EPIDURALNA ANALGEZIJA U POROĐAJU: SPECIFIČNOSTI, DILEME I KONTROVERZE.

EPIDURAL ANALGESIA IN LABOR: SPECIFIC CHARACTERISTICS, DILEMMAS AND CONTROVERSIES.

Introduction. Epidural analgesia has become the most popular method for labor pain relief. Analgesia in Labor: Yes or No? Labor pain is a complex phenomenon with sensory, cognitive, motivational, emotional, social, and cultural variables. Pain and anxiety lead to adrenergic hyperactivity, hyperventilation, hypocapnia with reduced uteroplacental blood flow and uncoordinated uterine activity, so pain relief is recommended and even indicated in cases of maternal comorbidity. Analgesia in Labor: Method of Choice. The quality of epidural analgesia is better than the one achieved by parenteral or inhalation agents, with increased uteroplacental blood flow and improved fetal-maternal oxygenation. Epidural Analgesia in Labor: What is Specific? The increased weight, lumbar lordosis, soft tissue edema and engorgement of epidural veins make it more difficult to perform epidural block in pregnancy. Epidural puncture should be performed by medial approach, at L2 - 3 or L3 - 4 level by loss of resistance technique between contractions. Epidural Analgesia in Labor: What With? Local anesthetics, bupivacaine, levobupivacaine, ropivacaine, are used and they can be combined with small doses of opioids (fentanyl or sufentanyl). Epidural Analgesia in Labor: How? Available techniques are epidural, spinal and combined spinal -- epidural analgesia. Epidural Analgesia in Labor: Controversies. The most important controversy is the influence of epidural analgesia on operative or instrumental delivery rate. Low concentrations of local anesthetic in combination with small doses of opioids, together with active management of labor by an obstetrician, would lead to increased spontaneous delivery rate. Conclusion. Although there still are some difficulties, complications and controversies, epidural analgesia provides safe and effective labor pain control. [ABSTRACT FROM AUTHOR]

Uvod. Epiduralna analgezija postala je najpopularniji metod za ublažavanje porođajnog bola. Analgezija u porođaju: da ili ne? Porođajni bol je složen subjektivni fenomen, u kome se nociceptivni stimulusi centralno primaju, prerađuju i interpretiraju u sadejstvu s fiziološkim, neurohumoralnim, emocionalnim, socijalnim, kulturološkim faktorima. Bol i anksioznost izazivaju adrenergičnu hiperaktivnost, hiperventilaciju, hipokapiju sa smanjenim uteroplacentnim protokom krvi i nekoordinisanom aktivnošću materice, te se preporučuje ublažavanje bola, što je čak i indikovano u slučajevima komorbiditeta majke. Analgezija u porođaju: metod izbora. Pomoću epiduralne analgezije postiže se bolji kvalitet nego parenteralnim ili inhalacionim agensima, s povećanim uteroplacentnim protokom krvi i boljom oksigenizacijom fetusa i majke. Epiduralna analgezija u porođaju: šta je specifično? Fiziološke promene u trudnoći (povećana telesna težina, edemi mekih tkiva, lumbalna lordoza, kongestija epiduralnih vena...) otežavaju izvođenje epiduralnog bloka u trudnoći. Epiduralnu punkciju trebalo bi izvesti medijalnim pristupom na nivou L2-3 ili L3-4 tehnikom gubitka otpora između kontrakcija. Epiduralna analgezija u porođaju: čime? Koriste se lokalni anestetici, bupivakain, levobupivakain, ropivakain, a mogu se kombinovati s malim dozama opioida (fentanilom ili sufentanilom). Epiduralna analgezija u porođaju: kako? Na raspolaganju stoje sledeće tehnike: epiduralna, spinalna i kombinovana spinalno-epiduralna analgezija. Epiduralna analgezija u porođaju: kontroverze. Najvažnija kontroverza je uticaj epiduralne analgezije na operativnu i instrumentalnu stopu porođaja. Niske koncentracije lokalnog anestetika u kombinaciji s malim dozama opioida, zajedno s aktivnim angažovanjem akušera prilikom porođaja, rezultirali bi povećanom stopom sponatnog porođaja. Zaključak. Iako još uvek postoje neke teškoće, komplikacije i kontroverze, epiduralna analgezija obezbeđuje bezbednu i efikasnu kontrolu porođajnog bola. [ABSTRACT FROM AUTHOR]

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