• What is painless delivery?
• The majority of expectant mothers are naturally afraid of the pain experienced during birth and want to benefit from the methods applied for painless birth. The process of eliminating or reducing the pain felt during labor with different methods and provinces is called "painless birth", "birth analgesia" or "birth anesthesia". Painless birth, also known as the "Kybele method", named after the fertility goddess in mythology; it is normal birth in which pains are prevented. Painless birth is a comfortable delivery method where labor pains are perceived not as pain but as pressure in the abdomen and pressure in the groin and expectant mothers do not feel discomfort.

• What is epidural analgesia?
• Today, although there are many methods for painless birth, epidural analgesia is the most recommended by modern medicine and the best known among the public. Epidural analgesia is the most preferred method because of its reliable and high efficiency.
• Analgesia is defined as painlessness, lack of pain sensation. Epidural analgesia is a form of regional anesthesia which is preventing the perception of sensations such as pain, temperature, touch in a certain part of the body by temporarily blocking the transmission of pain signals. Birth is only blocking the pain messages carried by the epidural analgesia in the rain. The senses and movements such as the sense of touch, the ability to move in the legs and the contraction of the uterus, which provide the active participation of the expectant mother to the birth, are not affected. The expectant mother who is applied epidural anesthesia can walk until the active birth phase begins. Surely a companion of the expectant mother may feel a slight weakness in the legs, although rare, may walk accompanied by a midwife or nurse and rile inhibitory.

• How does epidural analgesia work?
• The sensation of pain is first transmitted to the spinal cord via the nerves and then to the pain centers in the brain via the nerves in the spinal cord. The spinal cord is located in the bone structure known as the spine, which is formed by lining up bones called vertebra in our body. Cerebrospinal fluid circulates around the spinal cord in the canal at the spine. There are membranes around this liquid. The spinal cord ends at the beginning of the vertebrae belonging to the lumbar region, and the nerves coming out of the spinal cord leave the spine from this level and extend to the tips of the feet.
• Epidural analgesia is the prevention of pain transmission by applying local anesthetic drugs around the membrane called dura (epidural area) that surrounds the spinal cord from the outside, and the administration of some drugs that strengthen the pain relief effect. With the end of the effects of the drugs, the drowsiness felt also ends.

• From where on the body is epidural analgesia applied?
• The epidural space is the area at the base of the carotid area that extends from the beginning of the spinal cord to the end of the coccyx (sacrum) bone at the end of the waist, and its widest part is approximately 0.5 cm in the lumbar region. Entry into the epidural space for birth analgesia is made either through an intervertebral space in the lumbar region (lumbar epidural) or lower down through the sacral canal (caudal epidural). The possibility of direct damage to the spinal cord is very low in interventions performed at levels below the lumbar vertebra where the spinal cord ends.

• How is Epidural analgesia applied?
• While the expectant mother is lying on her side or sitting, the area on the waist where the needle will enter is wiped with an antiseptic substance. After the skin and subcutaneous tissues are anesthetized with a local anesthetic drug given through a thin needle, the epidural space is entered with a special needle, the tip of the needle is placed into the epidural area and a local anesthetic drug is applied with an amount known as test dose. With this procedure, drug sensitivity and allergy symptoms are observed, it is confirmed by testing that the needle tip is not in the intravascular or subarachnoid region (the area where the cerebrospinal fluid is located). Finally, the injection process is completed by giving the entire required dose.

• How is the catheter placed?
• These drugs can be administered through a catheter at the preference of the anesthesiologist. In this method, after the catheter is inserted into the epidural space through the needle, the epidural needle is removed, and the lumbar region is closed with sterile dressing. While the epidural catheter is being placed, the catheter touches the nerves in the epidural space, resulting in a momentary electric shock-like sensation in the hips and legs. This feeling is temporary. Although this sensation occurs during epidural injections, permanent nerve damage is extremely rare.

• What is the purpose of catheter insertion?
• The catheter has no pain relief feature. Pain relief effect is created with the local anesthetic drug administered through the catheter. Because of the catheter, the duration and effectiveness of the pain relief effect is increased by repeated administering drugs to the epidural area without the need for needles to be inserted each time.

• How long does Epidural analgesic take effect?
• The analgesic effect begins 15-20 minutes after the drug administration. The duration of the drug's effect varies from person to person. For this reason, the drug should be applied again when the expectant mother starts to feel pain again or when the pain starts to feel mildly. Sometimes, the local anesthetic drug may not reach the desired area and the expectant mother may feel pain in some parts of her body despite the application of epidural medication. In such a situation, the epidural catheter may need to be removed and reinserted. In this process, instead of enduring pain, sharing the sensations related to pain with the delivering team ensures successful implementation. Because the duty of the anesthesiologist is to ensure that the birth is painless and comfortable.

• Do the drugs used in epidural analgesia have a negative effect on the course of delivery and baby health?
• The drugs used in epidural analgesia pass very slowly into the mother's blood. In addition, the concentration of the drug in the circulating mother's blood further decreases when it passes through the placenta and reaches the baby. Therefore, no adverse effects on the baby are expected. The heartbeat of the baby is monitored periodically with a device called cardiotocography during the delivery, under epidural analgesia.

• Does epidural analgesia delay labor?
• It is very important to figure out when epidural analgesia should be applied. Epidural anesthesia is not applied to pain that occurs during contractions experienced before the start of real labor. However, if necessary, other medications can be given to relieve the pain.
• When epidural analgesia is initiated at the appropriate time, it does not have a negative effect on the first stage of labor. It is important for the expectant mother to be able to strain effectively during delivery. Therefore, in epidural analgesia applications, it is very important for the gynecology and obstetrician and anesthesiologists to decide together on the communication and timing of drug administration at the second stage of delivery. Therefore, prolongation of labor is not in question of drug applications with correct follow-up and appropriate timing. The most important thing is that the delivery is carried out comfortably and safely for the mother and baby. In case the birth is prolonged for other reasons, it may be possible to use auxiliary methods or to be performed by cesarean section.

• Who cannot get epidural analgesia?
• Epidural analgesia is not preferred in expectant mothers who have low blood pressure, are allergic to local anesthetic drugs to be used, have an infection in the skin area to be injected, have a suspicion of neurological disease, and whose blood cells (thrombocyte) count and function are insufficient. If the expectant mother does not want epidural analgesia, the procedure is not applied unless there is a very important medical reason.

• What are the advantages of epidural analgesia?
• Its biggest advantage is that it does not cause sedation (semi-drowsiness) and creates a pain relieving effect without altering consciousness. It is an anesthesia method that has not yet found a better alternative in terms of the mother's ability to see both the birth process and the first moments of her baby's birth, and touch and kiss her.
• Epidural anesthesia is a preferred application in unwanted situations such as high blood pressure that may develop during pregnancy, due to its medical advantages in premature babies or twin pregnancies. Although general anesthesia is a safe method for cesarean section operations, the baby almost never encounters general anesthetic drugs in cesarean sections performed under epidural analgesia.

• Is it possible to switch from normal birth to cesarean during epidural analgesia?
• During the course of the delivery, cesarean delivery can be performed with epidural analgesia, which is administered again through the catheter when necessary. Anesthesia is maintained with an epidural catheter after cesarean, and an additional painless and comfortable postoperative period is provided. Therefore, it is the most natural right of a mother to benefit from epidural anesthesia unless advised otherwise by the anesthesiologist.

Spec. Dr. Murat ÇELİK

Anesthesiology and Reanimation