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An epidural is a small plastic tube that sits in the space surrounding your spinal cord. The plastic tube is fed through a needle placed in your back to make sure it is in the correct position and then the needle is removed, leaving only the plastic tube itself taped to your back.

A local anaesthetic called Bupivacaine and a very small dose of a morphine-like drug called Fentanyl are injected through the plastic tube and act by numbing the nerves which pass out from your spinal cord and travel to the areas causing pain such as your womb, cervix and vagina.

At Worcestershire Royal Hospital we use a system called PCEA (patient controlled epidural analgesia). This means you have a button to press when you require pain relief, giving you more control over how much drug relief you receive and the ability to try and reduce side effects such as heavy leg.

Generally, anyone can be offered an epidural once in labour.

There may be certain circumstances when an epidural is unsafe or impossible to administer (for example problems with blood clotting and bleeding) and in the majority of cases we will have discussed these cases in the antenatal anaesthetic assessment clinic.

If you would like any further information then you can discuss this with your midwife or obstetrician, who can then refer you to the anaesthetic clinic if appropriate.

Once your midwife or obstetrician has confirmed that you are in established labour you may request for an epidural to be sited.

An epidural can take up to 30 minutes to give you adequate pain relief in labour. There may come a point, late in your labour, when your midwife or obstetrician suggest that you may well deliver your baby before you get any benefit or pain relief from your epidural.

This means the risks of having an epidural very late in your labour may outweigh any benefit you receive.

A specialist doctor called an anaesthetist will give you an epidural. They have have been specially trained to position epidurals for labouring women and will do this for you.

The process of placing an epidural in your back for pain relief in labour should take approximately 15 to 20 minutes. It can take significantly longer than this if the procedure is difficult (for example increased weight or Body Mass Index (BMI) or if the epidural is being inserted late in your labour).

You will need a cannula or drip in your hand if you have not already had one sited. You will then be asked to either sit on the side of your bed or lie on your side. Your anaesthetist will prepare your back with antiseptic and numb your skin with a local anaesthetic injection - this will sting for a few seconds but once the skin is numb you should not feel anything more than pressure or mild discomfort in your back. It is common for the plastic tube to brush against nerves in your back as it is inserted; you may feel this as tingling or an 'electric shock' in your hip or leg. It should be a momentary sensation but you should still mention to your anaesthetist if it occurs.

Once your anaesthetist has confirmed the plastic tube is in the correct position, it will be stuck to your back with tape and you will be asked to lie back in bed. The tube will be connected to a pump and you will be given a button to press which you can use to control the amount of painkiller you receive through the tube.

Your midwife will then monitor your blood pressure and the baby at regular intervals throughout your labour.

In the majority of cases you will begin to feel pain relief within approximately 30 minutes of insertion. Occasionally epidurals either do not work at all or work partially in an unpredictable way. If this is the case your anaesthetist can attempt to get your epidural working by changing your position on the bed or by injecting extra doses of local anaesthetic through the epidural. Ultimately, it may be that your anaesthetist suggests removing it and putting another one in but this will only be after discussion with you.

As well as giving you pain relief, epidurals will make your legs feel heavy. This heaviness will often prevent you getting out of bed and may stop you moving around the bed. By using your button less frequently you may be able to reduce the heaviness in your legs and so increase your mobility. All epidurals can be 'Mobile' epidurals and if you wish, and it is safe to do so, then an epidural does not have to restrict you to bed. You can discuss this with your midwife or anaesthetist at the time.

Epidurals are available to you as means of pain relief during labour. The purpose of an epidural is not necessarily to remove all pain and sensation therefore reducing your ability to participate actively in delivering your baby, but to assist you in getting through your labour and delivering a healthy child.

The loss in sensation you feel will disappear very quickly after the epidural has been stopped.

Although not 100% reliable, epidurals are the most effective form of pain relief we have to offer you.

If required, an epidural can be used to make you completely numb if you need either a caesarean or forceps assisted delivery.

They can have even greater benefits for people with heart and lung disease or if your blood pressure has been difficult to control (eg. Pre-eclampsia). These can be discussed with your anaesthetist.

Patients are generally more satisfied with their pain relief in labour from an epidural compared to other methods such as pethidine or gas and air (Entonox).

These are mostly predictable and will affect different individuals to a variable extent. They include:

• Dizziness and nausea caused by a fall in blood pressure (this often only lasts for a few minutes after the initial dose or a larger drug dose is given through the epidural)
• Itching (can last for several hours after stopping the epidural)
• Heavy, tingling legs (disappears soon after epidural stopped)
• Inability to feel a full bladder and pass urine whilst epidural is working (may mean you need a catheter tube passed into your bladder whilst the epidural is working. This is removed as soon a sensation returns)

Some complications are less serious but may happen more frequently and include:

• Failure to give you adequate pain relief in labour. Your epidural may need to be removed and replaced before it works adequately.
• Failure to work well enough if a caesarean section is required so that you need a general anaesthetic
• (Approximately 1 in every 20 women having an epidural)
• Headache (Post Dural Puncture Headache)
• (Approximately 1 in every 100 women having an epidural)

An area of numbness that lasts longer than expected (eg. Days to weeks) (There is no convincing research to tell us how often these mild and short lived complications occur but they are probably in the region of 1 in every 2000 to 4000 women having an epidural). Effects that last longer than 6 months are much less common at approximately 1 in every 24,000 women who have an epidural.

Possibly more likely to require an assisted delivery (Forceps or a Venteuse/suction cap) if stronger drugs need to be used due to the epidural not working well enough. very weak painkiller is used in our epidurals so that a good balance between pain relief and side effects can be reached.

Others are VERY rare but CAN be serious such as:

• The local anaesthetic affecting your breathing and making you so drowsy that you need a general anaesthetic (Total Spinal)
• (There is no evidence to suggest how often this occurs but is very rare in the order of
• 1 in every 5000 women having an epidural)
• Infection around the spinal cord (Epidural abscess)
• (Approximately 1 in every 50,000 women having an epidural)
• Meningitis (infection around the spinal cord and brain)
• (Approximately 1 in every 100,000 women having an epidural)
• Blood clot within the epidural space (Epidural haematoma)
• (Approximately 1 in every 170,000 women having an epidural)
• Damage to spinal cord resulting in permanent disability
• (Approximately 1 in every 250,000 women having an epidural)

These figures are based on the best evidence we have available at the momentand will be reviewed at regular intervals. The main sources of information that have been used are listed in a separate section of the website under “References to Research evidence for how we practice”.

Before you have an epidural your anaesthetist will go through any advantages, common side effects and serious potential complications. For any more detailed information you can either discuss with an experienced anaesthetist in the antenatal assessment clinic and/or refer to the websites listed below which provide sensible and reliable advice and information for mothers.

There's a lot of myths about the reality of an epidural. For example:

• Epidurals do not increase the risk of you having a caesarean section. Some women who have epidurals need them because their labour is more complicated or the doctors and midwives looking after them feel that there is a very high risk of needing an assisted delivery or caesarean section. This means that epidurals may be used or in place in mothers who end up having caesareans but research has shown that epidurals are not the cause of needing the operation.
• Epidurals do not cause back pain. If you have pain in your back after going through pregnancy, labour and then delivering a baby, it is easy to blame a needle in your back if the pain is close to where the needle was inserted. There has been a lot of medical research into this and the conclusion is that epidurals do not produce new back pain or make existing back pain worse.
• You can have an epidural at any time from when your midwife confirms you are in established labour and your anaesthetist has established it is safe for you to have one. If you ask for an epidural at the end of your labour then your anaesthetist and midwife may advise you that you will probably deliver your baby before an epidural can be sited and give you any pain relief. This means you run all the risks of and epidural but probably deliver before getting any benefit from pain relief.
• You will not be paralyzed by and Epidural or spinal. Permanent, severe damage to nerves which results in paralysis of your legs is profoundly rare in pregnant women. This can occur by introducing infection or a very damaging drug through the epidural onto the nerves or the needle makes direct, painful and prolonged contact with the nerves.

We are very restrictive with which drugs are injected into epidurals and the training anaesthetists receive to enable them to position and inject epidurals cleanly and safely is intensive and thorough. A specific project looked at all the epidurals sited in the UK over a year and found that with more than 320,000 epidurals and spinals performed on laboring women, none died or were paralyzed by a needle in their back.

The number of times this problem occurs is SO rare that it is impossible to collect enough information to give accurate estimates of how often they occur. The rough estimate of 1 case of paralysis in every 250,000 epidurals hopefully gives the correct impression that this problem is VERY rare and we would hope that this would not put women off having epidurals for pain relief in labour.

Additional information about epidurals can be found on:

• NHS.uk