Spinal anesthesia in obstetrics. Spinal anesthesia in obstetrics

If for some reason a pregnant woman has to give birth surgically (through a cesarean section), then one of the most important issues will be the choice of the method of performing such an operation, or more precisely, the method of pain relief.

Today, obstetricians use three types of anesthesia during Caesarean births: general anesthesia, epidural and spinal anesthesia. The first is resorted to less and less as an outdated method, but there are situations when it is the only possible method of pain relief. Preference today is given to two other types of anesthesia as safer and easier in terms of administration and in terms of “recovery” from anesthesia. They have other advantages, as well as disadvantages, of course.

The decision on the method of performing a CS (caesarean section) is made by the doctor together with the patient. It largely depends on the state of health of the mother and unborn child and on the characteristics of the pregnancy. But the desire of the woman in labor also plays an important role.

Today we propose to take a closer look at spinal anesthesia during childbirth, since among all types it is the highest priority among Western and even domestic doctors.

Spinal anesthesia for caesarean section: pros and cons, consequences, contraindications

Like epidural, spinal (or spinal) anesthesia refers to regional anesthesia, that is, a method of pain relief in which the sensitivity of a certain group of nerve impulses is blocked - and the anesthesia effect occurs in the part of the body necessary for medical manipulations. In this case, the lower part of the body is “switched off”: the woman does not feel pain below the waist, which is enough for a painless, comfortable birth and unhindered comfortable work for doctors.

The huge advantage of regional anesthesia is that the mother remains conscious, can think and talk clearly, understands what is happening to her and is able to see, pick up and even put her newborn baby to her breast immediately in the first minutes of his life.

If we talk specifically about the spinal method of administering an anesthetic, then it has the following advantages compared to other methods:

Fast onset of action. During spinal anesthesia, drugs administered for pain relief begin to act immediately. About two minutes - and doctors can already prepare the abdominal cavity for surgery. This is of particular importance when a CS has to be performed unscheduled, as an emergency: in this case, spinal anesthesia is the first choice and a life-saving remedy.
Very effective pain relief. The analgesic effect reaches 100%! This is a big plus not only for the woman in labor, who participates in the process but does not feel pain, but even a huge advantage for obstetricians, who can carry out their work in comfortable conditions. This requires a smaller amount of anesthetic drugs than with epidural anesthesia.
No toxic effects on the mother's body. Unlike other methods, this one is quite gentle in terms of negative effects on the woman’s body. In particular, intoxication of the central nervous and cardiovascular systems is minimized.
Minimal risks to the fetus. With a correctly selected and administered dose of anesthetic, the baby does not experience any negative effects of the drug; the infant’s respiratory centers (as with other types of anesthesia) are not depressed in this case. This is exactly what most women in labor who are about to give birth via CS worry about.
Easy to carry out. The choice of a qualified specialist is of paramount importance, and in this regard, a woman will have less fear and anxiety, because spinal anesthesia is easier to administer. In particular, the anesthesiologist has the ability to feel the “stop” of the needle, so there is no risk of inserting it deeper than is acceptable.
Using a fine needle. The needle itself is thinner than that used for epidural anesthesia. This allows for pain relief with a single injection of medication without inserting a catheter (as with an epidural).
Minimal postoperative complications. After just a few days (and sometimes even hours), the new mother can lead a normal life - move, get up, take care of the child. The recovery period is very short and easy. The resulting consequences in the form of headache or back pain are minor and short-lived.

Meanwhile, spinal anesthesia also has disadvantages:

Short validity period. The blockade of nerve impulses that transmit pain lasts for several hours (from one to four depending on the type of drug, but on average for two hours) from the moment the medicine is administered. Usually this is enough to safely deliver the baby. But in some cases, longer time is required. If such situations are known in advance, then another type of anesthesia is preferred.
Possibility of complications. In this case, much depends on the professionalism of the anesthesiologist and obstetric staff. But even with quality work, some complications cannot be ruled out, because each organism reacts individually to such interventions and influences. In particular, so-called post-puncture headaches (in the temples and forehead) often occur, which can persist for several days; Sometimes loss of sensation in the legs persists for a period of time after surgery. It is also important to prepare for spinal anesthesia, in particular to administer drugs that prevent a strong sharp drop in blood pressure, which occurs very often during spinal anesthesia. If the dose of anesthetic was calculated inaccurately, then additional medication can no longer be administered, otherwise neurological complications are possible.
Presence of contraindications. Unfortunately, this type of pain relief is not always applicable. You cannot resort to spinal anesthesia in cases where there are complications and circumstances that require a longer effect of anesthesia, and when the woman took anticoagulants on the eve of childbirth. Contraindications to spinal anesthesia include any bleeding disorders, severe cardiac pathologies, central nervous system dysfunction, exacerbation of herpes infection and other infectious and inflammatory processes, high intracranial pressure, patient disagreement, fetal hypoxia. This operation is not performed if the woman has lost a lot of fluid or blood.

Despite the presence of some disadvantages, this type of anesthesia for caesarean section is the most profitable in many respects, including from a financial point of view: spinal anesthesia is cheaper than epidural.

Technique of spinal anesthesia for caesarean section

As we have already noted, the technique of such anesthesia is simple to perform. The specialist uses a very thin needle to make a puncture in the lumbar region (between the vertebrae) and inject an anesthetic into the subarachnoid space - into the cerebrospinal fluid that fills the spinal canal. Thus, the sensitivity of the nerve fibers passing here is blocked - and the lower part of the body is “frozen”.

Spinal anesthesia requires a puncture of the membrane surrounding the spinal cord. This sheath is quite dense, that is, the anesthesiologist feels the moment of its puncture, which allows him to accurately determine when the needle “entered” the right place and avoid unwanted complications.

Spinal anesthesia drugs are administered to the woman in labor in the lateral position (usually on the right), but possibly also while sitting. In this case, it is very desirable that she tuck her legs bent at the knees as high as possible towards her stomach.

When the medicine is administered, the woman feels virtually no pain, except for a slight, very short-term discomfort. Soon a feeling of numbness in the lower extremities sets in - and the operation begins.

It should be mentioned that when performing a planned CS with spinal anesthesia, some preparation is required, which the woman in labor will certainly be told about. In particular, on the eve of the operation you should not drink or eat, or take sedatives or blood-thinning drugs. After surgery, you will need to stay in bed for a while and drink plenty of water. If necessary (based on the results of a study of the mother's condition), medications are prescribed to relieve unwanted symptoms (nausea, itching, urinary retention, chills, etc.).

Feelings during spinal anesthesia: reviews

No matter how thoroughly we study theory, we are also not least interested in practice. And so women go to the forum and ask women who have already given birth in this way many questions: how does a caesarean section work with spinal anesthesia, is it painful, is it dangerous, is it scary, what effect does it have on the child, and so on.

You can easily find on the Internet many reviews, descriptions and even entire stories about how this or that woman’s birth went, including with the use of spinal anesthesia. They talk in detail about everything: what sensations they experienced at the time the medicine was administered, how long the labor lasted, how they felt the next day and a few days after the operation.

But if we sum it all up, the main conclusions, according to the women’s stories, will be the following:

The biggest disadvantage of spinal anesthesia for CS is fear. It’s just scary, because it’s still an operation, it’s still anesthesia, it’s still the unknown (how everything will go, how the body will react, how the doctors will work). In practice, it turns out that everything ends wonderfully! Women are very happy with this kind of birth. But fear is inevitable for many.
Very often, after the administration of an anesthetic, a sharp drop in blood pressure occurs - shortness of breath occurs, and it becomes very difficult to breathe. This is not dangerous: doctors immediately give the woman in labor an oxygen mask and administer medications - and her condition quickly stabilizes. If you use medications for prophylactic purposes, such side effects can be completely avoided. The same goes for sedatives: taking them in advance allows you to avoid “shaking” during and after such childbirth.
Quite often, after such births, mothers suffer from back pain, and they even have to resort to painkillers. But such pain after a cesarean section does not always appear, it is not always very strong, and, as a rule, it lasts no more than 2-3 days.
For some time after the operation, attacks of trembling, aching pain at the injection site, and numbness may sometimes occur.

Individual reactions to anesthetics can never be ruled out. In some cases, women note a burning sensation in the lower extremities, loss of sensitivity in them for a long time after surgery, persistent headaches, especially in an upright position, vomiting after surgery, and poor tolerance to low temperatures. But these are all exceptional individual cases. However, if numbness or pain at the site of injection of the anesthetic persists for more than a day after the CS, then you must tell the doctors about this.

In general, women who have undergone spinal anesthesia during a caesarean section note that it is not painful, the postoperative period is quite favorable, and that they do not find any particular negative aspects in it, remaining satisfied with the results. Especially those who have something to compare with, that is, whose previous birth took place under general anesthesia.

Therefore, if you are facing such a birth, then there is no reason to worry. If surgical delivery is inevitable, then spinal anesthesia for caesarean section in the absence of contraindications is really the best solution.

Good luck to you!

Especially for - Margarita SOLOVIOVA

There are many indicators for carrying out a surgical operation called cesarean section, in which the fetus is removed from the mother's womb through an incision in the abdominal wall of the uterus, namely:

health of the expectant mother;
problems during pregnancy;
condition of the fetus.

There is also more than one method of anesthesia for it (today, general and spinal anesthesia are used).

In most foreign countries, births by cesarean section are performed under epidural or spinal anesthesia, but attention should be paid to the fact that the rate of use of the latter is constantly growing and often dominates over epidural.

Each method is “endowed” with its own advantages and disadvantages, and, therefore, indications and contraindications as well (the doctor must take all this into account when choosing a method of pain relief). Today we will talk in more detail about spinal (or spinal) anesthesia.

The introduction of an anesthetic between the vertebrae in the lumbar region of the back (in the subarachnoid space) is called spinal. With this method of anesthesia, a puncture is made in the dense membrane that surrounds the spinal cord (compared to epidural anesthesia, in this case the needle is inserted a little deeper), that is, the puncture site is the lumbar region. A local anesthetic is injected into the cerebrospinal fluid through a needle, which fills the spinal canal, as a result of which any manifestations of sensitivity are “blocked” in this area.

Most often, a puncture (puncture) of the spinal space is performed while lying on the side, and if the woman in labor has the opportunity, it would be advisable to tuck her legs towards her stomach. Less commonly, the procedure is performed in a sitting position.

Benefits of spinal anesthesia for caesarean section

the woman in labor is fully conscious;
rapid onset of anesthesia, which is very necessary in urgent emergencies;
100% pain relief;
you can begin preparing for surgery (treatment of the abdominal cavity) within 2 minutes after the administration of the anesthetic;
due to the fact that with spinal anesthesia it is possible to accurately determine the location of the needle insertion, it is easier to perform in terms of technique than general or epidural;
Compared to epidural anesthesia, in this case a thinner needle is used to administer an anesthetic;
absence of toxic reactions from the cardiovascular system or central nervous system (as is possible with epidural anesthesia);
there may be a very slight effect on the fetus of the anesthetic administered in small volumes - only about 4 ml;
Thanks to the fact that the muscles achieve complete relaxation, the surgeon receives excellent conditions for his work.

Disadvantages of spinal anesthesia for caesarean section

the occurrence of moderate post-puncture headache lasting 1-3 days in the frontotemporal region (the frequency of its occurrence largely depends on the experience of physicians);
the duration of the blockade lasts only 2 hours, which in principle is sufficient to carry out the entire operation;
if not all preventive measures have been taken, a decrease may occur due to a sudden onset of action;
More serious neurological complications may also occur in cases where the effect of spinal anesthesia has been prolonged. If the catheter was not positioned correctly, damage to the cauda equina (continuation of the nerve roots of the spinal cord, which begin from the lumbar segments) is possible. Incorrect insertion of the catheter requires additional doses of anesthetic, which can provoke a prolonged blockade;
in cases where the total dose of anesthetic was incorrectly calculated, additional injections cannot be performed. The catheter should be reinserted to help avoid complications such as spinal cord injury due to rupture or stretching.

And yet, spinal anesthesia has less effect than others on the fetus, guarantees higher protection of the body from postoperative pain, and it is comparatively cheaper. In many developed countries, spinal anesthesia for caesarean section (along with epidural) is widespread and recognized as a fairly safe method of pain relief (many doctors recognize it as the best pain relief technique).

Especially for Anna Zhirko

It is one of the most common and popular types of regional anesthesia (covers a limited area of the body) used in medical practice. The term "epidural anesthesia" is made up of the word "anesthesia", which means loss of sensation, and "epidural" characterizes into which space the anesthetic (the drug used to relieve pain) is injected. It is performed at different levels of the spinal cord, depending on the type of operation (obstetrics and gynecology, thoracic or abdominal surgery, urology) and which part of the body needs to be anesthetized. In obstetrics, epidural anesthesia is used at the level of the lumbar spinal cord.

In 1901, for the first time, epidural anesthesia was performed in the sacral region, with the introduction of the drug Cocaine. And only in 1921, it was possible to perform epidural anesthesia in the lumbar region. Since then, this type of regional anesthesia has been used in urology, thoracic and abdominal surgery. After 1980, epidural anesthesia was in demand and popular, it began to be widely used during childbirth, thus, a new medical field, “Obstetric Anesthesiology,” was born.

Epidural anesthesia is widely used in obstetrics: as anesthesia during cesarean section, or pain relief during natural childbirth. Until recently, caesarean sections were performed under general anesthesia. The transition from general anesthesia to epidural anesthesia during cesarean section made it possible to reduce the risk of possible complications during surgery: hypoxia (lack of oxygen) of the fetus, maternal hypoxia (several attempts at intubation, with unsuccessful intubation, in women in labor with anatomical features of the airways), blood loss , toxic effects of drugs on the fetus and others. The most important advantage of epidural anesthesia during a cesarean section, over general anesthesia, is the preservation of the mother’s consciousness in order to hear the first cry of her baby. But it should be remembered that not in all cases, the use of epidural anesthesia is possible.

The structure of the spinal cord, its functions

The spinal cord is an organ located in the canal of the spinal column. The spinal column is made up of vertebrae attached to each other by ligaments and joints. Each vertebra has a hole, so the vertebrae folded parallel to each other form a canal from the holes, where the spinal cord is located. Only up to the lumbar region the spinal cord fills the canal, then it continues in the form of a spinal filament, called the “cauda equina.” The spinal cord consists of 2 substances: on the outside - gray matter (in the form of nerve cells), on the inside - white matter. The anterior and posterior roots (axons or processes of nerve cells) emerge from the spinal cord, which participate in the conduction and reflex functions of the spinal cord. The anterior and posterior roots form the spinal nerves (left and right). Each pair of spinal nerves has its own section of the spinal cord, which regulates a certain part of the body (this is important in the mechanism of epidural anesthesia).

The spinal cord is covered, first by the so-called soft membrane, then by the web, and then by the dura mater. Between the arachnoid and pia mater a space is formed filled with cerebrospinal fluid, which plays the role of shock absorption. The dura mater and arachnoid form protrusions (dural couplings, radicular pockets), they are necessary to protect the nerve roots during the movement of the spine. Above the dura mater in front and the ligamentum flavum in the back, the epidural space is formed into which the anesthetic is injected during epidural anesthesia. The epidural space contains: fatty tissue, spinal nerves and vessels supplying the spinal cord.
The main functions of the spinal cord are:

reflex function- with the help of reflex arcs that pass through the spinal cord, muscle contraction occurs, they, in turn, participate in the movement of the body, and also participate in the regulation of the work of some internal organs;
conductor function- transmits nerve impulses from the receptor (a special cell or nerve ending) to the central nervous system (brain), where they are processed and the signal again passes through the spinal cord to the organs or muscles.

Mechanism of action of epidural anesthesia

When an anesthetic (a drug that provides pain relief) is injected into the epidural space, it penetrates into the subarachnoid space through the dural couplings (radicular pockets), blocking nerve impulses passing along the spinal roots. Thus, there is a loss of sensitivity (including pain) with muscle relaxation. Loss of sensitivity in a certain area of the body depends on the level at which the nerve roots are blocked, i.e. on the level of epidural anesthesia. In obstetrics (caesarean section), pain relief is performed in the lumbar spine. Epidural anesthesia can be performed in 2 ways:

in the form of long-term anesthesia: repeated injection of small doses of anesthetic into the epidural space, through a catheter, this type of anesthesia is used during natural childbirth or for postoperative pain relief;
or a single injection of an anesthetic in large doses, without the use of a catheter. This type of anesthesia is used for caesarean section.

Stages of epidural anesthesia

Preparation of the patient (mother in labor): psychological preparation, warn that on the day of the operation the patient should not eat or drink anything (during a planned operation), give sedatives to drink, identify which drugs she is allergic to;
Examine the patient:

measuring body temperature, blood pressure, pulse;
do a general blood test (red blood cells, hemoglobin, leukocytes, platelets), blood group and Rh factor, coagulogram (fibrinogen, prothrombin);

Carrying out epidural anesthesia:

Preparing the patient: puncture of a peripheral vein with insertion of a catheter, connect to the infusion system, install a cuff for measuring pressure, a pulse oximeter, an oxygen mask;

Preparation of the necessary equipment: swabs with alcohol, anesthetic (usually lidocaine is used), saline solution, a special needle with a guide for puncture, a syringe (5 ml), a catheter (if necessary), adhesive tape;
correct position of the patient: sitting or lying on the side with a maximum tilt of the head);

Determining the desired level of the spinal column where epidural anesthesia will be performed;
Treatment (disinfection) of the skin area at the level of which epidural anesthesia will be performed;
Puncture of the epidural space with the administration of the drug Lidocaine;

Monitoring of hemodynamics (pressure, pulse) and respiratory system.

Indications for the use of epidural anesthesia in obstetrics

Caesarean section (planned: in case of multiple pregnancy, other history of cesarean section; or emergency: sudden deterioration in the condition of the mother or fetus, premature birth);
High pain threshold during childbirth;
Pregnancy accompanied by chronic hypoxia (lack of oxygen) of the fetus;
Sudden change in fetal heartbeat;
Severe somatic diseases in a woman in labor (diabetes mellitus, hypertension, bronchial asthma, and others);
Malposition;
Anomaly of labor.

Contraindications for epidural anesthesia

Purulent or inflammatory diseases of the area where it is necessary to puncture for epidural anesthesia (can lead to the spread of infection during puncture);
Infectious diseases (acute or exacerbation of chronic);
Lack of necessary instruments (for example: a device for artificial ventilation of the lungs) with the development of possible complications;
Changes in tests: blood clotting disorders or low platelets (can lead to severe bleeding), high white blood cells and others;
If the woman in labor refuses this manipulation;
Anomalies or pathology of the spine (osteochondrosis with severe pain, herniated disc);
Low blood pressure (if 100/60 mmHg or lower), as epidural anesthesia lowers the blood pressure even further;

Benefits of epidural anesthesia during childbirth (caesarean section)

The woman in labor is conscious in order to receive pleasure at the first cry of her baby;
Provides relative stability of the cardiovascular system, in contrast to general anesthesia, in which during the introduction of anesthesia or at a low dose of anesthetic, pressure and pulse increase;
Can be used in some cases with a full stomach; general anesthesia is not used with a full stomach, as there may be reflux of gastric contents into the respiratory system;
Does not irritate the respiratory tract (in general, they are irritated by the endotracheal tube);
The drugs used do not have a toxic effect on the fetus, since the anesthetic does not enter the blood;
Does not develop hypoxia (lack of oxygen) of the woman in labor, including the fetus, unlike general anesthesia, during which hypoxia can develop as a result of repeated intubation, incorrect adjustment of the machine for artificial ventilation of the lungs;
Long-term anesthesia: first, epidural anesthesia can be used to relieve pain during childbirth, in case of complicated labor, with an increase in the dose of anesthetic, a caesarean section can be performed;
In surgery, epidural anesthesia is used against postoperative pain (by injecting an anesthetic into the epidural space through a catheter).

Disadvantages of epidural anesthesia during childbirth

Possible erroneous administration of the drug (in a large dose) into a vessel has a toxic effect on the brain, which can subsequently lead to a sharp decrease in blood pressure, the development of convulsions, and respiratory depression;
Erroneous injection of an anesthetic into the subarachnoid space, in small doses does not matter, in large doses (long-term epidural anesthesia with the introduction of a catheter), cardiac and respiratory arrest may develop;
To perform epidural anesthesia, high medical training of a specialist (anesthesiologist) is required;
Long interval between the administration of the anesthetic and the start of the operation (approximately 10-20 minutes);
In 15-17% of cases, there is insufficient (not complete) anesthesia, which results in discomfort for the patient and the surgeon during surgery, so additional administration of drugs into a peripheral vein is necessary;
Possible development of neurological complications as a result of trauma to the spinal root with a needle or catheter.

Consequences and complications of epidural anesthesia

The feeling of pins and needles, tingling, numbness and heaviness in the legs, which develops after the introduction of an anesthetic into the epidural space, is the result of the action of the anesthetic drug on the spinal roots. This feeling disappears after the drug wears off;
Trembling often develops a few minutes after the anesthetic is injected into the epidural space; this is a normal, harmless reaction that goes away on its own;
Reduction (relief) of pain when using epidural anesthesia during physiological labor;
Inflammatory processes at the injection site, with antiseptics (sterility); in such cases, local use of ointments or solutions (antibiotics) is possible;
An allergic reaction to a drug requires stopping the administration of the drug that caused the allergy and introducing antiallergic drugs (Suprastin, Dexamethasone and others);
Nausea or vomiting develops as a result of a sharp drop in blood pressure. When the doctor corrects the pressure, these symptoms disappear;
A drop in blood pressure and pulse in a woman in labor, therefore, when performing epidural anesthesia, solutions for infusion or cardiotonics (Epinephrine, Mezaton or others) must be prepared;
Post-puncture headache develops as a result of an erroneous puncture of the dura mater, so it is recommended to take a horizontal position for a day, and only on the second day can you get out of bed. This is explained by the fact that in a horizontal position, the pressure in the spinal cord canal increases, which leads to the outflow of cerebrospinal fluid through the punctured canal, and this in turn leads to the development of headaches. It is also necessary to use anesthetics to reduce pain (Analgin or other drugs).
Acute systemic intoxication develops as a result of erroneous injection of an anesthetic (in large doses) into a vessel, so the doctor, when administering an anesthetic, must be sure that the needle is in the epidural space (check using aspiration, using a test dose);
Pain in the back, due to trauma to the spinal root, or at the puncture site.

What happens after an epidural?

Once a dose of anesthetic is injected into the epidural space, shutdown of nerve function and numbness should occur within a few minutes. Usually the action begins within 10-20 minutes. As the anesthetic wears off, your doctor will give new doses as needed, usually every 1-2 hours.

Depending on the dose of anesthetic administered, the doctor may prohibit you from getting out of bed and moving around for some time after the operation. If there are no other contraindications associated with the operation, it is usually allowed to stand up as soon as the patient feels that sensation and movement in the legs have been restored.

If epidural anesthesia is continued for a long time, bladder catheterization may be required. Due to the disconnection of innervation, independent urination becomes difficult. When the anesthetic wears off, the doctor removes the catheter.

How much does epidural anesthesia cost?

The cost of the procedure may vary depending on the city and clinic in which it is performed. If epidural anesthesia is performed in accordance with medical indications, it is free. If there are no indications, but the woman herself decides to give birth with epidural anesthesia, then its cost on average will be 3000-7000 rubles.

What is the difference between spinal and epidural anesthesia and epidural anesthesia?

The words “epidural” and “epidural” are synonyms. This is the same type of anesthesia.

Spinal or spinal anesthesia is a procedure during which an anesthetic is injected into the subarachnoid space, located, as its name suggests, under the arachnoid membrane of the spinal cord. The indications for it are almost the same as for epidural anesthesia: cesarean section, operations on the pelvic and abdominal organs below the navel, urological and gynecological operations, operations on the perineum and lower extremities.

Sometimes a combination of spinal and epidural anesthesia is used. This combination allows:

reduce the dose of anesthetics administered into the epidural and subarachnoid space;
enhance the advantages of spinal and epidural anesthesia and eliminate the disadvantages;
enhance pain relief during and after surgery.

A combination of spinal and epidural anesthesia is used during cesarean section, operations on joints, and intestines.

Can an epidural affect a baby?

At the moment, many studies have been conducted to study the effect of epidural anesthesia on a child, and their results are ambiguous. During this type of anesthesia, there are factors that can affect the child’s body. It is impossible to predict how strong this influence will be in each specific case. It mainly depends on three factors:

dose of anesthetic;
duration of labor;
characteristics of the child’s body.

Since different drugs and their dosages are often used, there is no exact data on the effect of epidural anesthesia on a child.

It is known that epidural anesthesia can lead to problems with breastfeeding. Another negative consequence is that during natural childbirth under epidural anesthesia, the child becomes lethargic, which makes it difficult for him to be born.

What is caudal anesthesia?

Caudal anesthesia- a type of epidural anesthesia in which an anesthetic solution is injected into the sacral canal, located in the lower part of the sacrum. It is formed as a result of non-fusion of the arches of the fourth and fifth sacral vertebrae. At this point, the doctor can insert a needle into the final part of the epidural space.

The first epidural anesthesia in history was caudal.

Indications for caudal anesthesia:

operations in the perineal area, rectum and anus;
anesthesia in obstetrics;
plastic surgery in gynecology;
Pediatric epidurals: Caudal anesthesia is best for children;
sciatica- lumbosacral radiculitis;
surgical interventions on the abdominal and pelvic organs located below the navel.

With caudal anesthesia, the drug entering the epidural space disables sensitivity, and it can cover a different number of segments of the spinal cord, depending on the amount of the drug injected.

Advantages and disadvantages of caudal anesthesia:

Advantages

Flaws

Relaxation of muscles in the perineum and anus. This helps the surgeon during proctological operations.
Lower risk of low blood pressure.
The possibility of using this type of anesthesia in an outpatient setting - the patient does not need to be hospitalized in a hospital.

Higher risk of infection.
More complex implementation due to large differences in the structure of the sacral foramen in different people.
It is not always possible to predict the upper level of anesthesia.
There is a risk of poisoning from the anesthetic if a large amount has to be administered.
If you need to block the lumbar roots, you have to inject even more anesthetic.
It is impossible to perform operations on the abdominal organs due to insufficient nerve block.
Loss of sensation occurs more slowly than with epidural anesthesia.
During caudal anesthesia, a complete block of the anal muscle sphincter occurs - during some operations this interferes.

Is epidural anesthesia used in children?

In children, epidural anesthesia has been used for a long time, as it has a number of advantages. For example, this type of anesthesia is used in infants during circumcision and hernia repair. It is often used in premature, weakened children who do not tolerate general anesthesia well and have a high risk of pulmonary complications. But the child’s body has some characteristics that affect the technique of the procedure:

If the child remains conscious during the operation, then he experiences fear. It is often impossible, like an adult, to persuade him to lie still. Therefore, epidural anesthesia in children is often performed in combination with light anesthesia.
Doses of anesthetics for children differ from doses for adults. They are calculated using special formulas, depending on age and body weight.
In children under 2-3 years old and weighing less than 10 kg, caudal anesthesia is used.
In children, the lower end of the spinal cord is located lower in relation to the spinal column than in an adult. The fabrics are more delicate and soft. Therefore, epidural anesthesia must be performed with extreme caution.
In young children, the sacrum, unlike in adults, is not yet a single bone. It consists of individual unfused vertebrae. Therefore, in children, an epidural needle can be passed between the sacral vertebrae.

For what other operations can epidural anesthesia be used?

In addition to obstetrics, epidural anesthesia is widely used in surgery.

Epidural anesthesia may be used:

In combination with general anesthesia. This allows you to reduce the dose of narcotic painkillers that the patient will need in the future.
As the only independent method of pain relief, as with a caesarean section.
As a means to combat pain, including post-operative pain.

Operations for which epidural anesthesia can be used:

Operations on the abdominal organs, especially those located below the navel:
- appendectomy(surgery for acute appendicitis);
- operations in gynecology, for example, hysterectomy- uterus removal ;
- hernia repair for hernias of the anterior abdominal wall;
- bladder surgery;
- prostate surgery;
- operations on the rectum and sigmoid colon;
- sometimes they even perform it under epidural anesthesia hemicolectomy- removal of part of the colon.
Operations on the organs of the upper abdominal cavity (for example, on the stomach). In this case, epidural anesthesia can only be used in combination with general anesthesia, as discomfort or hiccups may occur due to the fact that the blockage is not blocked. diaphragmatic, wandering nerve.
Operations in the perineal area (the space between the anus and the external genitalia). Epidural anesthesia is especially often used during surgery on the rectum. It helps to relax the anal muscle sphincter and reduce blood loss.
Urological operations, including on the kidneys. Epidural anesthesia is primarily used in older people for whom general anesthesia is contraindicated. But when operating on the kidneys under this type of anesthesia, the surgeon must be careful: there is a risk of opening the pleural cavity in which the lungs are located.
Operations in vascular surgery, for example, for aortic aneurysm.
Operations on blood vessels, joints, leg bones. For example, hip replacement can be performed under epidural anesthesia.

Using an epidural to control pain:

Pain relief in the postoperative period. Most often it is performed when the operation was performed under epidural anesthesia or in its combination with general anesthesia. By leaving the catheter in the epidural space, the doctor can provide pain relief for several days.
Pain after severe injury.
Back pain (ischiolumbalgia, lumbodynia).
Some chronic pain. For example, phantom pain after removal of a limb, joint pain.
Pain in cancer patients. In this case, epidural anesthesia is used as a method palliative(alleviating the condition, but not leading to a cure) therapy.

Is epidural anesthesia performed for a herniated disc?

Epidural blockade can be used for pathologies of the spine and spinal roots accompanied by pain. Indications for blockade:

radiculitis;
protrusion intervertebral disc or formed intervertebral hernia;
narrowing of the spinal canal.

Epidural anesthesia is performed in cases where pain does not go away for 2 months or more, despite the therapy, and there are no indications for surgery.

Epidural administration of steroids (drugs of adrenal hormones, - glucocorticoids, - which have a pronounced anti-inflammatory and analgesic effect) in conditions such as radiculopathy, radicular syndromes, intervertebral hernia, osteochondrosis, spinal stenosis.

Often the anesthetic and glucocorticosteroids.

Is epidural anesthesia included in the birth certificate?

It depends on the circumstances.

If epidural anesthesia is performed according to indications, it is included in the birth certificate. In this case, this type of medical care is provided free of charge.

But epidural anesthesia can also be performed at the request of the woman herself. In this case, it is an additional paid service that will have to be paid in full.

Is epidural anesthesia used during laparoscopy?

Epidural anesthesia is performed during laparoscopic surgical interventions, including in gynecology. But it can only be used for short-term procedures and those that are performed on an outpatient basis (without hospitalization). Disadvantages of epidural anesthesia during laparoscopic operations:

Higher risk of oxygen deprivation due to increased levels of carbon dioxide in the blood.
Irritation phrenic nerve, whose functions are not disabled during epidural anesthesia.
The possibility of aspiration is the entry of saliva, mucus and stomach contents into the respiratory tract as a result of increased pressure in the abdominal cavity.
With epidural anesthesia, it is often necessary to prescribe strong sedatives, which can suppress breathing - this further increases oxygen starvation.
Higher risk of cardiovascular system dysfunction.

In this regard, epidural anesthesia has limited use in laparoscopic operations.

What drugs are used for epidural anesthesia?

Drug name	Description
Novocaine	Currently, it is practically not used for epidural anesthesia. It begins to act slowly, the effect does not last long.
Trimekain	It acts quickly (numbness begins after 10-15 minutes), but not for long (the effect stops after 45-60 minutes). Most often used for epidural anesthesia through a catheter or in combination with other anesthetics.
Chloroprocaine	Just like trimecaine, it acts quickly (numbness begins after 10-15 minutes), but not for long (the effect stops after 45-60 minutes). It is used for short-term and outpatient interventions, as well as for epidural anesthesia through a catheter (in this case it is administered every 40 minutes).
Lidocaine	It begins to act quickly (10-15 minutes after administration), but the effect lasts quite a long time (1-1.5 hours). Can be administered through a needle or through a catheter (every 1.25-1.5 hours).
Mepivacaine	Just like lidocaine, it begins to act in 10-15 minutes and ends in 1-1.5 hours. It can be given through a needle or through a catheter, but this drug is not recommended for long-term pain relief during labor because it enters the bloodstream of the mother and baby.
Prilocaine	The speed and duration of action are the same as lidocaine and mepivacaine. This drug is not used for long-term pain relief and in obstetrics, as it negatively affects the hemoglobin of the mother and fetus.
Dicaine	It begins to act slowly - 20-30 minutes after administration, but the effect lasts up to three hours. This is enough for many operations. But it is important not to exceed the dose of the anesthetic, as otherwise its toxic effects may occur.
Etidocaine	It begins to act quickly - after 10-15 minutes. The effect can last up to 6 hours. This drug is not used in obstetrics, as it causes severe muscle relaxation.
Bupivacaine	It begins to act in 15-20 minutes, the effect lasts up to 5 hours. In low doses, it is often used to relieve pain during labor. This anesthetic is convenient because it acts for a long time and does not lead to muscle relaxation, so it does not interfere with labor. But with an overdose or injection into a vessel, persistent toxic effects develop.

What medications can affect epidural anesthesia?

Taking medications that reduce blood clotting is a relative contraindication to epidural anesthesia. A certain amount of time must pass between taking the medication and the procedure for its effects to wear off.

Drug name	*What should you do if you are taking this drug?**	What tests need to be done before epidural anesthesia?
Plavix (Clopidogrel)	Stop taking 1 week before anesthesia.
Tiklid (Ticlopidine)	Stop taking 2 weeks before anesthesia.
Unfractionated heparin(solution for subcutaneous administration)	Conduct epidural anesthesia no earlier than 4 hours after the last injection.	If treatment with heparin lasted more than 4 days, it is necessary to take a complete blood count and check the platelet count.
Unfractionated heparin(solution for intravenous administration)	Conduct epidural anesthesia no earlier than 4 hours after the last injection. Remove the catheter 4 hours after the last insertion.	Definition prothrombin time.
Coumadin (Warfarin)	Conduct epidural anesthesia no earlier than 4-5 days after discontinuation of the drug.	Before administering anesthesia and before removing the catheter: definition prothrombin time; definition international normalized relations(blood clotting indicator).
Fraxiparine, Nadroparin, Enoxaparin, Clexane, Dalteparin, Fragmin,Bemiparin, Cibor.	Do not enter: in a prophylactic dose - 12 hours before the procedure; in a therapeutic dose - 24 hours before the procedure; after surgery or catheter removal - within 2 hours.
Fondaparinux (Pentasaccharide, Arixtra)	Do not administer within 36 hours before anesthesia; do not administer within 12 hours after completion of surgery or catheter removal.
Rivaroxaban	Epidural anesthesia can be administered no earlier than 18 hours after the last dose; administer the drug no earlier than 6 hours after completion of the operation or removal of the catheter.

*If you are taking one of these drugs, be sure to tell your doctor. Do not stop taking it yourself.

In practice, I have encountered the fact that patients often confuse spinal and epidural anesthesia, misinterpret general anesthesia, and are very frightened and distrustful.

Spinal and epidural anesthesia involve the injection of a local anesthetic in close proximity to the spinal cord. Although these types of anesthesia are fundamentally similar, each of them has its own anatomical, physiological and clinical features.
The spinal cord is located at the center of the spinal column and is surrounded by cerebrospinal fluid; and all this, in turn, is surrounded by the dura mater, then T.M.O. (pia dura). Hence, epidural - on top of the dura mater, subdural - under the T.M.O.

Spinal anesthesia

Spinal anesthesia - the fastest in terms of execution technique. An injection is made into the spine at the lumbar level with a long and thin needle. The thickness of the needle is slightly larger than a hair, so the puncture is practically painless (all painful sensations during the puncture are only from the skin). The needle passes almost to the spinal cord (behind the T.M.O.). The doctor determines the correct placement of the needle by the appearance of a drop of cerebrospinal fluid from the needle.

” The drug is administered once. The needle is removed. Since the local anesthetic reaches the spinal cord directly, clinical sensations develop within 1-2 minutes.

You must definitely talk about them to your anesthesiologist, since the anesthesiologist will determine the level of anesthesia that has developed, its depth, and possible complications that may develop based on his feelings.

What should it be?

warmth that appears in the buttocks and thighs and gradually decreases towards the feet;

heaviness in the legs;

"goosebumps";

tingling;

There may be general weakness, dizziness, nausea and vomiting - there is no need to be afraid of this.

Such sensations arise due to a decrease in blood pressure (BP), as all the vessels in the lower part of the body relax and dilate.

Spinal anesthesia blocks all types of sensation. Depending on the drug, it lasts from 30 minutes to 3 hours. It cannot be extended!

Conditions that must be met when using spinal anesthesia

There are certain conditions that must be met to reduce the risk of complications. The simplest and most important thing is a horizontal position without a pillow until sensitivity returns and with a pillow for 12 hours.
Why? - since there is a puncture of the T.M.O., cerebrospinal fluid can leak out in a vertical position and, as a result, headaches occur that are difficult to treat.

About back pain...

Obstetric anesthesiologists and neuraxial pain management techniques are often blamed for any neurological symptoms that occur in the postpartum period. However, it should be remembered that both pregnancy and the process of childbirth themselves can cause neurological disorders. Nerves can be damaged by the descending fetal head or during the application of obstetric forceps. Neurological disorders can also be caused by long, protracted labor. The use of retractors during cesarean section can also lead to neurological complications.

Epidural anesthesia

Epidural anesthesia - more complex and time-consuming to complete. It can be performed both for the treatment of incoordination of labor and for pain relief in the 1st stage of labor, cesarean section, and for postoperative pain relief.

” With epidural anesthesia, the drug is injected into the space surrounding the nerves exiting the spinal cord, so options range from pain relief with mild motor blockade to deep anesthesia with complete motor blockade.

Epidural anesthesia is technically more difficult than spinal anesthesia. First, the skin is anesthetized, then the doctor, working with a long and thick needle, approaches the space where the nerves go and inserts a catheter through the needle, through which the drug is delivered. In this case, the drug can be administered for as long as desired (maximum permissible 7 days).

The sensations develop within 5-20 minutes and are completely similar to the spinal anesthesia clinic. The difference is that with spinal anesthesia there is no sensitivity at all, while epidural anesthesia only relieves pain impulses at a certain specified level. At the same time, a woman may feel touching, stretching, pressure - this is the norm.

” With spinal and epidural anesthesia, the woman remains conscious (including); He hears everything, sees his anesthesiologist and can communicate with him. After extraction, they will immediately show the baby to her, give her a kiss, and put her to her breast.

General anesthesia

The worst word is general anesthesia. It is performed during a caesarean section only in conditions that threaten the life of the mother or child.

” All drugs are administered intravenously. There is an instant loss of consciousness. The woman sees nothing, hears nothing, feels nothing. Narcotic analgesics are used for general anesthesia. When administered intravenously, they reach the fetus very quickly, so obstetricians work quickly.

After the operation, if everything is in order, the mother will see the baby only in her room, after 2 hours. One of the discussed issues among patients is indications and contraindications. We sorted out the testimony.

Now why “not”. . .

Contraindications to the use of anesthesia

It is absolutely impossible:

Refusal of the woman in labor
. Lack of necessary conditions and equipment
. Severe hypovolemia and a real risk of massive bleeding (placental abruption, uterine rupture, hypotonic bleeding)
. Coagulopathy (blood clotting disorder)
. Signs of aorto-caval compression (to avoid them, the woman is turned on the table on her left side, while the vessels are released from the pressure of the pregnant uterus)
. Treatment with anticoagulants
. Sepsis
. Skin infection at the puncture site
. Increased intracranial pressure
. Allergy to anesthetics
. AV block and other heart problems
. Significant fetal distress (umbilical cord prolapse, bradycardia)
. Exacerbation of herpes infection

It is not possible regarding:

The urgency of the situation and the lack of time to prepare the woman in labor and perform manipulations
. Presence of fetal malformations, antenatal fetal death
. Emotional instability of the mother in labor
. Some heart diseases
. Existing opportunity to expand the scope of the operation
. Peripheral neuropathy
. Mental illness
. Low level of intelligence (mental retardation)
. Treatment with heparin
. Surgical team disagreement
. Spinal deformity
. Previously suffered spinal injuries.

How does anesthesia and drugs affect the fetus?

The question everyone asks is How do anesthesia and drugs affect the fetus?
NO way - if it is spinal or epidural anesthesia.
INFLUENCE - if it is general anesthesia.

Drugs for spinal and epidural anesthesia (lidocaine, bupivacaine, ropivacaine) are used all over the world, and nothing better has yet been invented. When introduced, they decompose “there.” They have a large molecule, and they enter the mother’s blood in extremely small quantities. If the placenta is mature and normal (by 32-40 weeks of pregnancy), then it will not miss the drug. In other cases, only a few molecules that are not destroyed in the blood will enter the fetal bloodstream. BUT,. . . By the time the drug reaches the baby’s blood, the woman will become a mother. Simply put, the drug does not have time to reach the child.

With general anesthesia, everything is different and depends on the speed of the obstetricians’ work - “the faster, the better.” The narcotic analgesics used in their entirety penetrate through the placenta to the fetus and, accordingly, cause the same effects as in a woman. This is depression of consciousness, breathing, and heartbeat. Newborn babies often sleep and breathe poorly...they are under anesthesia. But...and these drugs are different. Their use depends on the initial specific situation and the reasons for surgical delivery. Fentanyl, promedol, morphine opiates penetrate everywhere, oppressing everything. Ketamine is a synthetic drug. The only drug that causes reverse reactions. It raises blood pressure and stimulates the respiratory and cardiovascular centers. Although the baby will sleep, breathing and heartbeat will not be significantly disturbed. It should be remembered that for each drug there are clear and strict indications! The use of any drug depends on the specific situation, complexity, severity of the mother and baby.

In conclusion, I want to say that with any type of anesthesia, mutual understanding between the doctor and the patient is very important, how much trust you have in the doctor. This determines how quickly, painlessly and effectively the anesthesia will take place. First of all, calm down, ask the doctor everything that interests you. The doctor must tell you about the entire anesthesia process.

I am an anesthesiologist, before the operation I try to tell everything about anesthesia, and during the process I talk through what I will do and how. During the operation I try to talk with women and hold their hands. The entire anesthesia process goes more smoothly if the woman herself is calm and confident.
I am a patient. In her life, she herself found herself on the operating table more than once.
I am a mother. My motherhood began with a caesarean section under epidural anesthesia.

23.06.2011

Updated and supplemented 08.08.2015
Vereshchagina, anesthesiologist-resuscitator, category 2

Lately, we often hear and read on forums, “I gave birth with an epidural,” “but I had a spinal cord.” What is this? We are talking about anesthesia during childbirth. It just so happens that the process of giving birth to a child is accompanied by pain. For some it is tolerable, but for others it is such that you have to think about anesthesia.

In foreign countries, pain relief during childbirth is quite common. In our healthcare institutions, no one does this. Pain relief occurs only for a number of indications or on a paid basis.

Epidural and spinal anesthesia are one of the best options for relieving pain during childbirth. However, how do they differ or is there no difference here? Let's try to figure this out.

Name

Speaks for itself. It corresponds to the area where the anesthetic is injected. So, when executing epidural anesthesia the anesthetic is injected into the epidural space of the spinal cord. At spinal- into the spinal space. In both cases, the puncture is performed in the lumbar spine.

Mechanism of action of an anesthetic drug

For epidural anesthesia, it is based on the blockade of nerve bundles that are located in the epidural area. At spinal Anesthesia blocks a nearby section of the spinal cord.

Tools for performing the procedure

Epidural is done with a very thick needle, and spinal- thin. Before both punctures, local anesthesia is performed.

Clinic

The effect achieved by spinal and epidural anesthesia is very similar. In both cases, the muscles relax and sensitivity is lost.

Time of onset of anesthetic effect

At epidural pain relief, loss of sensitivity occurs after 20-30 minutes.

Spinal blocks sensitivity in 5-10 minutes.

This point is very important, since an epidural will not be suitable for emergency surgery.

Time of action spinal anesthesia lasts 1-2 hours, the epidural can be prolonged, that is, its effect can be prolonged.

Side effects can be observed with any anesthesia. The only difference is in the frequency of occurrence of one type or another. The most common negative effects of regional anesthesia include headaches, drop in blood pressure, nausea, vomiting, and pain at the puncture site. Side effects when epidural anesthesia less pronounced.

Anesthetic dosage

At spinal anesthesia, the dose of painkiller is significantly lower than with epidural. When performing the latter, after healing the needle, a catheter remains with which you can add an anesthetic during labor if necessary.

Indications To epidural anesthesia:

1. premature birth;

2. incorrect position of the fetus;

3. diseases of the heart, kidneys, lungs;

4. myopia;

5. late toxicosis;

6. discoordination of labor;

7. increased pain sensitivity.

Spinal Anesthesia is more often performed for planned and emergency caesarean sections.

Contraindications For epidural and spinal anesthesia:

Infectious lesions at the puncture site;

Hypotension;

Diseases of the central nervous system;

Allergy;

Problems with blood clotting.

It is difficult to say which anesthesia (spinal or epidural) will be best, because each has its own disadvantages and advantages. Most likely, the most optimal and less dangerous one will be the one prescribed and carried out by a competent specialist.