Epidural anesthesia through the eyes of Dr. Velichka Stoycheva

Childbirth is one of the most intimate and emotional moments in a woman's life, but it is often accompanied by fear of pain. In such moments, the anesthesiologist comes to the rescue - the person who is key to a calm and safe experience. Dr. Velichka Stoycheva is a specialist in anesthesiology and head of the Department of Anesthesiology and Intensive Care (OAIL) at Pulse Hospital. She has many years of experience in Germany and Bulgaria. In this interview, she debunks the myths about epidural anesthesia, shares her experience in the delivery room and explains why trust is the most important part of the doctor-patient relationship.

What motivated you to choose the specialty "Anesthesiology"? How many years have you been practicing?
- Anesthesiology is the broadest medical science, which encompasses the preparation of the patient for surgery, monitoring and maintaining the vital functions of the human body both during surgery and during the postoperative period in the Intensive Care Unit. The anesthesiologist takes away consciousness during surgery and applies various methods of anesthesia - from medication to regional and local pain treatment. In Germany, where I studied and specialized, Anesthesiology additionally encompasses Special Pain Therapy, Emergency, Intensive and Palliative Medicine, which makes it an extremely multifaceted and complex medical science. The anesthesiologist works with patients of every age group - from newborns to the elderly and with a variety of diseases, which requires competencies in all areas of medicine and makes the work very interesting, diverse and challenging at the same time. All this motivates me and gives me energy for continuous professional development. In 2013. I graduated from one of the most prestigious universities for Medicine in Germany - Tübingen and since then I have been working as an anesthesiologist.​

What do you find most satisfying about working with women in labor?
- Working with women in labor is extremely satisfying for every doctor because it is associated with a lot of emotions and adrenaline. We care for and support two lives at the same time – that of the mother and the baby in the most exciting and meaningful moment for every woman, namely – the moment when we give birth to a new life. There is nothing better than wiping the tears of happiness from the face of the mother who has just touched her long-awaited child. These are extremely emotional and personal moments that I am fortunate to share with mothers, and now with fathers, who are also increasingly present during childbirth.

What is epidural anesthesia and how does it work?
-Epidural anesthesia is the gold standard for pain relief during normal childbirth. Why is it the gold standard? – the application of this regional anesthesia blocks this severe pain while simultaneously preserving consciousness, motor functions and, most importantly, the preserved sensation of contractions. Thanks to epidural anesthesia, patients feel contractions all the time and can move in the delivery room, which allows their active participation in the birth process. Epidural anesthesia is administered once or at intervals, through a catheter that is placed by experienced anesthesiologists in the epidural space of the spine outside the dura mater. I apply interval epidural anesthesia, in keto the medications and their dose are infused according to the needs of the woman in labor and according to the stage of the birth process completely individually through the previously placed thin catheter. This blocks pain receptors while preserving sensation for contractions and movement, so that women can give birth much easier, without side complications and with many positive emotions. In a normal birth without epidural anesthesia, women in labor are so exhausted from the severe pain that they are unable to enjoy this very precious moment.

Are there any situations in which it cannot be used?
- Most often in patients who have spinal curvature or trauma or suffer from rare blood diseases leading to excessive bleeding. Therefore, I always recommend an anesthesiologist consultation so that an examination can be performed and the patient's history can be taken.

How long does the anesthetic take to work and how is it controlled?
- Analgesia occurs 15-20 minutes after the epidural anesthetic is used and with subsequent interval administration of the medication, it can last up to 48 hours after the catheter is placed, i.e. The period after the birth of the fetus, when the placenta is expelled and minor surgical interventions such as suturing after an episiotomy (cutting the tissues around the vagina) are often required, is also covered and is not painful.

Are there any risks for the mother and baby?
- Like any medical intervention, the placement of an epidural carries risks:

• Infection – that's why we work in a strictly sterile environment so that this risk can be minimized;
• Low blood pressure, low heart rate;
• Headache, nausea; reduced sensitivity and motor function of the lower extremities;
  • Allergic reaction;
    • Scientific articles have described very rare cases of hematomas around the nerves, which in the worst case could even cause paresis. In my many years of experience, I have never seen such a complication. We use the thinnest possible needles and insert the catheter using an atraumatic method.

Is it painful?
-I wouldn't say it's painful, more like a short-term burning and pinching sensation at the site where we first apply local anesthetic. The subsequent insertion of the catheter itself is not felt and does not hurt.

Can the mother feel the contractions and push effectively?
-Yes, this is the biggest advantage of this type of anesthesia. Not only does the mother feel the contractions, but she can also experience all the excitement and joy of giving birth without severe pain and stress.

What are the most common myths about epidural anesthesia and what is the truth behind them?
- One of the myths is that the woman in labor cannot move after the epidural catheter is inserted. On the contrary, movement is very important for the fetus to descend faster to the vagina.
Another myth – epidural anesthesia prolongs the birth process. When the epidural anesthesia is inserted in the early period of labor, when the cervix is ​​3–4 cm dilated, the woman in labor does not become exhausted, she can concentrate better and correctly follow the instructions of her obstetrician-gynecologist colleagues. This increases safety for the mother and baby and does not prolong the delivery.
The experience of the anesthesiologist is of great importance here - the right dose at the right time.

How do you manage to create peace and trust in women who are often scared and tense?
- With professionalism and a friendly attitude, I have always managed to calm my patients. It is good to have a pre-anesthesia consultation in order to get to know the anesthesiologist and the woman in labor, to create a relationship and trust between the two parties. There should be no fear, because epidural anesthesia is an established method of pain relief during normal childbirth and has been used for more than 50 years.

Are there any examples from your practice that show how much of a difference epidural anesthesia brings to the birth experience?
- Every birth with epidural anesthesia that I have witnessed has been associated with much less stress and pain for the mother, so that immediately after birth she has the strength to hug her child. The early bond between mother and baby, the so-called Bonding, is very important for the mental and physical health of mother and child and has been scientifically proven to reduce the risk of postpartum depression. It positively influences and regulates the hormonal balance in mother and baby, leading to the natural release of endorphins and oxytocin in the mother.

In your opinion, what is the most important thing a woman should know before making a decision?
- Birth is one of the most unforgettable moments in a mother's life and should be experienced as positively as possible. When you reach the point where the pain and fear become overwhelming, seek the help of the anesthesiologist. This is the right time to have an epidural.

What is your personal opinion and how do you see the role of epidural anesthesia in modern obstetrics?
- Epidural anesthesia is an indispensable part of modern obstetrics. A large Scottish study has already shown that it significantly reduces the risk of serious complications for the mother after childbirth. The study included 567,216 women who gave birth vaginally or by unplanned caesarean section between 2007 and 2017 in public hospitals. 125,024 women – more than one in five – received epidural anesthesia during childbirth. These women had significantly fewer severe complications following childbirth up to 42 days after birth compared to women without epidural anesthesia. The absolute risk was reduced by more than a third (35%). The absolute risk of serious illnesses requiring intensive care was reduced by more than half (54%). The significantly lower risk of severe complications following childbirth is particularly evident in women for whom the epidural was medically necessary (e.g., hypertension during pregnancy) and in women with preterm births.

What should a woman know before trusting an anesthesiologist?
- Ask all your questions and share your concerns during the pre-anesthesia consultation. This is the only way we can help you and reassure you so that you feel as confident as possible that you have chosen the right anesthesiologist.