayton, DNP, CRNA: Factors that can lead to failed epidurals during cesarean delivery

Cesarean delivery is recognized as the most common inpatient procedure performed worldwide, making the reliability of anesthesia a cornerstone of maternal safety. Beth Ann Clayton, DNP, CRNA, FAANA, FAAN, Practicing CRNA, Nurse Anesthesia program director, University of Cincinnati; Practices clinically at the University of Cincinnati Medical Center, level 4 High-Risk Maternity Care Unit; Member, American Association of Nurse Anesthesiology (AANA), discussed why a significant portion of these procedures encounter anesthesia complications. Despite the goal of providing minimal risk via spinal or epidural anesthesia, Clayton noted that approximately 15% to 17% of these administrations will fail at some point during the delivery.

"A patient with a high BMI makes it challenging for the anesthesia provider to be successful in placing that spinal or epidural midline, which we know midline is the optimal place for the medicine to go into," Clayton stated.

Beyond BMI, abnormal spinal anatomy such as scoliosis or a history of spine surgery can interfere with both technical placement and medication distribution. According to Clayton, "a patient who has a curved spine, or who may have some type of foreign object in the spine, can affect how the medication may flow," which can result in "areas that may not be numb, or even a whole side that may not be numb."

Physiological and surgical factors affecting analgesia

The effectiveness of local anesthetics can also be compromised by the patient’s clinical condition or history. For patients with a history of chronic pain or substance use disorder, providing adequate analgesia often requires a multifaceted approach. Clayton also highlighted how intrauterine infections, such as chorioamnionitis, create a localized environment that is hostile to anesthesia. "Because of the infection, it changes the pH of the environment, and that change in pH actually affects the local anesthetics," Clayton explained.

Furthermore, existing labor epidurals may fail when transitioned for surgery. Clayton noted that if a catheter has been in for a long time, it can deviate from the midline or the orifices can become blocked.

"Some of those holes will actually occlude because the tissue will start to occlude those holes. Therefore, if you don't have all the holes open, that can cause inadequate dispersion of that medication," she said.

The importance of realistic patient expectations

A final component of successful anesthesia is clear communication regarding what the patient will experience. Clayton emphasized that providers must help patients understand that they will still have some sensation.

"It's important for the anesthesia provider to explain that the patient will feel things. It won't be that they won't sense anything. They will sense movement, they will sense some tugging, they may sense some pulling, and they may sense some pressure," Clayton noted.