According to the Royal College of Midwives, 30% of women have an epidural during labour. Here, we look at what an epidural is, how to get one, and the risks and side effects.

What is an epidural?

An epidural is a procedure for pain relief in labour or childbirth. It involves an injection in the back to insert a very thin flexible tube, down which local anaesthetic (numbing medication) and painkillers can be given. These can be given in lower doses for labour, or higher doses if needed for procedures (e.g. forceps, C-section).

Why might I need an epidural?

An epidural is a procedure for pain relief in labour and childbirth – so the main reason for needing one is to help with pain. Your pain is unique to you, so only you will know when you feel you need relief. You can ask for an epidural at any time, and your midwife and doctors will discuss it with you.

There are some women who may need an epidural as a medical recommendation, particularly if it is expected they will need another procedure in labour or childbirth (e.g. forceps, C-section). This is to try to pre-empt any problems and prepare as much as possible for a safe and healthy delivery. However, this will be discussed with you, and it remains your choice whether or not to have an epidural.

You must be in the appropriate location to have an epidural (hospital labour ward), have a cannula (IV drip) in place, and your baby must be monitored. If you would like an epidural, your midwife/doctors will need to organise these things before it can be administered.

How is an epidural given?

An epidural is put in by your anaesthetist, a doctor with many years of specialist training in this and other procedures.

The anaesthetist will ask you some background questions about your medical history, medications and allergies, and check your notes and results to ensure an epidural is appropriate for you —  they will also explain the risks and benefits of the procedure. There are some specific situations in which an epidural cannot be done (e.g. in women who have significant problems with blood clotting – see below).

To have an epidural, you must be in an appropriate ward/unit in a hospital – you cannot have an epidural at home or in a midwife-led unit or birth centre. You must have a cannula in place (IV drip), and your baby must be monitored.

An epidural is done with you either sitting up on the edge of a bed/couch (more common) or lying on your side. You will need to be in a slightly curled-up slouched position to make the procedure easier. The doctor will find the right place on your back by feeling for your hip bones and the bones of your spine.

Your back will be cleaned with sterile liquid or spray, and a drape applied, to prevent infection. The doctor should talk the procedure through with you as it is happening – nothing should be a surprise! You should also communicate with the doctor, and if you have discomfort or a contraction during the procedure, let them know.

You will get a small injection to the skin at the start – this is a local anaesthetic, which numbs the skin, so the actual epidural needle itself won’t hurt (although it may feel like pushing or pressure on the back). Epidurals should not be painful but may be a little uncomfortable.

The doctor then passes the epidural needle between the bones of the spine, and identifies the epidural space itself – this is a tiny space of less than one millimetre, found between the ligaments of the spine and the membrane lining of the nervous system. This is a delicate and technical procedure that needs precision – stay as still as you can, and communicate openly with your doctor if you feel uncomfortable or have a contraction. Your midwife and birth partner can remain in the room throughout and can help you. A thin tube is passed through the needle and left in place. You might feel a brief tingling or electric shock sensation while the tube is positioned. The needle itself is removed – nothing sharp remains in your back!

The tube is then used to deliver local anaesthetic (numbing medication) and painkillers onto the nerves in the back. These nerves provide the sensation to the tummy, pelvic floor and legs, so discomfort in those areas should be relieved.

The procedure takes about 15 minutes to complete, and a further 15 minutes (approximately) for the pain relief to take effect.

What happens once the epidural is in?

Your pain will be assessed by your midwife or doctors regularly. Top-ups of medication will be given down the epidural tube regularly based on your level of discomfort. Sometimes this is done by the midwife (e.g. giving a dose each hour) and sometimes by you, with a hand-held button that delivers a dose (patient-controlled epidural analgesia, PCEA).

You should notice your contraction pain improves markedly, but you might still feel tightenings. As your baby descends later in labour, you might notice increasing discomfort in your lower back and bottom. This is common, and nothing to be concerned about – epidurals often work less well for this stage of labour.

Your vital signs (heart rate, blood pressure, breathing) will be monitored. Your baby will also be monitored.

You should still have movement and feeling in your legs, and some women are able to get out of bed and move around with an epidural in place. However, some women prefer to remain in bed and rest. You may be less able to feel your bladder and as a result may struggle to urinate. Your midwife might need to put in a catheter (tube into your bladder) to help with this.

There is a lot of information about “walking” or “mobile” epidurals. Whilst initially you may feel able to stand and mobilise, all epidurals need to be topped up with pain relief as labour progresses. With successive top-ups, your legs will become heavier and you will be able to move less.

If you need a procedure like a forceps delivery or a C-section, your doctors might use the epidural to provide pain relief for these, using a much stronger dose. This will be discussed with you. After your baby is born (whether vaginally or by C-section) your epidural is usually removed.

Are there reasons I can’t have an epidural?

The following things will prevent you having an epidural:

• Major abnormalities of blood clotting that cause you to bleed more easily than normal (including some anti-clot medications)
• Infection of the skin on the back where the epidural needs to be put
• Serious allergy to drugs used in the epidural (local anaesthetics, opioids)

The following things will make an epidural more tricky or risky, but still possible (after review by a doctor):

• General infection elsewhere in the body (especially sepsis)
• Significant scoliosis, or other changes to the shape of the spine
• Previous spinal surgery
• Spina bifida

It may be that the baby is coming faster than the anaesthetist is able to perform an epidural — in this situation, it may not be possible to get the epidural in before labour is over.

Is an epidural safe?

Epidurals are very safe. The overall risk of serious problems for mother or baby is extremely low. The important epidural risks and side-effects are outlined below, and your anaesthetist should go through these with you prior to putting in your epidural.

Common side effects of an epidural are shivering or a mild fever. Epidurals do not cause backache. This is usually related to pregnancy and the positions of labour itself. The following epidural risk list is adapted from the Epidural Information Card (2008) available from the website of the Obstetric Anaesthetists’ Association (OAA). Your local maternity hospital may have slightly different statistics. Ask your anaesthetist if you wish to discuss them.

Risk or Side Effect	Chances of this happening	Is it common or rare?	Possible treatment
Epidural not working well enough to reduce labour pain	One in 8 women	Common	Oral or injected painkillers
Epidural not working well enough for C-Section	One in 20 women	Occasional	Spinal anaesthesia, or general anaesthesia
Significant drop in blood pressure	One in 50 women	Occasional	IV fluids or other drugs to support blood pressure
Severe headache	One in 100 women	Uncommon	Painkillers, maybe a “blood patch” (another kind of injection in the back)
Nerve damage (numb patch on foot or leg, or weak leg)	Lasting less than 6 months (temporary): one in 1000 women lasting more than 6 months (permanent): one in 13,000 women	Rare	Follow up and review by senior anaesthetist
Epidural abscess (infection)	One in 50,000 women	Very rare	Antibiotics, may need draining via surgery
Meningitis	One in 100,000 women	Very rare	Antibiotics
Epidural haematoma (blood clot)	One in 170,000 women	Very rare	May need draining via surgery
Accidental unconsciousness	One in 100,000 women	Very rare	Supportive care by senior anaesthetist
Paralysis or severe injury	One in 250,000 women	Extremely rare	Follow up and review by senior anaesthetist

 

Recovering from an epidural

There is minimal “recovery” required with an epidural and you should feel well and normal in yourself.  However, if the epidural medication made your legs feel slightly numb, or weak (especially if you had an extra-strong epidural dose for forceps or C-section), you will need to wait for this effect to wear off gradually. This normally takes a few hours, after which time everything should return to normal. Be extra careful getting out of bed after your epidural. The sensation to your bladder may take longer to return and most urinary catheters are left in place for 12 hours. The skin around the epidural site may be a bit tender for a day or two afterwards.

Main Points

• An epidural is used for pain relief in childbirth. Local anaesthetic is administered through a thin tube which is inserted into the back.
• Higher doses of anaesthetic can be given for procedures such as a caesarean section.
• The procedure is quite common – about one third of women will have an epidural in labour.
• You must have an epidural in a hospital in an appropriate ward and have a cannula in place. The baby must also be monitored.
• The procedure will be carried out when you are either sitting in a slouched position at the edge of the bed or lying on your side.
• Before the tube is inserted, you will have an injection to numb the skin. The epidural needle itself should not hurt.
• It’s important to stay as still as possible while the doctor inserts the epidural needle so that it is easier for them to identify the epidural space.
• The thin tube is passed through the needle, and then the needle is removed.
• The procedure takes 15 minutes to complete and roughly another 15 minutes to take effect.
• Top-ups of medication will be given down the tube based on your level of discomfort. If patient-controlled epidural analgesia (PCEA) is used, you control the dosage with a handheld button.
• Because the tube delivers local anaesthetic to the nerves in the back, the epidural should help improve your contraction pains, but it’s normal to still feel some discomfort in your lower back and bottom as the baby descends during later labour.
• During an epidural, your heart rate, blood pressure and breathing will be monitored.
• It normally only takes a few hours for the numbing effect of an epidural to wear off.
• You can ask the doctors or your midwife for an epidural at any time.
• An epidural may be medically recommended if you’re expected to undergo a forceps delivery or C-section.
• There are some conditions that will mean it’s not safe to use an epidural. Your anaesthetist will ask you questions to determine whether the procedure is appropriate for you.
• Epidurals are overall very safe, and the risk of serious problems for the mother and baby are very low.

References

* Pain and epidural use in normal childbirth, Denis Walsh PhD MA, RN,RGN, 2009