Epidural Leaflet

Epidural Leaflet

An Epidural is usually the most effective method of pain relief during labour that we can offer. This can only be provided by an anaesthetist, who is a doctor that is specially trained to give anaesthetics and pain relief. 

What is an epidural?

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.

How does an epidural work?

• 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 transmit pain sensation from areas such as your womb, cervix and vagina.
• At Worcestershire Royal Hospital a system called PCEA (patient controlled epidural analgesia) is used. This means you have a button to press which tells the pump to deliver a set dose of painkiller through the epidural tube. You should then have more control over how much drug you give yourself and so the opportunity to reduce side effects such as heavy legs.
• It also means that you should be more aware of your contractions and be able to move around in bed to deliver in the position of your choosing.

Who can have an epidural?

• 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) but we will usually have discussed these cases in the antenatal anaesthetic assessment clinic before you are in labour.
• 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.

When can you have an epidural?

• Once your midwife or obstetrician has confirmed that you are in established labour you may request for an epidural to be sited.
• Epidurals are only given on Delivery suite as you will need additional monitoring.
• An epidural can take up to 30 minutes after it has been sited to give you any 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. This means the risks of having an epidural very late in your labour may outweigh any benefit you receive.

Who will give you an epidural?

• A specialist doctor who has been specially trained to position epidurals for labouring women will do this for you (An anaesthetist). We always have an anaesthetist available 24/7 on delivery suite, if they are busy, we can contact other anaesthetists to come and site an epidural, there may be a short delay if this occurs, we will offer you additional pain relief in the meantime.

How is your epidural inserted?

• 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)).
• 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 possible that the plastic tube may 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 only 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 controls 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.

What can you expect from your epidural?

• 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 your anaesthetist is unable to make the epidural work, it may be that he/she suggests removing it and putting another one in; this will only be after discussion with you.
• As well as giving you pain relief, epidurals will make your legs feel heavy. This heaviness may well 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. 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 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.

What are the benefits of an epidural?

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

1. If required, an epidural can be used to make you completely numb if you need either a caesarean section or forceps assisted delivery.
2. They can have even greater benefits for people with heart and lung disease or if your blood pressure has been difficult to control (e.g. Pre-eclampsia). These can be discussed with your anaesthetist.
3. 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).
4. Compared to when you use drugs like pethidine or morphine for pain relief in labour, there is less need to use medication to stimulate your baby to breathe and less acid in your baby’s blood after delivery.

What are the side effects?
These are mostly predictable and will affect different people to a variable extent. They include:

1. Dizziness and sickness caused by a fall in blood pressure (this often only lasts for a few minutes after the initial dose or when a larger drug dose is given through the epidural)
2. Itching (can last for several hours after stopping the epidural)
3. Heavy, tingling legs (disappears soon after epidural stopped)
4. 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 either when your bladder is empty or as soon a sensation returns)
5. Increase in temperature. This may occur as your labour progresses and can cause distress to your baby. If it does occur it is usually easily treated with regular paracetamol.

Are there any complications?
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 (e.g. 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 1000 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 Ventouse/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.

Other side effects 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 moment and are reviewed at regular intervals.

Before you have an epidural your anaesthetist will go through any advantages, common side effects and serious potential complications. For further information see the resources below.

Epidural analgesia – Labour Pains

Epidural – NHS

The Myths about Epidurals!

1. 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.

2. 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.

3. 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 an epidural but probably deliver before getting any benefit from pain relief.

4. You will not be paralyzed by an 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 labouring 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.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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