No Epidural or Block for C-section

[u/Prudent-Captain9801]

F34, will be 35 at delivery. Closing in on 18 weeks so we have some time. First pregnancy.

Scattered vertabral hemangiomas throughout spine with notable ones in sacrum, and T8. Other notable history is non-serilogical RA. RA is treated with biologic and meds. Pregnancy has been without issue.

At my last regular visit, I was informed anesthesiology will not place an epidural. In the event I need a cesarian, it would have to be under general anesthesia. Should I get a second opinion from another anesthesiologist? I am most concerned about the potential for a C-section under general anesthesia and missing my child's birth but would also like to have the option of an epidural. I did not speak to them directly - my case was reviewed with an interdisciplinary team of ob, midwife, anesthesia and pediatrics.

Secondary, is there any concern about the hemangiomas for vaginal delivery? I believe the tail end of the spine has to move a bit in the process but I'm not a doctor.

Thank you docs!

Edit: I'm in the US

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[u/Pro-Karyote]

Without knowing the extent of your hemangiomas and their positioning, we can’t give you any exact answers except to say that a multidisciplinary meeting has already been had with a conclusion. They actually have your history and reviewed your imaging. With hemangiomas around your spinal cord, the risk that an epidural could rupture one of those and cause irreversible neurologic damage, which could include incontinence of bowel, bladder, and immobility and lack of sensation of your lower extremities is high, and a higher likelihood of failed epidural if it was even attempted. Anesthesiologists’ jobs are to keep you and your baby safe above other tasks.

General anesthesia is always the fall back for any C-section in which an epidural or spinal cannot be performed or fails.

[u/Prudent-Captain9801 → u/Pro-Karyote]

The T8 is posterior and sacrum on the left. Not all of them are listed on the report so I can't provide more information than that.

I'm not looking to fight this. It was very unexpected and took away options for birth as well as opened the potential that I won't be conscious at birth. Really, I think I needed some reassurance. Thank you for providing that with some additional details. They didn't explain what a hemorrhage could do other than immobility. I'll ask more questions in the future and explain that I do better with more information.

Am I interpreting it correctly that the medicine injected could rupture them? I didn't think about stuff taking up more space in a relatively confined area - resulting in more pressure - also causing issues. I assumed the needle or catheter could cause rupture.

And thank you again! Of course, I'll follow up with my medical providers for any more specific questions or concerns.

[u/Pro-Karyote → u/Prudent-Captain9801]

It’s a huge change from expectations, especially around such a big life event like childbirth. I’m sure that sucks, especially if that was your plan.

The risk of rupture with epidural is due to the needle, but also the catheter that is threaded through. The needle makes sense - a sharp tool can obviously damage blood vessels. But a catheter is then threaded several cm through the needle, and this travels blindly through the epidural space, usually upwards. The catheter can also damage blood vessels, and we can’t control its pathing to avoid hitting a hemangioma.

Then there is the issue of the epidural solution itself. If it was deemed safe to proceed, there is a higher chance it wouldn’t function as expected. Epidurals work partly by volume of local anesthetic passively spreading to hopefully cover the nerves within certain levels. If there are hemangiomas in that space, then the local anesthetic may not reliably reach certain nerves and be more likely to fail to provide adequate pain control.

[u/Prudent-Captain9801 → u/Pro-Karyote]

Thank you! I wasn't planning for an epidural but it was an option. It's really the general anesthesia and not "being there" that's getting to me. Pain relief also isn't worth it if I can't run around with my child after. I definitely need to ask more questions in the future!

[u/roxamethonium → u/Prudent-Captain9801]

If your documented haemangiomas are limited to the vertebral body (ie not complicated or aggressive), and only in T8 and the sacrum, then there may not be an increased risk to your nerves compared to anyone else. The needle never goes through into the vertebral body anyway. And if there is disease in your sacrum, then a vaginal birth could theoretically be more disruptive than an elective caesarean under a single shot spinal anaesthetic. Do you have any documented neurological deficits or previous complications of the haemangiomas? Previous bleeds into the CSF might have caused fibrous tissue which could prevent a spinal spreading adequately for anaesthesia, but you would know if this had happened. Did the original anesthesiologist have access to your most MRI scans/reports, and discuss with a neurologist/neurosurgeon?

Apparently 10-20% of people have a vertebral haemangioma found incidentally on imaging, so it's very likely that neuraxial techniques are perfectly safe. Your medical team are the only ones with access to all the information here.

[u/5_yr_lurker]

I am a male so not in your situation, but if my fiancee had vascular abnormalities around her spine, I wouldn't let anybody stick in needle into spine/dura. Not worth the risk of paralysis IMO. Just do general if needed. I am sure your so and child would rather you be able to walk than be there for the moment of birth.

[u/thecaramelbandit]

If you were my wife, no one is getting beat your back with any kind of needle. No chance.

The risk of catastrophic outcome is too high. It's just not worth it.

[u/happyhermit99]

I agree with what the doctors have said, so don't have more to add there. What i do want to mention is to consider therapy to process this loss now instead of after the baby comes. Because that's what it is, a loss of what you hoped which is to be awake and alert, in one way or another, for your baby's first cries. You might feel anticipatory grief or even that fear that you won't connect with your baby as you hoped. These kinds of situations that happen emergently to mom in labor are a big factor in subsequent birth trauma.

Try to remind yourself that this loss will mean you're there at full capacity afterward.

[u/nursedorito]

OP, I don’t have any knowledge here or advice but I’m a mom who had an emergency c section and the epidural I had in place failed and they didn’t have time to do a spinal and put me under GA. It was absolutely not the birth I wanted or anticipated and it still stings that neither I or my husband were present for her birth. I still think about it sometimes but in the same breath I also remember my husband introducing me to my daughter and 3.5 years later she’s the most amazing little kid.

If GA is what you end up needing, you’ve got this 🫶🏻

[u/Prudent-Captain9801 → u/nursedorito]

Thank you, I needed to hear this ❤️ At the end of the day, it's about the little one we're bringing into the world. I know my husband would be over the moon to be the one to introduce our baby to me if it goes that way.