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Epidural in childbirth

Epidural analgesia stops you feeling pain without putting you to sleep. It's usually given at the start of a vaginal delivery (childbirth).

Epidurals are also used for the treatment of chronic back pain and sciatica (shooting pain down one or both legs) and for pain relief during and after surgery, but these won't be discussed here.

Your care will be adapted to meet your individual needs and may differ from what is described here. So it's important that you follow your anaesthetist's advice.

  • About epidural in childbirth
  • How does an epidural work?
  • What are the alternatives?
  • Preparing for your procedure
  • About the procedure
  • What to expect afterwards
  • What are the risks?
  • Further information
  • Sources
  • Related topics

About epidural in childbirth

Local anaesthetic and/or pain relief medicines are injected into your lower back, just above your waist. This means you probably won't be able to feel anything in your abdomen or the tops of your legs.

Epidurals are usually very effective but take about 30 minutes to work. If you have an epidural, your second stage of labour (childbirth) may take longer because you won't feel the urge to push. It may also make moving around more difficult because you have less feeling in your back and legs.

How does an epidural work?

The spinal cord runs through a channel formed by the vertebrae and is surrounded by three protective membranes called the meninges.

The spinal cord carries signals, in the form of electrical impulses, between the brain and the network of nerves that branch outwards from the spine to all parts of the body.

At each level of the spine, main nerves join the spinal cord from specific parts of the body. For example the nerves from the lower part of the body join the spinal cord in the lower back.

The epidural space surrounds the outermost membrane of the spinal cord. Injecting local anaesthetic into the epidural space in the lower back blocks feeling in your abdomen and the tops of your legs. Your anaesthetist can control how much feeling is lost, depending on the amount and type of medicines used. Even a caesarean delivery can be done with an epidural.

What are the alternatives?

There are several other methods of pain relief that you can try if you don't wish to use an epidural. Talk to your midwife about these and ensure that you are aware of the risks and benefits of each.

Gas and air (eg Entonox)

This is a mixture of nitrous oxide and oxygen. As you feel a contraction starting, you breathe it in through a mouthpiece or a mask placed over your nose. It's a mild painkiller and will probably make your contractions less painful, although not all women find it effective.

Opiates

These medicines include diamorphine and morphine. They are stronger and very effective at relieving pain but can make you feel sick or dizzy. Opiates can also make your baby feel sleepy and sometimes can temporarily reduce your baby's ability to breathe at birth.

TENS (transcutaneous electrical nerve stimulation) machine

Two electrodes are placed on your back and electrical impulses are sent to the nerves to block the perception of pain going from your womb to your brain.

Preparing for your procedure

Your anaesthetist will explain how to prepare for your epidural. An epidural may not be suitable for you if you have a blood clotting problem or any condition affecting your nervous system or lower back. You must tell your anaesthetist if you are taking blood-thinning medicines such as aspirin, warfarin or clopidogrel.

You may be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

About the procedure

You will be asked either to lie on your side, with your knees drawn up to your tummy and your chin tucked in, or to sit up on the bed and lean forward. Both positions open up the space between the vertebrae.

Your anaesthetist carefully selects a point to inject by feeling for specific bones in the spine and hips. He or she may mark this site with a pen to show where to put the injection. A small amount of local anaesthetic is injected into your skin.

When the skin is numb, a larger epidural needle is passed into the epidural space. When the needle reaches the correct spot, a fine plastic tube (cannula) is inserted through the centre of the needle. The needle is then removed and the cannula is left running from the epidural space to the outside.

The cannula is held in place with adhesive tape. Your anaesthetist uses the cannula to inject local anaesthetic and/or other pain relief medicines directly into the epidural space. Your anaesthetist may attach a pump to the cannula so that you can have a top up as and when needed. You may be allowed to control the pump yourself. This is called patient-controlled analgesia or PCA.

It's very important to stay still while your anaesthetist is preparing the site for the epidural injection and especially whilst the epidural needle is being inserted as any movement makes positioning the needle more difficult.

When the need for pain relief has passed, the cannula is carefully withdrawn and the area covered with a plaster.

What to expect afterwards

Effects of an epidural can wear off completely within two hours or with top-ups last for several hours.

What are the risks?

An epidural is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side-effects

These are the unwanted, but mostly temporary effects of a successful procedure. Common side-effects are listed here.

  • Backache. The epidural relaxes your back muscles and because of this you may develop back pain after giving birth. You are more likely to develop back pain if you have back pain before or during pregnancy, give birth to twins or if your work involves heavy lifting.
  • A drop in blood pressure. Your blood pressure will be checked frequently. If it drops, you may be given medicines to correct it.
  • Loss of strength or control of leg muscles. This wears off with the anaesthetic.
  • Difficulty in passing urine. You may need to have a catheter fitted to help drain your urine until the effects of the epidural wear off.
  • Itchy skin. This is an allergic reaction and your anaesthetist will change the medicine to deal with this.

Complications

This is when problems occur during or after the procedure. Most women are not affected. With any procedure involving anaesthesia there is a very small risk of an unexpected reaction to the anaesthetic. Complications specific to epidural are uncommon but can include the following.

  • Headache. The epidural may puncture the membrane covering the spinal cord and fluid can leak out. This puts pressure on the surrounding nerves causing headaches. These can last up to a week or maybe longer.
  • Bleeding. A blood vessel may be damaged and cause bleeding into the spinal cord. This may require careful observation in hospital.
  • Assisted birth. You may find it difficult to push. It's possible that forceps, a ventouse or some similar assistance may be needed to help you give birth.
  • Infection. This is very uncommon because the skin is cleaned before the (sterile) needle is inserted. If you develop an infection, drainage of the infected area and antibiotics may be necessary.
  • Long-term numbness. You may have patches of numbness lasting up to three months. Permanent damage, such as paralysis (complete loss of sensation and movement) is extremely rare.

The exact risks are specific to you and differ for every woman, so we have not included statistics here. Ask your anaesthetist to explain how these risks apply to you.

Further information

National Institute for Health and Clinical Excellence (NICE)

Royal College of Obstetricians and Gynaecologists

Sources

  • Findley I, Chamberlain G. ABC of labour care: Relief of pain. BMJ 1999;318:927-930
  • Visser L. Epidural Anaesthesia. World Anaesthesia Online. www.nda.ox.ac.uk/wfsa, acessed 27 February 2008
  • Rodgers A, Walker N, Schug S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321:1493-1497
  • Howell CJ, Dean T, Lucking L, et al. Radomised study of long term outcome after epidural versus non-epidural analgesia during labour. BMJ 2002;325:357-580

Related topics

Local anaesthesia and sedation

Giving birth vaginally

Caesarean delivery