The vast majority of cesarean section operations in Russia today are performed using epidural anesthesia. It allows a woman to maintain a clear consciousness during the entire period of surgical procedures and at the same time not feel pain. The main thing that this type of anesthesia gives is the opportunity to see the moment of birth of the baby, to enjoy his first breath and the first cry. These minutes are truly priceless. In this material, we will talk about how epidural anesthesia is done, what effect it has, what complications can develop after it, and whether there are alternatives.
What it is?
Epidural anesthesia belongs to the category of modern gentle methods of anesthesia. In medicine, there is a second name - epidural anesthesia, and women and doctors in everyday life often call it "epidural". For caesarean section, this method of pain relief has been widely used in recent years. A large accumulation of nerves is concentrated in the human spine, and therefore the introduction of anesthetics directly into the spine allows you to achieve narrow goals - to anesthetize one or another part of the body for subsequent surgical procedures.
Epidural anesthesia involves the "delivery" of drugs through a thin catheter into the epidural space of the spine. The anesthetic gets into the space between the walls of the spine and the pleura of the spinal cord. The nerve roots are washed with anesthetic and stop transmitting nerve impulses to the brain. Thus, the pain center in the brain does not receive information about the sensitivity in the blocked part of the body, which means that any manipulations in this part are permissible, and the patient will not be hurt.
Epidural pain relief is used in both vaginal delivery and caesarean section. But in the first case, small doses of analgesics are administered, for example, lidocaine or ropivacaine. They provide partial pain relief while maintaining sensitivity in the lower body.
With a cesarean section, which involves penetration into the abdominal cavity, a longer and deeper blocking of pain is required. Therefore, opiates are added to analgesics - buprenophrine, promedol, etc. Ketamine can be used.
All solutions undergo preliminary pharmacological purification, they are intended exclusively for spinal or epidural administration. When it gets into the zone of nerve roots in the epidural space of the spine, the drugs act stronger and longer, and therefore the doses themselves are used less than with intravenous anesthesia.
What dose to administer to a particular woman is decided by a specialist anesthesiologist based on analyzes, the general health of the expectant mother, her weight and height. Moreover, it is the growth in this case that is of decisive importance: for each segment of the spine that needs to be anesthetized, an average of 2 ml of solution is used. The description of dose calculation methods is rather complicated; doctors use special algorithms and formulas.
How is it done?
A caesarean section lasts on average 20 to 40 minutes. It lasts a little longer with epidural anesthesia. Additional time is required in order to gradually, step by step, correctly and accurately anesthetize the lumbar spine, which must be blocked, so that the sensitivity in the abdominal cavity and groin region temporarily disappears.
Before anesthesia is given, the anesthesiologist must make sure the patient is doing well. To do this, measure the pressure, temperature, pulse rate, be sure to look at the latest blood test results. A cuff is attached to a woman, which in direct mode will itself control the level of blood pressure, heart rate.
The woman in labor is placed on the operating table so that she is on her side, her head is asked to tilt as low as possible. Thus, the back is rounded, the vertebrae better protrude through the skin, which makes it easier for the doctor to find a place to insert the catheter. The anesthesiologist marks the patient's back with a special pencil and proceeds to insert the catheter.
The skin is thoroughly disinfected. Next, the needle is inserted through the yellow ligament between the required vertebrae. There are several methods for checking the correctness of the introduction. The doctor can be guided by the ingress of cerebrospinal fluid into the needle, or can use a syringe with air attached to the catheter. If the plunger meets resistance, the catheter is still in the ligament, but if the resistance disappears, this is a sign of entering the epidural space.
After the anesthesiologist is in the right place, he administers the first dose, which is called the test dose. The assessment takes about three minutes. After that, the rest of the medicinal solution assigned to the woman is injected gradually, in stages and slowly, the support is stretched as long as it takes surgeons to complete the operation.
After the test dose, it is usually possible to achieve the pain relief necessary for the start of the operation within 10-15 minutes. The woman's condition is closely monitored and, if necessary, a new dose of drugs can be added. When the baby is born and the stitches (internal and external) are in place, the catheter is removed. The woman is transferred to the intensive care unit to monitor her during the recovery from anesthesia.
The operation takes place, as already mentioned, with the patient's full consciousness. So that she does not see the manipulations of the surgeons, a screen is placed in front of her face, and when the baby appears, he must be shown to the mother and can be left next to her while the second phase of the surgical intervention is underway, during which the surgeon manually removes the placenta and stitches.
Pros and cons, possible consequences
Such pain relief is considered one of the safest but it is impossible to call “epiduralka” completely safe.
- In 1 case in 50 thousand births, there are various complications. In about 17% of cases, after the injection of the drug into the epidural canal, it is not possible to achieve a complete blockade. A woman retains sensitivity to one degree or another, which is undesirable for either a woman in labor or a surgeon who would like to perform the operation on a patient relaxed, not straining the muscles.
- If the expectant mother has problems with blood clotting, then a hematoma may develop at the puncture site, and blood may enter the cerebral fluid.
- Much depends on the qualifications and experience of the anesthesiologist himself. Inappropriate or negligent needle insertion can injure the hard spinal cord. This is often dangerous due to leakage of cerebrospinal fluid, which can lead to the development of severe headaches, as well as disruption of the normal functioning of the central nervous system.
- If the subarachnoid space is injured, the consequences may be more severe - convulsions, spasms, loss of consciousness, paralysis of the lower extremities.
- Quite often you can hear the opinion that epidural anesthesia does not harm the child, in contrast to general anesthesia. This is not entirely true. The development of weakness of respiratory activity, the occurrence of postpartum hypoxia, disturbance of the heart rhythm under the influence of medications in the fetus after birth are not excluded.
Recovery from the anesthesia performed through the epidural space takes about 2 hours. The sensitivity in the lower body gradually returns, along with pain. It is stopped by injections of anesthetic drugs intramuscularly. At the same time, drugs that reduce the uterus are injected, for example, oxytocin. And in this recovery period is not much different from the same period after general anesthesia.
With epidural anesthesia, the woman's condition remains more stable - the vessels and heart work without interruption. A significant disadvantage of the method is the psychological unwillingness of many women in labor to "be present" at their own operation. This is scary, understanding what is happening right now can cause a sharp rejection.
If not all nerve endings are blocked, then the woman will feel a limited range of unpleasant moments, but she will not feel any sharp pain.
Contraindications
Women have the legal right to choose the method of anesthesia for a caesarean section. If, despite all the advantages of regional anesthesia, the woman is firmly committed to general anesthesia, it will be enough only to write a corresponding waiver of epidural anesthesia. General anesthesia has no contraindications. If a woman, on the contrary, wants to take the most active and direct part in what is happening and insists on epidural anesthesia, the doctor may not always allow this, since the method has certain limitations.
- With severe gestosis or obesity, trauma or deformity of the spine, systemic infections, local inflammatory process on the skin in the area of the intended introduction of the catheter needle, allergies to medications used for such anesthesia, CNS lesions and low pressure, suspected bleeding or opened bleeding, epidural anesthesia is denied.
- The issue of epidural anesthesia and emergency caesarean section is not considered, if there is a need to remove the baby from the mother's womb as soon as possible.
If a cesarean section involves the removal of the uterus after the birth of the baby for medical reasons, only general anesthesia will be recommended.
Alternative
The main alternative to epidural anesthesia today is general (endotracheal anesthesia). With it, drugs are injected intravenously, and after the woman falls asleep and the tube is inserted into the trachea, the patient is connected to a ventilator and begins to operate. During the operation, the woman is unconscious, the quality of anesthesia is higher than that of the epidural, any sensitivity during surgical procedures is completely excluded.
The effect of drugs on the baby is not excluded, while his central nervous system is also suppressed. But the likelihood of serious consequences and complications is small. Many women have heard that there is also spinal anesthesia. It is a type of epidural, only the differences lie in the depth of the introduction of drugs into the spine. Epidural differs from spinal in less deep blockade.
Lumbar puncture occurs not in the epidural, but in the subarachnoid space of the spine. Spinal or spinal anesthesia is performed with a thinner needle, and doses of pain relievers are required slightly less than with epidural anesthesia. The effect of spinal pain relief occurs much faster, almost immediately after the administration of medication. Otherwise, epidural and spinal anesthesia are almost the same.
Patient reviews
Many women note that after the epidural, their back hurts a lot, and the pain does not go away even after being discharged from the maternity hospital and persists for several weeks. Women who have done more than one cesarean section with different anesthesia claim that after epidural anesthesia, the process of getting out of anesthesia is easier.
About a third of women in labor complain of headaches that start after the operation and can last for quite a long time. There are also reviews on the Internet of those on whom such anesthesia acted “wrongly”: there was a feeling of numbness in the legs, but the abdominal wall remained sensitive. Such women in labor had to undergo general anesthesia at the last moment in order not to cause painful shock.
Almost all moms say that epidural pain relief is scary in itself. And then lying on the operating table for more than half an hour, listening to the doctors' conversations and the clatter of instruments, is too hard for the psyche.
But the moment of the birth of a baby, which you will never see under general anesthesia, is not forgotten. Often, for the sake of him alone, you can endure all the other fears and inconveniences.
For the methods of pain relief for caesarean section, see the following video.
