Epidural anesthesia during childbirth: benefits, risks and expert opinion

Video. Epidural anesthesia.

Epidural anesthesia (EA) involves the injection of a solution of local anesthetic and/or analgesic into the epidural space (ES) of the spinal cord and is an alternative method of anesthetizing the caudal half of the body.

Main indications for epidural anesthesia:

• Surgical interventions on the pelvic limbs, abdominal organs, perineum;
• The presence of pain caudal to the diaphragm (for example, with peritonitis, pancreatitis, severe injuries to the pelvic bones and pelvic limbs);
• Elimination of postoperative pain;
• Patients for whom general anesthesia is undesirable.

Epidural anesthesia technique

ES puncture can be performed at the level of the cervical, thoracic, lumbar and caudal spine. Puncture in the area of ​​the cervical and thoracic vertebrae is technically more difficult than in the area of ​​the lumbar and caudal vertebrae, requires a lot of experience and is associated with many risks. Because of this, the most common site for epidural injections is the lumbosacral space.

The thecal sac ends at L6 in most dogs and extends to S2 in cats. Therefore, there is a greater risk of accidental subarachnoid injection in cats.

The patient can be in a ventrodorsal position (on the chest) with the pelvic limbs extended cranially or in a lateral position (on the side).

The injection area is prepared in compliance with the rules of asepsis (the fur is shaved, the skin is treated with an antiseptic solution) (Fig. 1).

The injection site must be identified. When puncturing the lumbosacral space, the injection site is the intersection of the lines between the wings of the ilium and the spinous processes of the 7th lumbar and 1st sacral vertebrae (Fig. 2, 3, 4).

Fig.1. Preparing the injection area

Rice. 2. Puncture of the epidural space in the lumbosacral region

Rice. 3. Puncture of the epidural space in the lumbosacral region

Rice. 4. Puncture of the epidural space in the lumbosacral region

The spinal needle is inserted at an angle of 90° to the skin surface. The needle cut should be directed cephalad. In addition to resistance when inserting a needle, getting into the ligamentum flavum causes a characteristic sensation of something hard and rough. A sudden sensation of loss of resistance as it moves through the ligamentum flavum indicates that the needle has entered the ES. At this stage, it is necessary to remove the mandrin and check for the presence of blood and cerebrospinal fluid in the needle hub (Fig. 5, 6, 7).

Rice. 5. Insertion of the spinal needle at an angle of 90°

Rice. 6. Removing the mandrin from the needle

Rice. 7. Passing the needle through the ligaments

There are two main methods for identifying ES:

Rice. 8. Administration of local anesthetic.

1. “Loss of resistance” technique - the needle is advanced with translational movements, moving it forward a few millimeters at a time, after which they stop and carefully press the piston of the syringe with saline solution, trying to determine by sensation whether the needle is still in the thickness of the ligaments, or resistance has already been lost, and she ended up in the ED. 2. “Hanging drop” technique - before entering the ES, a drop of saline solution is suspended from the needle pavilion, which, when the end of the needle enters the ES, disappears into the lumen of the needle under the influence of negative pressure.

The administration of local anesthetics is carried out fractionally and slowly (Fig. 8).

Why is ES puncture performed exclusively with spinal needles?

Spinal needles have 3 features:

1. The short bevel of the needle makes them “relatively blunt,” so the needle tends to move between the nerves, pushing them apart rather than cutting them. The "relative dullness" also gives a greater "pop" sensation as it passes through the ligamentum flavum (Figure 9).
2. The step in the needle hub tells you which way the needle bevel is.
3. Mandren reduces the likelihood of needle obstruction by skin, subcutaneous tissue, ligaments, bones and intervertebral disc.

Rice. 9. Spinal needles.

EA is recommended to be performed only if fully provided with the equipment and medications necessary to correct possible complications (from mild arterial hypotension to circulatory arrest).

For EA, most patients are sedated, because even slight movement of the animal increases the risk of unintentional puncture of the dura mater and, accordingly, entry of the anesthetic into the subarachnoid area. If general anesthesia is not recommended for the patient, then EP puncture is performed after infiltration blockade of the injection site up to the ligamentum flavum with 1-2% lidocaine. Before the start of EA, intravenous catheters are installed and the availability of resuscitation equipment is ensured (Fig. 10).

During EA, minimal monitoring of basic hemodynamic parameters is carried out (an electrocardiogram is recorded, blood pressure and arterial blood oxygen saturation are measured) (Fig. 11).

Rice. 10. Providing general anesthesia for puncture. Rice. 11. Monitoring hemodynamic parameters during puncture.

What is an “epidural”: briefly about the main thing

This regional method of pain relief (also called epidural anesthesia) has become quite popular recently and is used not only in obstetric practice.
The idea is to inject a painkiller in small doses into the epidural space of the spinal cord, which runs along the entire spine. Entering the bloodstream, the anesthetic blocks the nerve areas in the desired area, and the person loses sensitivity and the ability to respond to pain. Thus, epidural anesthesia is used for operations on the chest and abdominal cavity, but in obstetrics it is the lumbar spine that is “switched off”; accordingly, everything below the belt loses sensitivity and stops working.

At the same time, the woman in labor remains fully conscious, can take a break from exhausting contractions and leave strength for the most crucial moment in childbirth - pushing.

“Epidural” is convenient and interesting because the effect of the painkiller can be controlled continuously and for as long as desired: the effect remains as long as the medicine is delivered. This is very convenient for alleviating the condition of patients in the postoperative period or, as in our case, if it is necessary to restore sensitivity to a woman during the period of pushing.

Catheterization of the epidural space

The most important advantage of EP catheterization at the lumbar level is long-term analgesia of the abdominal organs, pelvic bones and pelvic limbs without repeated punctures.

Most often, epidural catheters are installed in animals to provide adequate long-term analgesia of the caudal half of the body in the postoperative period.

The puncture technique when installing a catheter is identical to a single epidural injection. The exception is the use of a special Tuohy needle (Fig. 12). As a rule, special kits for EA are used (this kit includes: Tuohy needle, epidural catheter, bacterioviral filter, aseptic patch) (Fig. 13).

Rice. 12. Tuohy needle. Rice. 13. Epidural anesthesia kit.

The epidural catheter is advanced into the ES cranially, usually by 1-2 vertebrae. The catheter together with the filter is sutured to the skin. The correct placement of the catheter in the ED is confirmed by x-ray. If the catheter is not radiopaque, it is necessary to inject a radiopaque substance into it (Fig. 14, 15, 16).

Catheters are installed aseptically under sedation or anesthesia and maintained under aseptic conditions. Under the right conditions, they can be used for up to 14 days. The puncture site is assessed at least 2 times a day for swelling and bleeding.

The most common complication of epidural catheterization is catheter migration. It is recommended to periodically check the correct placement of the catheter using x-ray.

When catheterizing an EP, the same doses of anesthetics and opioids are used as for a single puncture. But most often in the postoperative period, infusion of local anesthetics and opioids is carried out at a constant rate (CI). Bupivacaine – 0.25% 0.2 mg/kg/hour IPA. Ropivacaine – 0.2% 0.2 mg/kg/hour IPA. Morphine – 0.3 mg/kg/day. IPA 3.0 ml/hour. Morphine – 0.3 mg/kg/day. + Bupivacaine – 0.5% 0.75 mg/kg/day.

Positive points

It is worth briefly citing the advantages of using this anesthesia, because it is not for nothing that it has been so widespread in recent decades:

• the first and most important thing is that the woman does not feel pain, sometimes forcing her to scream furiously, literally climb the walls and painfully wait out these painful contractions, not finding a place or position in which it can be tolerated. This is the main reason why women agree to this procedure (2 out of 3 women ask for pain relief);
• the woman in labor can fully rest and prepare her strength for pushing;
• during the entire period of action of the drug, the woman is conscious, can listen to doctors and act as necessary;
• an undoubted advantage as a consequence of the previous one is the possibility of the first contact between mother and child, skin to skin and attachment to the breast immediately after birth. A conscious mother can hug her baby, hold him close, and breastfeed. This very important ritual in all respects, unfortunately, is impossible under general anesthesia.

How is the procedure performed?

In terms of duration, insertion of a catheter and needle into the epidural space takes a matter of minutes, and another 10-15 minutes are required for the medicine to begin to act.

• The anesthesiologist asks the woman in labor to sit with her back bent or lie on her side, bending her back as much as possible in the fetal position, while pressing her knees to her chest as much as possible.
• The lumbar spine is treated with an antiseptic, after which a catheter is installed and a needle is inserted. The anesthesiologist determines the correct position of the needle by the resistance during its insertion. Typically, the needle does not encounter resistance when it enters the epidural space. However, there are other methods.
• New doses of the drug in varying concentrations are administered to the woman as needed.

The process of pain relief

How is epidural anesthesia (pain relief) done during childbirth, what is the sequence of actions? The procedure takes place in accordance with the protocol, namely, under the supervision of the doctor responsible for childbirth (gynecologist-obstetrician). The anesthetic is administered by an anesthesiologist:

• the lower part of the back (puncture site) is completely treated with antiseptics to disinfect and degrease the surface skin;
• a “quiet” time is selected in the interval between contractions. At the same time, the woman is warned that it is necessary to urgently report the onset of the next contraction, sit still, the outcome of the procedure depends on this;
• a local anesthetic injection is administered (so as not to feel the injection with a long needle);
• a puncture is made and a needle is inserted for an epidural (as a rule, it is wider in diameter than for spinal anesthesia);
• the catheter is inserted, the needle is removed;
• An anesthetic is administered in portions through the catheter.

Childbirth with epidural anesthesia is easier, the only thing is that the woman in labor cannot feel the beginning of a contraction, for this she needs to listen to the doctor and push at the moment when the stomach is strongly compressed.

What drugs are used for epidural anesthesia?

The first procedures during childbirth were carried out using a simple painkiller - lidocaine or novocaine. However, today there are other drugs that are slightly higher in price, but there are fewer side effects during the postpartum period.

Today, analgesia, popular among anesthesiologists, is presented in the form of a wide range of drugs:

• Trimecaine;
• Chloroprocaine;
• Upivacaine;
• Etidocaine.

However, these drugs cannot be combined with Nadroparin, Tsibor, Heparin, Coumadin, Dalteparin. Such drugs prevent the spread of anesthetics and make it impossible to carry out an anesthetic procedure. In any case, the drugs that are administered to the woman in labor are compared with the possible risks, because the difference between the above medications is not only the price, but also the time of action. Some drugs begin to act within a minute, while others only after 10-20 minutes. At all stages of the procedure, constant monitoring of the mother’s condition is carried out, and the baby’s heartbeat is also monitored.

Interesting! During childbirth, a child experiences enormous stress, and therefore a heart rate of 130-155 beats per minute is considered normal, while for an adult the norm is 75-90.

Price

Pain relief for the back during childbirth (epidural) is given both according to indications and at the request of the woman in labor. However, in any case, it is interesting to know the cost of such manipulation. The cost of an epidural depends on the clinic where the procedure is performed, as well as on the drug that is planned to be administered.

The most expensive drug will cost about 15 thousand rubles. However, to this amount it is necessary to add the services of an anesthesiologist, which are equal to the same amount. In general, in different maternity hospitals in Russia, the price for epidural anesthesia ranges from 3 thousand rubles to 35 thousand.

Consequences and possible complications of epidural anesthesia during childbirth

In fact, four years ago, English researchers analyzed all recorded observations of the use of epidural anesthesia. We are talking about thirty-eight studies that were conducted on almost ten thousand patients. In accordance with the data obtained, it is possible to clearly determine the consequences of epidural anesthesia during childbirth:

• After anesthesia, the risk of using forceps or a vacuum extractor during delivery increases significantly, i.e. so-called instrumental childbirth;
• Epidural anesthesia can affect a woman's blood pressure, significantly lowering it. A decrease in pressure leads to disruption of blood flow into the placenta;
• When the painkiller is removed from the body, the mother's body temperature may increase; the consequences of epidural anesthesia may include a possible febrile state, fever and nausea. Now imagine that it’s already difficult for mom during labor, and then there’s this;
• After epidural anesthesia, there are cases of urinary retention, i.e. problems arise with the process of urination in a woman in labor. In addition, the duration of labor increases noticeably, especially in the second stage. Because of this, oxytocin is often used, a hormone that provokes and intensifies contractions. A woman may feel sharper and more intense contractions;
• anesthesia of this kind can provoke distress syndrome in the fetus, which most likely occurs due to a sharp jump in blood pressure. And fetal distress requires immediate cesarean section even in cases where it could most likely be avoided;
• there is a small chance (about 15% of cases) that the administered drug will be ineffective, the woman may not feel the effect of anesthesia at all, or may not feel it fully;
• The appearance of hematomas after the procedure cannot be ruled out. This is a consequence of incorrect actions by the anesthesiologist, or can occur in patients with low blood clotting.

As you can see, complications after epidural anesthesia are extremely unpleasant, so the decision to use one or another method of pain relief is made by the doctor based on the wishes of the patient, indications for use and possible contraindications.

Side effects

It is worth noting the possible side effects that can be observed after administering a dose of the drug as a reaction of the body to this procedure. These include:

• increased body temperature, chills and trembling;
• nausea and vomiting;
• feeling of numbness in the limbs;
• possible delayed “arrival” of milk;
• lumbar pain, headaches.

Typically, if such effects occur, they disappear immediately after or a short time after stopping the dose of the drug.

Young mothers' fears of epidural pain relief

Most of a pregnant woman's fears concern the safety of the drug for the baby. Is epidural anesthesia harmful, how does it affect the child, and why do many women have an extremely negative attitude towards such procedures?

In most cases, such a negative impact is due to ignorance in this area, bad experiences of friends and relatives. It is worth remembering that each body has its own individual characteristics, and if a woman has a low pain threshold and is simply physically unable to bear the pain, then it is advisable to save strength to meet her baby by taking advantage of new options for simple and painless childbirth.

Caesarean section: which method of pain relief is less harmful?

As for births that were performed by caesarean section, i.e.
surgically, then the use of epidural anesthesia should be considered from a different perspective. The fact is that this procedure is carried out either under general anesthesia or under local anesthesia, i.e. under epidural anesthesia. The consequences for the child can be unfavorable in both cases, but the risk of complications is still higher with general anesthesia, since with it several medications are introduced into the mother’s body, and not just one, as with epidural anesthesia.

Indications

Indications for this procedure are quite variable. Much depends on the country in which the birth is planned. For example, in Europe, the very fact of childbirth is already a sufficient basis for conducting EA. All that remains is to obtain the consent of the patient herself.

Russian medical institutions also often offer this procedure. However, most often it is prescribed if a woman experiences such pain during contractions that there is a risk of loss of consciousness and other complications. In this situation, it is better to perform anesthesia so that the woman in labor remains conscious and does not experience such severe discomfort.

Epidural (epidural anesthesia) is indicated during childbirth

In some private centers, anesthesia is administered at the first sign of uterine contractions. In other medical centers, the procedure is performed only if the uterus has dilated by 3-5 cm and labor will definitely begin soon.

There are no clear indications for epidural anesthesia . This is a relatively new method, so many expectant mothers try to avoid such a procedure if possible, fearing that the use of an anesthetic may have a detrimental effect on childbirth.

Complications after epidural anesthesia

The consequences of epidural anesthesia during caesarean section are that after a few hours the mother may feel a sharp headache or back pain.
This is quite normal, as the drug is eliminated from the body. Back pain will go away in 3-4 hours, but the headache may last for several days after childbirth. The resulting headaches are called post-puncture headaches - a possible consequence of the use of a regional anesthesia method. This is an extremely rare case, but still worth mentioning. The fact is that the anesthesiologist, when inserting a needle into the epidural space, does this virtually by touch, using his own techniques for determining the position of the needle. Sometimes, due to mistake or careless insertion, the needle can perforate the membrane behind the epidural space, which will lead to leakage of cerebrospinal fluid. It is this fact that causes pain, and the pain becomes more intense the more cerebrospinal fluid leaks out.

In addition, a woman may experience allergic reactions to the drug in the form of swelling, itching, and redness, which experienced doctors can deal with very quickly. This applies to the introduction of any drug into the body, not necessarily with regional anesthesia, but this fact cannot be excluded either.

Naturally, when performing epidural anesthesia, there is a likely risk of injury to the spinal cord or nerve, but only the experience of the anesthesiologist and the human factor play a role here. A highly professional anesthesiologist knows how to perform the procedure correctly and values ​​his reputation, so there is no need to worry about incompetence in this situation.

What complications can a child have after epidural anesthesia?

Epidural pain relief affects the baby's body because after the medicine is administered, it passes through the mother's bloodstream directly to the fetus.
The side effect directly depends on what drug the anesthesiologist administers, because it can be either just an anesthetic or its combination with narcotic substances. Basically, of course, in practice only anesthetics such as lidocaine, mercaine, etc. are used. Since after spinal anesthesia the risk of using a vacuum extractor or forceps is increased, the possibility of injuring the child during childbirth increases, which poses a significant threat to his further full life.

If a woman giving birth has a decrease in blood pressure, this leads to oxygen starvation of the child in the womb, and therefore to a high probability of fetal hypoxia. Also, due to a decrease in blood pressure in a woman, blood flow to the placenta worsens and the baby’s heart rate decreases. Moreover, when using drugs of a narcotic nature, the baby’s breathing may be impaired after birth, which sometimes requires artificial ventilation.