As apprehended as desired, epidural anesthesia allows the expectant mother to no longer suffer from pain due to contractions during childbirth. Despite the relief it brings during labor, this procedure can quickly be scary. In question ? The size of the needle used, but also the area concerned. We take stock to reassure you!
The epidural, or peri, for the intimate, consists in relieving the pain of childbirth thanks to a locoregional anesthesia at the level of the epidural space, carried out using a needle and a catheter.
The epidural is an act more than common in France. According to figures revealed in 2018 by The world in collaboration with the French Federation of Perinatal Health Networks (FFRSP), 8 out of 10 women use it during their childbirth, one of the highest figures in the world which can be explained in part because this medical procedure is 100% reimbursed by Social Security. Perfectly mastered, the fitting of the epidural remains impressive, however, because it involves a tool that is often dreaded by mothers but also many other people: the needle, as well as the very sensitive and risky area of the vertebrae. More fear than harm, however, as you will discover!
What does the epidural needle look like?
The needle used for the epidural differs from the one used for blood tests and infusion in its size and circumference. There are several models of needle, but the most commonly used is the Tuohy needle.
This sterile, disposable, silicone-coated stainless steel epidural needle generally measures 80 mm, or 8 centimeters. Its length can vary up to 15 mm (15 centimeters) to facilitate intervention on women with obesity and whose fatty layers extend the path of the spinal needle to reach the epidural area.
The needle has a beveled, slightly curved tip, and centimeter markings along its length indicating the depth of penetration of the epidermal layers. The diameter of the needle is expressed in Gauge and may vary depending on the size of the catheter, but the most common is 18G, or approximately 1.30 mm.
The Tuohy needle also has a transparent base, making it possible to visualize any reflux of blood or cerebrospinal fluid, as well as removable wings. It is on this base that the standardized color code specifying the needle diameter appears (red: 17G, pink: 18G, yellow: 20G and green: 21G).
What is the epidural space?
The epidural therefore makes it possible to introduce a catheter using this needle into the epidural (or epidural) space. It is located between the yellow ligament and the dura mater, which surrounds the spinal cord, and it runs most of the way down the spine from the occiput to the sacrum. It contains both fat and blood vessels, but above all, nerve branches. Epidural anesthesia during childbirth concerns more particularly the area either between the 3rd and 4th lumbar vertebra, or between the 4th and the 5th lumbar vertebra, because this is where the communication with the nerves responsible for transmission is located. pain from the uterus during labor. Thanks to the injection and diffusion of an analgesic, this transmission will be blocked and the pain greatly reduced or even eliminated, and the expectant mother will be able to concentrate better on the thrusts of childbirth.
How is the epidural going?
Since the epidural is a medical act involving anesthesia, it is performed by an anesthetist, often assisted by a midwife. If it is systematically offered by the medical team, it however requires a preliminary interview, often a few weeks before the estimated pregnancy term), with the anesthesiologist in order to determine whether the mother-to-be has no contraindications (which are few, see below in the article). The epidural is not just for vaginal birth and can also be given for a cesarean section.
The procedure is done in a sterile setting. The anesthetist therefore wears gloves, a mask and a cap. The future mother is put either in a sitting position or in a lying position on her side, with a well rounded back to better bring out the vertebrae. The lower back is first disinfected, then local anesthesia is applied. By palpation, the doctor locates the lumbar vertebrae between which he will introduce the needle which will help guide the catheter. Although fast, this operation requires a lot of precision and it is important that the mother does not move and that she warns when she feels a contraction coming. Once the catheter is in place, the needle is withdrawn. The pain reliever can then be injected and it begins to work within 15 minutes. It can then be reinjected in doses, at the mother's request, or using a pump that she can activate herself depending on the intensity of the pain and the duration of the effect of the anesthetic product. The blood pressure, the pulse and the quality of the analgesic will be checked regularly by the medical team throughout the delivery. It is only after the baby is born that the catheter is removed, usually in the delivery room.
When can an epidural be placed during childbirth?
As soon as the cervix is 2 to 3 centimeters dilated, the epidural can be inserted. But if the mother-to-be does not immediately feel the need because the pain of the contractions is bearable, she can wait. Provided he is available when the request for an epidural is expressed, the anesthesiologist can intervene at any time during labor. However, the procedure is no longer possible when cervical dilation is at its maximum. This means that the delivery is too advanced and that the product will no longer have time to have an effect on the body upstream and may act while the baby has to be expelled. The medical team can then suggest alternatives to alleviate the pain, if time permits.
Also note that just because you confirmed, during the interview with the anesthesiologist, your desire to have an epidural during childbirth that it will be performed automatically. It will only be done at the request of the mother-to-be and she is perfectly entitled to change her mind and want to give birth without this anesthesia.
Does the epidural pose any risk to the baby?
One of the biggest concerns for expectant mothers about epidural anesthesia is its potential effect on the health of their babies, after the size of the needle and the possible complications during insertion.
However, epidural anesthesia injected into the epidural space acts locally and the amount of analgesic product diffusing into the blood (and therefore passing through the placenta to the fetus) remains tiny. It is therefore safe for the baby as well as for the mother. No study on this method has revealed any risks or even effects on the birth, development or growth of the child and the epidural remains recommended by the World Health Organization to relieve the pain of expectant mothers during delivery when it can be administered and if they request it.
Does an epidural slow down childbirth?
Among the other misconceptions around the epidural, there is the idea that anesthesia prolongs labor and slows childbirth. Following this belief, the medical team sometimes made the decision to reduce or even discontinue the effects of the anesthetic at the end of labor. A study published in 2017 in the journal Obstetrics and Gynecology however, revealed that the duration of childbirth was roughly the same between women who received painkillers to the end and those for whom they were arrested. The findings also confirmed that the epidural had no effect on babies' health or their position at birth.
However, do not hesitate to express your fears or questions during the interview with the anesthetist or with the medical team who are monitoring your pregnancy. It is part of their job to make sure that you make fully informed decisions until you are finished and even after.
Contraindications to the epidural
The 8th month interview with the anesthesiologist will determine the existence or not of contraindications to the installation of an epidural. The doctor will take note of the family history as well as any medical treatment undergone by the expectant mother. The main contraindications identifiable upstream are:
- Coagulation disorders
- Certain neurological disorders
Other criteria may also complicate catheter placement and lead the doctor to recommend an alternative:
- A very severe scoliosis that would prevent the needle from reaching the epidural space
- A tattoo located where the needle should normally be inserted as it could cause the ink to migrate with the puncture
Even if no prior contraindication was determined during the interview, others may intervene during installation:
- Fever
- A skin infection in the lower back
- Intracranial hypertension
- The need for an emergency caesarean
Adverse effects and complications of an epidural
Placing the epidural is painless, but inserting the needle and placing the catheter into the epidural space can cause a very brief sensation of electric shock, cold snap, or tingling. Such sensations can also be felt when withdrawing the catheter.
Anesthesia can lower your blood pressure. The blood pressure is therefore regularly checked by the medical team, as is the mobility of both legs, which may appear heavy or even numb. As the product acts on the bladder, the mother-to-be may have difficulty urinating and may therefore be probed. Depending on the pain reliever, itching and nausea may also appear.
It is not uncommon for headaches to appear and persist for hours or even days after childbirth. They are caused by needle rupture of a membrane of the dura mater (located after the epidural space) and leakage of cerebrospinal fluid. Rest and painkillers are usually enough to get them through but in case of prolonged pain, specific treatment may be decided by the doctor. Back pain, generally localized around the lower back or more precisely where the puncture was performed, can be felt after birth but they are not serious and are not necessarily linked to the epidural but rather to pregnancy and tension and movement during labor.
Like any anesthetic procedure, an epidural can cause serious complications such as paralysis caused by an epidural hematoma or abscess (which can be resolved surgically), heart problems or seizures. These remain extremely rare, a few isolated cases out of the hundreds of thousands of epidurals made each year around the world!