Epidural analgesia is a type of regional anesthesia, which has found a significant place in obstetrics, i.e. pain relief during natural childbirth. Epidurals are widely used in the world, especially in the countries of Western Europe (Great Britain 35-40%, France 70%, USA 50%). In the special gynecological-obstetrical hospital in Postojna, Slovenia, where our anesthesiologists were trained for this type of anesthesia, as many as 90% of births are performed under epidural analgesia.
In our case, the situation is different, in the Clinical Center the percentage of epidural births is 7-8% (250 to 300 epidural births per year), with a growing tendency since September 2015, when we introduced the preparation of anesthesiologists for epidural anesthesia. The reasons are primarily prejudices (damage to the spine, nerves, negative impact on the baby), lack of information, lack of anesthesiologist, and financial moment.
Pregnant women who are thinking about giving birth in an epidural must first talk to the chosen gynecologist, who is managing their pregnancy, then do the following tests: blood count (platelet count >= 100 thousand), bleeding time, coagulants and INR, and schedule an examination with an anesthesiologist. The anesthesiologist will examine the findings, then the spine of the pregnant woman and inform her about the technique itself, contraindications, and side effects of this type of anesthesia.
When labor begins, the pregnant woman is brought into the delivery room after preparation, and after adequate monitoring and preparation (measurement of blood pressure and pulse, infusion of 500 ml of castor), the anesthesiologist approaches the placement of the epidural catheter. The procedure itself is not painful, first local anesthesia is applied, usually between 3-4 lumbar vertebrae, then the epidural space is identified with an epidural needle, using the method of loss of resistance, a catheter is passed through the needle, and the technically most difficult part of the procedure itself is over. The catheter is fixed at some depth in the epidural space, glued over the back, and usually leads to the right shoulder. Administering local anesthetic through an epidural catheter is strictly associated with a favorable obstetric outcome (regular contractions of the uterus for 3-4 minutes that last up to 1 minute, dilation of the cervix 2-3 transverse fingers, or 3-5cm).
First, a bolus dose of local anesthetic is applied, and then the local anesthetic is continuously applied with a syringe pump at a certain speed. It is ideal for a pregnant woman to feel no pain, but to feel mild contractions and tensions. The continuous administration of anesthetic lasts until the end of the delivery, after which a single bolus dose is usually given to relieve the pain of the eventual suturing of the episiotomy or revision of the uterine cavity, and the catheter is removed.
Adverse effects of epidural analgesia are a significant drop in blood pressure due to sympathetic blockade, pain or subcutaneous hematoma at the injection site, and post-puncture headache (epidural hematoma or abscess – rare complications).
Absolute contraindications for applying an epidural catheter are refusal of a pregnant woman, infection at the injection site, hemodynamic instability, high intracranial pressure, stenosis of the aortic or mitral valve, hematological diseases (disorder in the coagulation status), allergy to local anesthetic…
Relative contraindications for applying an epidural are earlier neurological deficit, spinal injuries and operations, mild hypotension, and therapy with low molecular weight heparins (a therapeutic window of 12 hours must be established).
Due to sympathetic blockade (vasodilator effect, relaxation of the structures of the small pelvis, uterus, and birth canal), the epidural accelerates the first period of labor (dilation phase), while due to a mild motor blockade, it can slow down the expulsion phase (second period of labor).
Epidural labor must be actively managed and last no longer than 3 hours from the placement of the epidural catheter.
Epidural analgesia is an excellent anesthetic method, which, if used in controlled conditions, brings comfort to the pregnant woman and the baby, and does not affect the natural flow and dynamics of childbirth.