Epidural Anaesthesia

The following information about the use of an epidural for pain relief in labour will assist you to make an informed decision that is in line with your preferences and values. It’s important to learn about the benefits, risks and alternatives and to have a discussion with your healthcare provider to answer any questions before labour begins.

What is an Epidural?

An epidural:

• Is a procedure that provides medication into the epidural space around the covering of the spinal canal that blocks or numbs the nerves involved in labour pain.
• Will also numb the rest of your body from your waist to your toes. 
• Will relieve the pain caused by the contractions and stretching of the cervix and vagina but will not fully relieve the pressure feelings associated with the baby moving down through the pelvis.

The following are population level benefits and risks. It's important to speak with your healthcare provider to discuss how these may apply to your individual situation to make an informed decision for your care.

Benefits

Generally provides very effective pain relief.^{7 8 12} It can be very useful for a long labour where rest is needed. Can be used for assisted birth and caesarean section as the dose can simply be increased.

Risks for You and Your Baby:

• Epidurals block the motor nerves in your lower body, so you will not have the strength to stand or walk and will be restricted to bed for the remainder of your labour and birth.⁷ This restricts how much you are able to move around and change or choose positions to help labour progress.
• Your labour contractions may slow after an epidural and this may lead to further intervention called augmentation of labour to help your labour progress.⁷
• There is a 4 times greater chance that the baby's head will not be in the best position for birth (occiput posterior).¹⁰
• There is an increased chance that your baby will need to be born with the assistance of forceps or vacuum extraction⁸ (lower dose epidurals may decrease this risk¹²) or by caesarean birth for fetal distress.⁸
• Your blood pressure may drop suddenly^{7 8} which may make you feel dizzy or nauseous. This can also decrease the flow of oxygen to your baby and cause your baby’s heart rate to slow. An intravenous will be started prior to the epidural procedure to give you extra fluid to help prevent your blood pressure from falling or treat it if this happens.²
• Depending on which medication is used, you may feel itchy.^{2 8}
• You may need a catheter to empty your bladder when necessary as you won’t feel the urge to pee.^7 12 This procedure increases the risk of a urinary tract infection (bladder infection).

• Epidurals may occasionally not work as effectively as anticipated, and you may not have complete pain relief.

• You may feel shivery.²

• You may develop a fever.^{7 8 12} This may make your baby at risk of needing antibiotics and closer observation in the NICU.

• You may have a longer first and second (pushing) stage of labour.⁷

• Mild, temporary back pain from the insertion of the epidural needle. Sometimes multiple attempts are needed to find the epidural space.

• There is a between 1 in 100 and 1 in 500 chance that you may develop a severe headache.^4 12 This can happen if the epidural needle punctures the membrane containing the spinal fluid and some of the spinal fluid leaks out.⁴ This can be patched with some of your own blood after the baby is born.⁴ The patching may need to be done again to be effective.⁴

• There is a very small risk of nerve damage that may leave a numb patch or patches on your lower body, leg or foot or a sensation of pins and needles.^5 12 You may feel pain or muscle weakness.⁵ This is usually temporary.⁵
• Extremely rarely, infection.⁵

• The narcotic medication used in the epidural solution can cross the placenta and can make your baby drowsy and affect your baby’s breathing. The Neonatal Intensive Care Unit (NICU) Team will be called to the birth if the baby shows signs of needing assistance.²

• It may interfere with your baby’s ability to breastfeed after birth due to a diminished early suckling reflex^{3 6}  and drowsiness. For more information go to Rebecca Dekker's Evidence Based Birth Effect of Epidurals on Breastfeeding webpage.

Alternatives

There are a variety of effective coping techniques you can use to manage the pain you experience during labour.⁸ Comfort measures do not involve the use of medications for pain relief. They allow you to have a better sense of control, and can result in a shorter labour with fewer medical interventions. Using comfort measures to avoid unnecessary interventions also supports your birth hormones. This will help you to have a labour that feels less intense and progresses more quickly. It also sets you up for better breastfeeding success. There is also no risk for you or your baby. See our Comfort Measures webpage for more information.

Contraindications (Reasons why you may not be able to have an epidural)

Some women are not eligible to receive an epidural during labour. Epidural may be contraindicated if you:

• Have a bleeding disorder, low platelet count, and/or are taking anticoagulants (blood thinners).⁹

• Have an infection in the area of your lower back which is at risk of spreading if punctured.⁹

• Have certain back surgeries or brain or spine disorders.⁹

If you have a lower-back tattoo, direct puncture of it will be avoided if possible. Otherwise, there is no evidence-based reason to not have an epidural.¹¹

If you have concerns about whether you are a candidate for an epidural, you can request an anesthesia consult during the prenatal period.

The Procedure

Your support person may be asked to wear a mask and to stay in front of you as the process is a sterile procedure. To avoid overcrowding, usually only one support person is permitted in the room.

• In order to have an epidural, an intravenous (IV) will need to be in place and blood work results will need to be available for the doctor (anesthesiologist).
• The anesthesiologist will discuss any risks and benefits of the epidural procedure and answer any questions you may have prior to doing the procedure.
• Once you have provided your informed consent for the procedure, you will be asked to sit on the edge of the bed (or sometimes curl up on your side) to allow the space between your bones in your spine to open. The doctor will wash your back with an antiseptic (cleanser) and feel with their fingers to determine where the epidural needle will be inserted.
• They will put some freezing into the skin in the small of your back. It will sting for about 10 seconds and feel a bit like the freezing needle you get at the dentist.

• Once the freezing starts to work, the doctor will insert an epidural needle into the muscle of your back.

• You will be asked to remain very still during this procedure. Let the doctor know when you start a contraction, so the doctor knows to stop until it passes.

• You should feel only pressure but not pain.

• The doctor will remove the inner part of the epidural needle and then continue to the epidural space. You may feel a popping sensation and pressure as the epidural needle passes through the muscles of your back. This is normal. The insertion may need to be done more than once to find the correct space.

• Once in place, a fine flexible catheter (tube) will be threaded into the space. The outer part of the needle is then removed leaving only the catheter in the epidural space (the space around the covering of the spinal canal).
• The doctor will inject some medication into the catheter and within the next 10 minutes, you will start to feel warmth and tingling in your toes. It normally takes about 10-20 minutes for the medication to reach the level of your belly button.
• The epidural tubing is taped in place, up your back, and is attached to an infusion pump, which will allow you to receive a continuous flow of the medication. The medication is a combination of narcotic (pain medication) and anesthetic (numbing or freezing medication).

• Watch the LHSC video about the Epidural Anaesthesia procedure →

After the Procedure

• After the doctor puts in the epidural tubing, your movements are generally restricted to the bed.
• You will be positioned on your side and assisted to turn every hour.
• You and your baby will need more frequent monitoring after the epidural procedure and after any change in dose of the medication. The nurse will monitor your baby's heart rate¹ and your blood pressure, pulse, and respirations every 5 minutes for a period of time.
• Your nurse will frequently assess the effectiveness of your epidural block by asking about your pain and comfort levels, asking you to move your legs and using ice to check the level of your block on your abdomen and legs.
• As your labour progresses, you may require adjustments to the amount of medication to keep you comfortable.
• You will likely not have an urge to pee, so the nurse will use a catheter to empty your bladder when necessary.
• As labour progresses and your baby moves down the birth canal, you may feel discomfort or pressure. This is a normal sensation, even with an effective epidural. During pushing, this feeling of pressure is helpful for you to know when and where to push.
• Shivering is a common side effect of the epidural. Warm blankets can make you feel more comfortable.

After the Birth

• Following the birth, the epidural catheter is removed.
• The effects of the epidural may last several hours before complete feeling and movement in your lower body is regained.⁷
• This return of sensation may be experienced as “pins and needles.”
• Generally, you will be on the Mother Baby Care Unit before the effects of the epidural have fully worn off.
• The nurses will continue to assess your sensation and leg strength and will assist you the first time you get up to go to the bathroom.

It is very important to have the assistance of a nurse the first time you get out of bed after having an epidural.

For more information, decision aids & tools

• Ottawa Family Decision Guide
• My Health Alberta: Pregnancy: Should I Have an Epidural During Childbirth?
• Making Informed Decisions About Your Care - other decision aids & tools

If you have specific questions

• Speak with your healthcare provider
• If you are giving birth at LHSC, speak with the nurse at the London Health Sciences Centre (LHSC) Preadmission Clinic.