Pregnancy, scoliosis and anaesthesia

Anita Holdcroft, Reader in Anaesthesia and Honorary Consultant Anaesthetist at Imperial College London, and Chelsea and Westminster Hospital, discusses the role of anaesthesia and pain relief in labour.

Scoliosis is a condition that a woman may live with for years without knowing until an epidural is sited to manage labour pain or else, at the other extreme, she may have had surgical correction.

Potential complications

Anaesthetists are aware of the complications that may arise from scoliosis. For example, it may lead to an epidural not working or only working on one side because, unusually, within the epidural space there are tissues that obstruct drug penetration. These structural barriers have been imaged in women where epidurals have failed to provide adequate pain relief.

Scoliosis has also been identified to create a situation where the epidural catheter left in to deliver drugs moves away from the central area and to one side. Re-siting the catheter at another level of the spinal canal seems to be the most satisfactory method to overcome this failure but it means another intervention. It is therefore helpful for both the mother and the anaesthetist to be prepared for this eventuality.

Options for pain relief

Pain relief for labour can be managed in many different ways – if one route is likely to be difficult then other options should be considered. However, if delivery by caesarean section is planned, then an anaesthetic is unavoidable.

There are different approaches that an anaesthetist may advise and a number of anaesthetists have written about these. Usually, in order to avoid the epidural failing to deliver adequate conditions for surgery, spinal anaesthesia is preferred either in the form of a single shot spinal, a combined spinal and epidural (CSE), or a continuous spinal technique. These latter two techniques differ in the place where the catheter that can supply drugs is positioned. The CSE has the catheter placed epidurally while the continuous spinal has it further in, placed in the fluid that bathes the nerves. A single shot spinal has no catheter, so if surgical complications arise or if the spinal drugs do not work, a general anaesthetic may be the only option.

Anaesthetic clinics

Many anaesthetic departments have antenatal anaesthetic clinics for women who anticipate problems during pain relief for labour or for caesarean section. An anaesthetic consultation is advised for those who have had spinal surgery.

Tailor-made choices

Women who have back pain and scoliosis should take steps to consider the best approach for their own condition. Not only would an anaesthetic opinion be useful but also the advice of a women’s health physiotherapist (who can recommend exercises and the best positions to use in labour) and a midwife or obstetrician (who can advise on the plans for delivery).

One major advance in epidurals for labour pain relief has been the use of low doses of drugs and a drug combination of a local anaesthetic and the opioid fentanyl. This mixture should allow good mobility while keeping some feeling to prevent overstretching joints and muscles which could occur if all sensation was lost. The management of labour using an epidural then becomes a joint process in which the mother and her support team (including birth partner) can keep reviewing progress and decide when to add more of the drugs and what position to use.

The Obstetric Anaesthetists’ Association does not offer specific advice on scoliosis because each mother is assessed individually. It is important that an anaesthetist knows if someone has scoliosis and that this consultation is planned in advance before the delivery date – for the benefit of both mother and practitioner.

First published in Disability, Pregnancy & Parenthood international, Issue 57, Winter 2007.

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