Your spinal cord runs through a channel formed by your vertebrae (bones in your spine) and is surrounded by three protective layers of tissue called the meninges. A protective layer of fluid lies between two of these tissue layers (this is known as the cerebrospinal fluid or CSF). The area just outside all these layers is called the epidural space.
Your spinal cord carries signals, in the form of electrical messages, between your brain and the network of nerves that branch outwards from your spine to all parts of your body. At each level of your spine, nerves leave your spinal cord to go to specific parts of your body. For example, nerves from the lower part of your body join your spinal cord in your lower back.
Your anaesthetist will inject the local anaesthetic, through a catheter (small plastic tube) that’s been inserted into the epidural space in your lower back. This blocks the nerves in your spine that lead to the lower part of your body, stopping you feeling pain. The sensation will feel like you’ve got ‘pins and needles’. Your anaesthetist can control how much feeling is lost, depending on the amount and type of medicines used. Different people require different doses of anaesthetic. And because it works for a short period of time, your anaesthetist will top up the anaesthetic to provide lasting pain relief.
Your anaesthetist will discuss with you what will happen before, during and after your epidural. This is a good time to make sure you understand what will happen. Feel free to ask any questions you may have. Especially about the risks, benefits and any alternatives. This will help you to be informed, so you can give your consent for the epidural to go ahead.
An epidural isn't suitable for you if you have a blood-clotting problem. You must tell your midwife or anaesthetist if you're taking blood-thinning medicines, such as aspirin, warfarin or clopidogrel. An epidural may not be suitable for you if you’ve had an operation on your back. Ask your midwife or anaesthetist for more information.
Before your anaesthetist gives you an epidural, you will have a small tube (cannula) inserted into a vein in your hand or arm. You may have an intravenous drip set up too. This is used to give you fluids and medicines that you may need during labour. Your blood pressure and pulse will be monitored while your anaesthetist is putting in the epidural and at any time when the dose is topped up. Your baby will be monitored too, to ensure that he or she is safe during labour and birth.
There are several other methods of pain relief you can try if you don't wish to have an epidural. Talk to your midwife about the risks and benefits of these. Evidence shows that you're less likely to have an epidural if you're mainly cared for by a midwife during pregnancy and childbirth. However, this is only if you're at a low risk of complications.
- Combined spinal and epidural (CSE) anaesthesia. This involves an injection of a painkilling drug into your spine just before or after an epidural is put in place. It has the advantage of giving faster pain relief. Because you’re having an epidural, you’re still at risk of the side-effects and complications that can happen with an epidural.
- Gas and air (Entonox). This is a mixture of nitrous oxide and oxygen and is a mild painkiller. As you feel a contraction starting, you breathe the mixture in through a mouthpiece or a mask placed over your nose. It should make your contractions less painful. It can sometimes make you feel sick or light-headed for a short time.
- Opioid medicines. These are strong painkillers and include diamorphine, morphine and pethidine. Opioids are usually given by your midwife injecting them into a large muscle in your arm or leg. The pain relief is often limited and side-effects include making you feel sick, dizzy or very sleepy. Opioid medicines can also make your baby feel sleepy and can sometimes temporarily reduce your baby's ability to breathe at birth.
- Transcutaneous electrical nerve stimulation (TENS). Four electrodes are placed on your back and electrical impulses are sent to your nerves to block the pain signal going from your uterus (womb) to your brain. You can change the strength of the electrical impulses to help control your pain. There’s no strong evidence that TENS is effective at reliving pain in labour although some women may find it helpful.
You will be asked to lie on your side, with your knees drawn up and your chin tucked in. Alternatively, you may be asked to sit up on the bed and lean forward. Both positions open up the space between your vertebrae.
Your anaesthetist will carefully select a point to inject by feeling for specific bones in your spine and hips. Your anaesthetist will clean the skin on your back with a sterilising solution and give you an injection of local anaesthetic in this area. They will also cover your back in a sterile drape, with a square hole around the site of the epidural.
When your skin is numb, your anaesthetist will pass a larger, hollow needle into the epidural space. You may feel some pressure or a pushing sensation, but you shouldn’t feel any pain. When the needle reaches the correct spot, he or she will insert a fine plastic tube (catheter) through the centre of the needle. Your anaesthetist will then remove the needle and leave the catheter in place, running from the epidural space to outside of your body. The catheter is held in place with adhesive tape.
Your anaesthetist will use the catheter to inject local anaesthetic and other pain relief medicines directly into the epidural space. After 15 to 20 minutes, your anaesthetist will confirm that the epidural is working by checking how sensitive your legs are to cold, such as with a cold spray or using a pinprick.
Your anaesthetist may attach a pump to the catheter so that you can have a top-up as and when you need it. You may be allowed to control the pump yourself. This is called patient-controlled epidural analgesia or PCEA.
It's very important that you stay still while your anaesthetist is preparing the site for the epidural injection. Especially while the epidural needle is being inserted. Any movement makes positioning the needle more difficult. When you no longer need any pain relief, the catheter is carefully withdrawn and the area is covered with a plaster.
When you no longer need any pain relief, the catheter is carefully withdrawn and the area is covered with a plaster.
After an epidural, you will need to rest until the effects of the anaesthetic have passed. You may not be able to feel or move your legs properly for a period of time after your epidural. This is normal but different for everyone. Your anaesthetist will monitor you closely to make sure the feeling in your legs return. It will also be difficult for you to pass urine while the epidural is still working so your catheter will remain in until the effects have worn off.
Epidurals are 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.
These are the unwanted, but mostly temporary effects of having an epidural. Common side-effects are listed here.
- Feeling dizzy or shivery.
- A drop in blood pressure. Your blood pressure will be checked regularly. If it drops, you may be given fluids or medicines to raise it back to normal.
- Loss of strength or control of your leg muscles. Your muscle strength will return with time after the epidural has been stopped.
- Difficulty passing urine. You may need to have a catheter fitted to drain urine from your bladder into a bag, until the effects of the epidural wear off.
- Itchy skin. This may happen with some medicines and your anaesthetist will change your medicine to deal with this.
This is when problems occur during or after the epidural. Most women don’t have any complications. However, with any procedure involving anaesthesia there is a very small risk of an unexpected reaction to the anaesthetic. Complications specific to an epidural are uncommon but can include the following.
- Headache. The epidural needle may puncture the membrane covering your spinal cord and fluid can leak out. This is called a dural tap, which can cause a headache. This happens to about 1 in every 100 women. Headaches can last for a number of days and may need further treatment. You may need an epidural blood patch, which means that some of your blood is taken and injected near to the puncture where it will clot and seal the hole.
- Assisted birth. You may find it difficult to push. It's possible that your doctor may need to use forceps, a ventouse (vacuum extraction), or some similar assistance to help you to give birth.
- Infection in your back. This is very rare because your skin is cleaned before the sterile needle is inserted. If you develop an infection, the catheter will be removed, the infected area will be drained and you will need to take antibiotics. If you develop a fever after you’ve returned home, this could mean you have an infection. Contact the hospital or your GP for advice about what to do next.
- Nerve damage. This can range from long-term numbness to permanent damage, such as paralysis (complete loss of sensation and movement).
As with every procedure, there are some risks associated with an epidural. The chances of these happening are specific to you and differ for every person. Ask your surgeon or anaesthetist to explain how they apply to you.
- An epidural gives good pain relief during labour for 95 out of 100 women.
- An epidural gives better pain relief than non-epidural pain relief.
- You may not need more analgesia/general anaesthetic if you need to have an assisted birth involving forceps, vacuum extraction or caesarean section. Although this isn’t always the case.
- An epidural is only available in birthing units so you will not be able to have an epidural if you’re having a home birth.
- If you have an epidural, you may not be able to move around easily during labour, although this depends on the type of epidural you have and the medicines used.
- You may not be able to feel the urge to push, and you may not be able to push effectively.
- An epidural can slow down your labour and you‘re more likely to need oxytocin to speed up the delivery.
- An epidural increases the chance of needing a vaginal instrumental birth – forceps or ventouse (vacuum delivery).
- If you have an epidural, you and your baby will need to be monitored more closely during labour. This may mean you can’t walk around easily.
- The medicines used for epidurals cross the placenta to the baby and may cause short-term breathing problems in the baby and make the baby drowsy.
Can I still push if I have an epidural during childbirth?
Yes, you can still push. But depending on the exact type of epidural you have, the epidural can make it difficult for you to feel when to push. The epidural may also affect how hard you can push.
An epidural won't stop you from pushing your baby out during delivery, but it will weaken your urge to push. This means you may find it difficult to feel when to push. The epidural may also relax the muscles in your pelvis, affecting how hard you can push. Because of this it may take longer for you to give birth. If your labour goes on for too long, it's possible you may become too tired to push.
Your midwife may suggest stopping the epidural when it's time to push. Stopping the epidural will help you feel the urge to push, but it also means you will begin to feel the pain of your contractions.
Your doctor may use forceps or a ventouse (vacuum extraction) to help you to give birth if you find it difficult to push hard enough. Forceps are like large tongs with curved ends that fit around your baby's head. Your doctor will pull gently on them while you push. A ventouse uses suction. A cup is placed on your baby's head and attached to a vacuum machine. The air is sucked out which attaches the cup strongly to your baby's head. Your doctor then pulls on the cup as you push.
Do I need to decide whether to have an epidural before I come to hospital, or can I decide as I'm giving birth?
No, you don’t have to decide before you go to hospital but it’s good to be informed about all the options. It's a good idea to talk to your midwife and make a birth plan early on in your pregnancy.
During your pregnancy you will have several check-ups with your midwife. It's a good idea to make a birth plan with your midwife during your pregnancy. This will help you decide how you would like your labour and birth to be managed and where you would like to give birth. The choices you make will influence whether an epidural is available when you give birth or not. For example, it's very unlikely that you will have access to an epidural if you have a home birth.
If you decide to give birth to your baby in hospital, you will have a wider choice of pain relief methods available to you. You can decide before you go into labour that you would like to have an epidural. Or if you're planning to have a natural birth, you can change your mind at any time during labour and ask for an epidural.
It's a good idea to discuss pain relief, including epidural pain relief, with your midwife before you come into hospital. This gives you an opportunity to find out what services your hospital offers and you can ask your midwife to explain the benefits and risks of having an epidural.
Will an epidural affect my memory of the birth or stop me from holding my baby immediately after birth?
No, an epidural won't affect your memory or stop you from holding your baby after birth.
An epidural involves injection of local anaesthetic and/or pain-relief medicines. These medicines will block pain in the lower part of your body, but shouldn't affect your memory. Immediately after the birth, your baby will usually be handed to you so that you have skin-to-skin contact if you wish. You may also want to put your baby to your breast.
Will I be able to see what the surgeon is doing during a caesarean delivery under epidural anaesthesia?
No, during the operation your abdominal (tummy) area is shielded from you, so you won't be able to see your surgeon perform the operation. However, you may be able to ask for the screen to be lowered to see your baby being born.
If you have a caesarean delivery under epidural anaesthesia you will stay awake during the operation. You won't feel any pain from your waist down, but you may feel some pushing or pulling during the operation.
You will be lying on your back during the operation. A raised sheet or shield is usually placed just below your breasts as a screen to hide your abdominal area from your view. However, you may be able to ask for the screen to be lowered to see your baby being born.
Your surgeon will usually ask your birth partner to sit beside you at the top end of the table. This means your birth partner won't be able to see the operation either.
Your surgeon will make a cut through your abdomen and carefully deliver your baby. Usually you will be able to see and hold your baby immediately after the birth. The raised sheet or shield will only be removed after your surgeon has closed your wound and dressed it.
Will an epidural cause me to have backache in the long term?
No, there is no evidence that epidurals lead to long-term backache.
The effect of an epidural is short-term and there is no lasting injury to your back. Therefore, there’s no reason why you will have long-term backache. Studies of women during labour found no difference in the incidence of long-term backache between women who had an epidural and those who did not.
Short-term backache after surgery is a common side-effect that happens to about one in 100 people. It may be caused by lying on a firm, flat operating table, but isn’t affected by the type of anaesthesia you have.
You may have some slight bruising or soreness where the needle was inserted. This usually settles without treatment.
If you have backache after your operation that gets worse, you need to contact your surgeon or the hospital where you had the operation. It’s very rare, but you may have an infection. This happens to less than one in 100,000 women. You would need to have the area drained and be treated with antibiotics.
Before you have an epidural you will have an opportunity to meet your anaesthetist and surgeon. They will explain how the risks and complications of your procedure relate to you.
- Pain relief in labour. PatientPlus. www.patient.co.uk/patientplus.asp, published 16 June 2014
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- Epidural nerve block. Medscape. www.emedicine.medscape.com, published 6 May 2013
- Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. doi: 10.1002/14651858.CD009234.pub2
- Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. doi: 10.1002/14651858.CD004667.pub3
- Intrapartum care: care of healthy women and their babies during childbirth. National Institute for Health and Care Excellence (NICE), September 2007. www.nice.org.uk
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- Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews 2012, Issue 10. doi: 10.1002/14651858.CD003401.pub3
- Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database of Systematic Reviews 2004, Issue 4. doi: 10.1002/14651858.CD004457.pub2
- Antenatal care: care of healthy women and their babies during childbirth. National Institute for Health and Care Excellence (NICE), March 2008. www.nice.org.uk
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- Important complications of anaesthesia. PatientPlus. www.patient.co.uk/patientplus.asp, published 25 June 2014
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