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Delivering a baby can be scary for a new mother-to-be. Let alone the fear of what might happen during the process, but the amount of pain one is likely to feel is considered immeasurable. But it is possible to have a normal birthing process without the pain -- by the use of an epidural. Dr Hemant Shinde, consultant anesthesiologist at Hinduja Healthcare Surgical Hospital, Mumbai, tells you about epidurals, what it entails and its possible complications.
What is an epidural?
Dura is a thin covering on the human brain which extends from the skull downwards through the spinal column covering the nerves leaving the spinal cord and ends at the sacrum. From the skin if one approaches the spinal cord then there are following layers that will be encountered - skin, subcutaneous tissue, supra spinous ligament, infra spinous ligament, ligamentum flavum, dura and lastly the spinal cord.
Epidural space is the space between the dura and the Ligamentum Flavum. In common language it means the space that lies outside the dura is epidural space. If one enters inside the dura or goes beyond the dura then it is called intradural space.
When anesthetic medications like opioid agents or local anesthetic agents are deposited in the epidural space it can be used either to cause analgesia (relief from pain) or anesthesia (where there is total numbness and an operation can be performed on a patient).
How does it work?
The anesthetic medications which are deposited in the epidural space act by two mechanisms. The nerves that are leaving the spinal column are blocked by these medicines hence the nerve conduction is blocked and hence analgesia or anesthesia is achieved depending upon the dosage of the medicine.
There are opioid receptors in the spinal column that are blocked by these opioid medicines, which then results in pain relief or anaesthesia.
The concentration of the medicine determines whether the medication is an analgesic or anesthetic in nature. When higher concentration of a medicine is used it will block all the sensations carried by that nerve and lead to anesthesia. If the same medicine is used in lower concentration it will block only the pain fibers and will cause analgesia which means only the pain relief without causing muscle weakness.
This mechanism is used in giving labour analgesia or what is commonly called as painless labour. Here the nerves that carry pain sensation -- caused by strong uterine contractions -- is blocked at the spinal level and not allowed to reach the brain; where normally humans feel pain. Therefore, the pregnant woman can deliver the child with very little or no pain.
How is it administered?
There are two main techniques to administer an epidural, they are:
Single shot epidural: The epidural space is usually injected with opiod medication, by injecting it into the epidural space. This usually involves the doctor administering an injection on the patient's back (in the cervical, thoracic or lumbar region).
Epidural catheter technique: Alternatively a fine bore tube can be passed into the epidural space and the medication can be deposited into the epidural space continuously or intermittently.
While administering an epidural, finding the epidural space is most important. The trick here is not to puncture the dura or stay outside the dura.
Can there be any complications?
Any procedure in medicine has complications and epidural is no exception to that!
The most serious complication that can occur is that the desired effect is not achieved which means failed epidural, or it can act partly which is called a patchy epidural.
As explained earlier the trick is to stay outside the dura but sometimes due to technical difficulty, anatomical problems or if the patient moves suddenly during the procedure one can puncture the dura and an epidural becomes a spinal. In such instances a patient can have severe headache, vomiting with blurred vision for 2-3 weeks on assuming erect position or on coughing.
If this puncture is not noticed and the whole dose of the medicine is injected in a patient then a patient can suffer from fall in blood pressure, difficulty in talking as well as breathing leading very rarely to even a cardiac arrest.
Sterile aseptic precautions are a must while doing an epidural otherwise infection is a possibility which if spread to meninges (covering of the brain) can lead to meningitis.
If a catheter is used then it can migrate to deeper layers like the dura or a blood vessel, may get knotted inside the space or can break while being removed. These are called catheter related complications of the epidural. Very rarely it can lead to backache of short duration.
Who should not be administered an epidural?
The contraindications for an epidural anaesthetic are patients with following conditions:
Image source: webmm.ahrq.gov
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