What to know before you get an epidural in labour
Whether or not to have an epidural is often one of the biggest decisions women think about before giving birth. I hope this guide will give you the information you need to make the decision that's right for you. Ultimately, choosing whether or not to have an epidural is a very personal decision, and one that often depends on how your labour unfolds. My advice is to keep an open mind about pain relief during labour, so that if the time comes, you feel informed, confident, and able to make the decision that feels right in the moment.
What is an epidural?
An epidural is a type of regional pain relief that numbs the nerves carrying pain signals from your uterus and the birth canal. It is the most effective form of pain relief available during labour and allows you to remain awake and alert throughout the birth.
What happens when I get an epidural?
Although every hospital works slightly differently, the overall process is very similar across NHS maternity units. The first thing to do is to get you ready. Your midwife will make sure that:
- You are wearing a gown and TED stockings
- Your observations are normal (this includes your blood pressure, heart rate, breathing rate, oxygen levels and temperature)
- You have a cannula (this is so that if your blood pressure drops low, a common side effect of an epidural, the midwife can give you fluids to help bring your blood pressure up)
- Any blood tests that are needed are up to date
- Your baby's heart rate appears normal - your baby's heart rate will be assessed before the epidural is inserted, and you will then have continuous CTG monitoring once the epidural is in place
- You are not about to deliver your baby - you may be offered a vaginal examination, but this is always optional and you can decline it
When the anaesthetist arrives, they will run through the risks associated with an epidural and make sure that you have given informed consent to getting the epidural.
The midwife will then help you into a good position - usually you are sitting on the bed with your legs over the edge of the bed in a slumped position, pushing your back out. This position helps the anaesthetist to insert (or 'site') the epidural more easily.
… top tip
If you are contracting when your epidural is being sited, make sure you have Entonox to hand, and tell the midwife or anaesthetist when you feel a contraction coming on so they can pause or adjust what they are doing to keep you safe.
The anaesthetist will then:
- Put a sticky drape on your back
- Have a thorough feel of your back - they are feeling for the bones in your back and making sure that they have found the correct space to insert the epidural into
- Give you some local anaesthetic into your back (this is a small injection)
- Insert the epidural into your back using a needle, a catheter is then threaded over the needle and taped down to your back and the needle is removed. This epidural catheter will remain in your back for the duration of your labour
The anaesthetist gives the first dose of the epidural and stays in the room to make sure that it is working well.
Getting an epidural shouldn't be painful. The local anaesthetic will sting as it goes in, and you may feel pressure, but it shouldn't be painful.
What are the time frames associated with getting an epidural?
It takes about 20 minutes for the midwife to set up an epidural, 20 minutes for the anaesthetist to site the epidural, and 20 minutes for the epidural to start working after it has been sited. It may also take up to 30 minutes for the anaesthetist to come to you.
So the time from you deciding to have an epidural to it being effective is about 60 - 90 minutes.
… top tip
If you think you want an epidural, remember that it can take over an hour from the time you decide you want one to being comfortable.
What does having an epidural actually feel like?
Once the epidural is working, contractions should become comfortable rather than painful. You may still feel tightening of your tummy, pressure in your pelvis and you may get the urge to push later in labour. Your legs may feel warm, heavy or numb depending on how dense your epidural block is.
How will my labour change after I have an epidural?
There are a few ways that you can expect your labour to change once you have an epidural:
- You will be on the obstetric-led labour ward as opposed to the midwife-led birth centre
- You will have more frequent monitoring of your observations, especially your blood pressure
- You may lose mobility and struggle to change position
- You may lose the ability to pass urine temporarily, and need an indwelling urinary catheter to ensure your bladder remains empty during labour
- Your midwife will check your epidural 'block' (how well the epidural is working) every hour using a cold spray and record it
- You will need continuous CTG monitoring to make sure that baby remains well
- The second stage of labour (the pushing phase) could lengthen by about 20 minutes
How long does the pain relief work for?
Your epidural will last until baby is born - it does not run out!
How your epidural is delivered during labour depends on your hospital's regime. Often women are able to 'self-administer' their epidural doses via a handheld button. For example, you may be able to press the epidural button and get a dose every 20 minutes (there is a lock out so you cannot overdose).
This means that you can get the right level of 'block' for you - some women like to be completely numb and unable to feel any contractions, other women would prefer to feel their contractions a little bit.
Whilst epidurals are the best form of pain relief for labour, roughly one in nine epidurals do not work and need to be re-sited. Sometimes, women need extra top ups of the epidural to be comfortable, and sometimes epidurals work better on one side than another. Whilst you will still feel pressure, contractions should be painless if the epidural is working well.
When should I get an epidural?
Generally, epidurals are offered to women once they are in established labour. However, occasionally women can get an 'early epidural' if this has been discussed antenatally.
What are the benefits of getting an epidural?
- Epidurals are the best form of pain relief for labour, and can provide relief if labour is long or particularly intense
- You remain awake for labour, and you may be able to rest during labour
- Epidurals are often patient controlled meaning that women have a degree of control of the epidural
- An epidural does not prolong the first stage of labour (4cm - 10cm)
- An epidural can be topped up quickly and used in theatre for an emergency delivery if required
What are the possible side-effects of an epidural?
More common:
- Heavy legs and reduced mobility
- Need for a urinary catheter
- Itchy skin
- A drop in your blood pressure
Less common:
- The epidural doesn't work and needs to be re-inserted
- Increased length of second stage (pushing) due to a reduced sensation to bear down and push
- A raised temperature
Rare:
- A severe headache (caused by a dural puncture)
- Infection
- Nerve damage
Women often wonder if they will still be able to push with an epidural, and the answer is yes. If you have no urge to push and cannot feel your contractions at all, your midwife will put their hand on your tummy to feel your contractions for you, tell you when you have one, and then encourage you to push into your bottom. You will still feel pressure whilst you are pushing and as baby is being born.
Pushing can take longer, and you may be at a slight increased chance of needing an instrumental delivery, but having an epidural does not mean you will necessarily need an instrumental delivery or that you will be unable to push.
What are the alternatives to an epidural in labour?
There is a whole spectrum of pain relief that can be used in labour, from non-pharmacological methods to pharmacological methods. It is useful to think of the options on a step ladder going from breathing techniques and massage up to a an epidural (or general anaesthetic for caesarean sections).
The most comparable alterative to an epidural is remifentanil. Briefly, remifentanil is an opioid that is administered into a vein via a cannula. It is fast acting and short lasting - women press the button every time they feel a contraction starting, and the dose covers that contraction only.
Remifentanil can make women breathe very slowly and women often need to be on nasal oxygen to maintain their oxygen levels.
Some women choose remifentanil over an epidural because it does not come with the same risk of immobility.
Occasionally, women are not able to get an epidural if, for example, they have certain medical conditions). Remifentanil will then be suggested as the next best option.
A note from the labour ward
Women are often worried that they will be 'too late' for an epidural. In reality, this is very rare - but not impossible. Sometimes, women ask for an epidural as the baby's head crowns. Given how long it takes to site an epidural, at this point it is too late to get an epidural - but the good news is that you will have your baby very soon.
The bottom line is that anaesthetists are keen to avoid you being exposed to all the risks of getting an epidural without getting any of the benefits (if baby arrives before the benefits start to take effect). So even if you are 10cm (fully dilated), it is often still possible to have an epidural if baby is not too close to being born. But if the team think that baby will be born before the effects take place, then they will encourage you to continue without an epidural.