A modern anesthesiologist has several types of labor anesthesia in his arsenal. But most often it is epidural anesthesia that is used. This choice is completely justified. Well-developed techniques, modern instruments, and the use of new local anesthetics and antimicrobial drugs for treating the skin at the puncture site make this type of anesthesia widely available and quite safe. In developed countries, epidural anesthesia is used as the main method of pain relief for both natural childbirth and caesarean section. Compared to other methods of pain relief, epidural anesthesia has a number of advantages.
Firstly, this is an effective pain-relieving method in which the woman in labor remains conscious. Secondly, epidural anesthesia has a relaxing effect on the cervix. Thirdly, in the case of uncoordinated labor, in which the muscle fibers of the uterus do not contract synchronously, it is capable of exerting a coordinating influence. Finally, epidural anesthesia, as practical observations show, has minimal effects on the child.
Mechanism of pain relief
To understand how epidural anesthesia works, a short excursion into anatomy is necessary.
As you know, the spinal cord is located in the spinal canal and is surrounded by several membranes. Nerves - the so-called spinal cord roots - stretch from the brain to other organs. The anterior roots are “responsible” for the contraction of skeletal muscles, i.e. for movement, and the rear ones for sensitivity, including pain. Nerve roots exit through the dura mater into the epidural space
, where they are surrounded on all sides by adipose tissue. It is into this space that the anesthetic substance is injected.
Note.
Sometimes
the epidural space
is called the epidural space. The words “peridural” and “epidural” are derived from the Latin dura mater - dura mater, epi - above, peri - about.
Why is a procedure affecting the part of the central nervous system - the spinal cord - relatively safe?
- The anesthesiologist's needle does not reach the spinal cord and, naturally, does not penetrate it.
- The anesthetic substance is delivered to the sensitive dorsal roots and, if it affects the anterior motor roots, it is usually insignificant (a woman giving birth usually retains the ability to move independently, although sometimes she may feel numbness in her legs - this depends on the drug used),
- An anesthetic introduced into the epidural space enters the blood very slowly. The liver manages to neutralize the medicine before its concentration in the blood becomes sensitive to the child.
How is epidural anesthesia performed?
A woman sits or lies on her side, arches her back (in this position, which is sometimes compared to the pose of an angry cat, the distance between the spinous processes of the lumbar vertebrae increases - these processes protrude in the center of the back, and you can feel them yourself; in thin people they clearly visible). Before performing a puncture, the skin is treated with antibacterial treatment and anesthetized.
.
Note.
Anesthesia of the skin and subcutaneous tissue is carried out by administering an anesthetic with a separate injection using a thin needle. But, since inserting a needle into the epidural space feels comparable to a regular injection, this procedure often does not provide pain relief.
The anesthesiologist then inserts a special needle between the spinous processes of adjacent vertebrae at the lumbar level. To make sure that the needle actually entered the epidural space, the doctor performs a special test
.
Note.
The doctor pulls the plunger of the syringe towards himself, checking whether blood enters it (this can happen if the needle gets into a blood vessel) or cerebrospinal fluid (if the needle gets into the spinal canal).
Then a thin catheter is passed inside the needle to the level of those spinal cord roots that are responsible for the pain sensitivity of the abdominal and pelvic organs. After this, the needle is removed, the catheter is secured on the back with an adhesive tape and a special adapter lock is installed on it for administering drugs. The woman lies on her back. In order to check whether the catheter is installed correctly and whether the woman has an allergic reaction to the drug, a test dose of anesthetic is administered. After this, the main dose of the drug is administered. Subsequently, the painkiller is administered in portions - as pain appears or at 30-minute intervals. Each time before the administration of an anesthetic, the woman in labor is examined by an obstetrician.
A few minutes after the administration of the drug, the woman in labor begins to feel warmth and weakness in her legs, contractions become painless. If the uterus contracts ineffectively, then after the start of the procedure, normal full-fledged contractions are very often established, and the process of dilation of the cervix is accelerated. High blood pressure during epidural anesthesia is stabilized by relieving spasm from small vessels, so this method is recommended for patients with arterial hypertension, coronary artery disease and some types of heart defects, and renal failure. At a normal level of blood pressure, in order to prevent its possible decrease, the woman in labor is given an IV with solutions that are harmless to the baby and increase blood volume.
.
Note.
Maintaining the level of blood pressure in the body is ensured by vascular tone and the filling of blood vessels with blood. Since vascular tone decreases as a result of epidural anesthesia, there is only one way to maintain blood pressure - introducing an additional volume of fluid into the bloodstream.
Before the end of the first stage of labor, pain relief stops: restoration of sensitivity helps the development of normal pushing. In some countries, anesthesia is provided for the first and second stages of labor, but in Russia it is customary to anesthetize only the first stage. The fact is that under the influence of an anesthetic, the second stage of labor often lengthens, which often leads to the need for surgical intervention. Sutures are placed on the tears or incision of the perineum after the introduction of a new portion of the anesthetic. For two hours after birth, the young mother is under the supervision of an anesthesiologist and obstetrician. Before transferring the woman to the postpartum ward, the catheter is removed.
Typically, epidural anesthesia is performed during a planned cesarean section. Note that epidural anesthesia, in which the woman in labor is fully conscious at will, is carried out only until the baby is born. When doctors sew up the incision, the woman is given sleeping pills.
If a woman is afraid of surgery, she is given epidural anesthesia, after which she is given a sleeping pill before the operation begins. This does not require artificial ventilation (as with anesthesia), which means the risk of complications to the lungs is reduced. Therefore, this method of pain relief is recommended for smokers, patients with chronic bronchitis, and bronchial asthma. After the operation is completed, a solution of a narcotic drug is injected into the epidural space. As a result, the woman does not feel pain at the incision site for six to ten hours.
Note.
From the epidural space, the drug enters the blood so slowly and its concentration is so low that it has no side effect on the baby, who is applied to the breast 10-12 hours after birth. In some clinics, the baby is put to the breast immediately after birth, even before the uterus is sutured; in this case, the drug also does not have a negative effect on the baby, since it is administered after suturing.
During epidural anesthesia, as well as the day after childbirth, the woman must remain in bed.
Modern drugs used for anesthesia, as a rule, do not cause allergic reactions, have a strong analgesic effect, and are practically harmless. For vaginal delivery, short-acting drugs are used, and for caesarean section - long-acting drugs. The main drugs are short-acting lidocaine (up to 1 hour) and long-acting bupivacaine (up to 3 hours).
Ways to eliminate headaches
How to get rid of headaches that appeared after anesthesia? Sometimes it goes away on its own after the patient rests for a day, limits his movement, and drinks plenty of fluids.
Medications
You cannot start taking any medications for headaches on your own if just a few hours ago you had surgery under anesthesia. In a hospital setting, the patient may be prescribed:
- Askofen, Citramon. These drugs contain caffeine, which has a stimulating effect on the nervous system, blocking pain centers.
- Paracetamol, Ibuprofen. Drugs of this type have not only an analgesic effect, but also an anti-inflammatory effect.
Tablets should be dosed according to your doctor's recommendations. You should not take medications for more than a day if they do not relieve headache pain.
Special procedures
If the headache does not go away after spinal anesthesia for more than 24 hours, treatment includes special procedures to restore cerebral blood flow. All manipulations must be performed by an anesthesiologist under completely sterile conditions.
A blood patch is considered the most effective and safe. Venous blood is collected from the patient, the volume is selected individually. Using a thin needle, venous blood is injected into the area of the spinal column where spinal anesthesia was previously performed. When administered, the blood coagulates naturally and closes the hole in the membrane, stopping the outflow of cerebrospinal fluid. Very rarely does the procedure need to be repeated. Possible complications:
- Infection.
- Bloody discharge at the patch site.
- Loss of sensation in the legs.
- Numbness of the lower extremities.
Instead of blood, saline solution can be injected into the subarachnoid space. Typically, this method of restoring cerebral fluid is carried out directly on the day. when the operation is performed, if the patient complains of intense headache. Depending on the volume of lost cerebrospinal fluid, the dose of the solution is selected - from 1 ml to 1500 ml. The saline solution is poured in gradually throughout the day.
Severe headaches after spinal anesthesia can only be eliminated in a hospital setting; this allows the doctor to observe the patient and monitor any changes in his condition.
Contraindications and complications
Epidural anesthesia is unacceptable in cases of unconsciousness or eclampsia
, bleeding disorders, purulent lesions of the skin of the back, general blood poisoning (sepsis), injuries to the brain and spinal cord, spine, high intracranial pressure, migraines, allergic reactions to the anesthetic used.
Note.
Eclampsia is a severe form of gestosis, accompanied by life-threatening disorders: convulsions, arterial hypertension, loss of consciousness.
Relative contraindications are curvature of the spine and diseases of the nervous system. In these cases, the doctor makes a decision about anesthesia based on the specific situation.
Sometimes complications may occur during and after epidural anesthesia:
- Headache. It usually appears on the first to third day after birth as a result of damage to the dura mater and leakage of cerebrospinal fluid into the epidural space. The pain may last for 1-2 weeks, sometimes lasting up to 6 weeks. Treatment usually includes bed rest, sedatives, painkillers, and caffeine.
- If the sterility of the manipulation is violated, inflammation at the injection site, epidural space, and the membranes of the spinal cord and brain is possible.
- When the main dose of the drug is administered instead of the epidural space into the spinal canal, the patient may temporarily lose the ability to move. This condition lasts only for the duration of the drug's effect.
- When the main dose of anesthetic is introduced into a blood vessel, a sharp drop in blood pressure and disruption of the heart may occur.
- Manifestations of allergic reactions to the drug used.
When anesthesia is administered correctly, complications are rare. It should be said that special scientific studies of the effect of epidural anesthesia on a child have not been conducted, but practical experience shows that the effect of epidural anesthesia on a child is minimal. However, with the development of complications, such as a pronounced drop in blood pressure, placental circulation may be disrupted.
In conclusion, I would like to say that labor pain is a sensation that allows a woman to navigate what is happening to her and act as necessary at the moment of childbirth. It should be said that the sensitivity threshold is different for different people, and accordingly, women experience the process of childbirth differently. Normal mild labor pain does not require pain relief (as you would not want to use anesthesia to relieve pain after strenuous exercise). Fear of pain is the real psychological cause of a vicious circle in which pain causes fear, and fear increases pain. This often causes disruption of labor. It is only in cases where the pain is so severe that it overpowers all other sensations, or when the use of anesthesia is mandatory (for example, during a caesarean section), intervention by anesthesiologists is really necessary.
Dmitry Ivanchin Anesthesiologist-resuscitator, senior doctor of the operational department of the Center for Emergency Medical Care of the Moscow Health Committee.
Nature of postoperative pain
The duration of anesthesia ranges from 2 to 5 hours, depending on the amount of medication administered. Unpleasant sensations may occur already during the administration of the drug, which should be reported to the anesthesiologist. Headaches appear immediately after the anesthesia wears off or after a short period of time, during the day.
Since the main problem is a change in intracranial pressure, it is this pathology that affects the patient’s condition. The following sensations arise:
- Shootings in the back of the head.
- Dull aching pain in the forehead.
- Bursting pain all over the head.
- Feeling of head being squeezed like a hoop.
- Feeling of heaviness of the skull.
Some patients not only have a headache after spinal anesthesia, but also experience dizziness and a feeling of loss of support under their feet. In any case, subarachnoid anesthesia is easier to tolerate than general anesthesia. After general anesthesia, patients experience not only headaches, but also a sharp decrease in blood pressure, nausea, and hallucinations.
