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Epidural anaesthesia

Introduction

Epidural anaesthesia, often referred to as an epidural, is an injection into a person's back that numbs either the upper or lower half of the body and stops pain being felt.

The areas that can be numbed by an epidural include the:

  • chest (thoracic area)
  • abdomen
  • pelvic area
  • legs

How an epidural works

During an epidural, an anaesthetist uses a fine needle to carefully inject anaesthetic medication into an area of the spine known as the ‘epidural space’. An anaesthetist is a doctor who has been specially trained to provide pain relief during surgical procedures.

The anaesthetic works by blocking the nerve roots in the spine that lead to the lower part of the body. The extent of the numbness will depend on the type of anaesthetic that is used and the amount injected. Once the medication has worn off, the feeling in the affected areas will return.

Read more about how an epidural is performed.

When is an epidural used?

An epidural can be used to provide pain relief in a number of different situations including:

  • during natural childbirth
  • during a Caesarean section - where a baby is delivered through a cut that is made in the abdomen
  • after surgery that has been carried out under general anaesthetic (where you are given medication to make you unconscious)

Read more about why an epidural is used.

This topic focuses mainly on having an epidural during labour and childbirth.

Safety

Epidurals have been routinely used for many years and are widely accepted as an effective method of providing pain relief after surgery and during labour and childbirth.

However, as with many medical procedures, there are some associated risks that, although small, you should be aware of before deciding whether to have an epidural. Two possible risks include:

  • puncture of the dura - the dura is the thickest, outermost layer that surrounds the spinal cord and brain; the risk of the dura being punctured is about 1 in 100 
  • infection - which can very rarely occur in the weeks following an epidural; the risk of this occurring is about 1 in 47,000

Read more about the complications of an epidural.

Effectiveness

Although epidurals are commonly used to provide pain relief, they are not always effective at reducing labour pain. The Obstetric Anaesthetists Association estimate that 1 in 8 women who have an epidural during labour need to use other methods of pain relief.

Read more about the side effects of an epidural.

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What is it used for?

An epidural is a type of local anaesthetic, which means that it can be used to completely block pain when you are awake.

This has the advantage of allowing you to avoid the common side effects of general anaesthetic, such as feeling sick and dizzy.

Epidural anaesthesia can be used to numb sensation and provide pain relief in a number of situations including:

Epidurals are most commonly associated with being used to reduce pain and discomfort during labour and childbirth. This topic focuses mainly on this use of epidural anaesthesia.

Labour and childbirth

Some women decide to have an epidural during labour and childbirth. Your midwife will be able to advise you about having an epidural and whether they think it is necessary. However, remember that the final decision will be yours.

An epidural is usually recommended to help relieve pain during:

  • a particularly painful, complicated or prolonged labour
  • the delivery of twins or triplets
  • Caesarean section delivery
  • an assisted delivery – where the use of forceps is required
  • a ventouse delivery – where a suction cap is attached to the baby's head to help with the delivery

Read more about pain relief during labour.

Mobile epidurals

Mobile epidurals, also known as walking epidurals, are low-dose epidurals that are often used during labour. A small amount of local anaesthetic is used in combination with painkilling medication.

As your nerve sensations will not be completely blocked, a mobile epidural provides pain relief without as much of the numbness or heavy-legged feeling that is experienced during a full epidural.

Another advantage of having a walking epidural is that you will be able to feel the contractions and the need to push during the final stages of labour.

As you will still have some sensation in your legs, you will also be able to move around if you need to, although it is not always recommended.

When epidurals are not used

In some, rare cases, an epidural is not recommended. For example, it may not be suitable if you:

  • are allergic to local anaesthetic
  • you are taking medication to thin your blood, such as warfarin
  • have a blood-clotting abnormality that increases your risk of developing a haematoma (a collection of blood within the tissue).
  • have previously had back surgery, or you have other problems with your back
  • have a spinal deformity or severe arthritis in your spine
  • have a neurological condition that affects your nervous system, such as spina bifida
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How is it performed?

If you choose to have an epidural, the procedure will be carried out by an anaesthetist. An anaesthetist is a doctor who is specially trained in providing patients with pain relief during medical procedures.

Having an epidural

Nowadays, most epidurals are given while the patient is sitting down and leaning forwards. Alternatively, an epidural can be carried out while you are lying on your side with your knees drawn up and your chin tucked in.

Lying or sitting in these positions opens up the spaces between the vertebrae (bones of your spine) and allows the epidural needle to be passed through them into the epidural space. This is the area in your back that is close to your spine, through which the nerves from your spine to your body pass.

Before the epidural needle is inserted, a sterilising solution, such as alcohol or a solution that contains iodine, will be rubbed into your back. Sterile drapes will be placed over your back, leaving the injection site exposed.

You will have an injection of local anaesthetic to numb the area where the epidural anaesthetic is to be given, which helps to reduce any discomfort. A hollow needle is inserted into the numbed area and an epidural catheter, which is a thin, plastic tube, is passed through the middle of the needle and into the epidural space. The epidural anaesthetic is then injected through the tube.

If you are having an epidural during childbirth, you will need to have a drip in your hand so that medication can be given to help prevent low blood pressure. The drip may restrict you from moving around freely.

Effects of an epidural

While you are having an epidural, you may experience a brief stinging sensation while the local anaesthetic is being given and some slight discomfort in your back when the epidural catheter is being inserted.

As the epidural catheter is inserted, you may experience some pain or an electric shock-like feeling. If you do, tell your anaesthetist because the epidural catheter may be pressing up against the root of a nerve in your back and may need to be repositioned by the anaesthetist.

Shortly after having an epidural you will start to experience a warm, numbing sensation in your lower back and your legs may feel heavy and be difficult to move. It usually takes about 20 minutes for the epidural to take full effect.

The nerves in your bladder are also likely to be affected by the anaesthetic, which means that you won't know when your bladder is full and whether you need to go to the toilet. Therefore, a thin plastic tube (catheter) will be used to drain urine from your bladder instead.

Read more about the side effects of an epidural.

After having an epidural

Following epidural anaesthesia, you will probably be advised to rest in a lying or a sitting position until the feeling in your legs returns.

It usually takes a couple of hours for the feeling to return your legs. As the feeling returns, you may experience a slight tingling sensation on your skin as the anaesthetic starts to wear off. You may need some help getting out of bed.

If you start to feel any pain, you should tell the doctor or nurse who is treating you. They will be able to give you medication to help control it.

After having an epidural you will be able to breastfeed your baby.

How long does an epidural last?

Epidurals are commonly used for longer operations and procedures. The anaesthetic usually lasts for a few hours before its effects begin to wear off and the feeling starts to return.

Sometimes, the epidural catheter will be left in throughout the procedure so that more anaesthetic can be given as and when it is needed.

The catheter can be connected to an automatic pump to allow the medication to be continuously topped up. Pumps that allow you to control the dose of analgesia are also sometimes used.

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Side effects

There are several potential side effects that can occur after having epidural anaesthesia.

Low blood pressure

Low blood pressure (hypotension) is the most common side effect that is associated with having an epidural. This is because the local anaesthetic that is used affects the nerves that go to your blood vessels, resulting in a fall in blood pressure.

Therefore, your blood pressure will be closely monitored while you are having an epidural. If necessary, medication can be passed through a drip to treat low blood pressure.

Pain and discomfort

It is likely that you will experience some slight discomfort when medication, such as local anaesthetic, is injected.

Sometimes, it is also possible for an epidural to be unsuccessful or for the pain relief to be inadequate. For example, this might occur if:

  • it proves difficult to fit the epidural catheter (the thin, flexible tube through which the anaesthetic is injected)
  • the local anaesthetic does not spread evenly around the epidural space
  • the catheter falls out

If you have an epidural that fails to work effectively, there are other types of pain relief available.

Loss of bladder control

After having an epidural, you will not usually be able to tell whether you need to pass urine. This is because the epidural affects the nerves around your bladder.

You will therefore have a catheter inserted into your bladder to allow urine to be drained away when your bladder is full. Your bladder control will return to normal as soon as the epidural wears off.

Itchy skin

Sometimes, the painkillers that are combined with local anaesthetic and given during an epidural can cause itchiness. If you develop itchy skin it can usually be effectively treated using antihistamines (anti-allergy medicines).

Sickness

You may feel sick (or actually be sick) after having an epidural. However, you are less likely to experience this side effect than after having a general anaesthetic. If you do feel sick, anti-sickness medicines will usually help.

Backache

A study that was carried out in 2010 found that there is no increased risk associated with the use of epidural anaesthesia and long-term backache.

Your epidural care team will try to ensure that you are lying in a comfortable position during and after the procedure, but being in the same position for a prolonged period may inevitably make existing backache worse.

If you experience severe backache in the weeks following an epidural, you should report your symptoms to your care team as soon as possible so that they can investigate the problem.

The Yellow Card Scheme

The Yellow Card Scheme allows you to report suspected side effects from any type of medicine that you are taking. It is run by medicines safety watchdog the Medicines and Healthcare products Regulatory Agency (MHRA).

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Complications

Epidural anaesthesia is usually a safe and reliable method of providing pain relief. However, as with most medical procedures, complications can sometimes occur.

Severe headaches

Following surgery, minor headaches are common. Occasionally, a more severe headache can develop after having an epidural. This is sometimes known as a post-dural puncture headache.

Post-dural puncture headaches are thought to be caused if the lining of the fluid-filled space that surrounds your spinal cord (dura) is accidentally punctured as the local anesthetic is injected into the epidural space.

During an epidural, local anaesthetic is injected just outside the dura. However, if the needle punctures the dura, the fluid inside will leak out, resulting in a fall in the pressure of the fluid that surrounds your brain and spinal cord. The decrease in pressure can lead to a persistent headache.

A procedure known as a 'blood patch' can be used to seal up the hole. It involves taking a small sample of your own blood and injecting it into the epidural space. When the blood clots (thickens), the hole will be sealed and your headache will stop.

It should be noted that headaches that are caused by a punctured dura are uncommon following an epidural. There is just a 1 in 100 to 1 in 500 chance of it happening.

Infection

Infections are also a rare complication of an epidural, occurring in about 1 in 47,000 cases.

However, it is possible for an infection to develop at the site of the injection in the weeks following an epidural. This can lead to serious complications, such as the formation of an abscess (a painful collection of pus).

Measures will be taken before the epidural is given to prevent an infection developing at the injection site. These include:

  • using a sterile solution to clean the area of skin before the injection is given
  • using a sterile needle and catheter (thin tube) when carrying out the epidural

It is very rare for an infection to spread beyond the injection site.

Epidural haematoma

An epidural haematoma is a very rare complication of epidural anaesthesia, occurring in around 1 in 120,000 cases.

A haematoma is a collection of blood (a blood clot) that builds up in an organ, a tissue or space. It occurs as a result of a break in a blood vessel wall.

The epidural space is filled with a number of veins. If the veins are punctured, blood can build up within the epidural space. A build-up of blood can result in the formation of a haematoma, which can place pressure on your spinal cord.

This can lead to serious complications, such as paraplegia (complete loss of movement of the lower half of the body, including your legs). However, this further complication is also very rare.

Other complications

Other possible, although rare, complications of an epidural include the following:

  • fits (convulsions)
  • breathing difficulties
  • nerve damage

Before deciding to have an epidural, you should discuss the procedure with your anaesthetist (a doctor who is specially trained to provide pain relief during surgical procedures). They will be able to provide further information and advice about the risks of developing complications such as those described above.

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