Every epidural question

This might be phrased by an examiner as 'tell me about the anatomy of labour pain'.

• In the first stage of labour, contractions and stretching of the cervix activate the uterine and cervical afferents that travel with sympathetic fibres to the sympathetic chain
• This joins the spinal cord at T10 - L1 and causes visceral pain
• This is why we check our block up to the umbilicus (T10 dermatome) to ensure adequate coverage
• In the second stage, pain is increasingly somatic pain, due to perineal stretch, carried via the pudendal nerve entering the spinal cord at S2-S4

This is why mothers report intense 'pressure' in the sacral area despite a good working epidural.

Pharmacological

• Paracetamol
• Opioids IM/PO
• Entonox
• Epidural
• Remifentanil PCA

Non-pharmacological

• TENS machine
• Acupuncture or acupressure
• Water birth

Ibuprofen and other NSAIDs are avoided in labour as they risk causing premature closure of the ductus arteriosus.

We will signpost you to the excellent LabourPains website here.

If you apply local anaesthetic to a nerve, it temporarily blocks that nerve from sending signals.

An epidural is a very thin plastic tube that allows us to wash local anaesthetic around the pain nerves that supply the uterus and lower abdomen, as they pass through your back.

The procedure involves passing a needle (after lots of local anaesthetic) into the back and inserting the thin plastic catheter before removing the needle and applying lots of dressings to keep it clean and fixed firmly in place.

• A spinal involves a single injection into the fluid that surrounds the spinal cord
• An epidural involves inserting a small plastic catheter just outside this fluid compartment
• A combined procedure can be done, where a low-dose spinal anaesthetic is performed first, and then an epidural catheter inserted, to provide faster and possibly more effective analgesia

Both involve an injection of local anaesthetic and dull pressure in the middle of the lower back, and both carry similar risk profiles.

Normally it's a combination of local anaesthetic and an opioid.

• Bupivacaine
• Levobupivacaine
• Ropivacaine
• Lidocaine
• Fentanyl
• Diamorphine
• Preservative-free morphine

It will depend on the institution, the procedure and the anaesthetist, however NICE currently recommends for labour analgesia:

• 0.0625-0.1% bupivacaine or equivalent plus
• 2 micrograms/ml fentanyl

Epidurals are performed by an anaesthetist who is specifically trained to perform the procedure.

It usually takes between ten minutes and half an hour to perform, and then another fifteen minutes or so to work.

Pain is highly personal, so there is no rule as to which techniques 'work better', however there are documented trends in analgesic efficacy.

• A working epidural is the most effective analgesia for labour pain, and can provide excellent or even complete analgesia
• Entonox is variable, providing moderate pain relief for some patients, however others will find it less effective or unpleasant to use
• Opioid injections also provide 'moderate' pain relief, but can also cause nausea, itching and constipation
• Non-pharmacological interventions such as TENS and acupressure can provide mild to moderate relief however this is highly variable between patients

Yes.

• Around 30% of all mothers choose to have an epidural in the UK
• Around 60% of first-time mothers will have an epidural
• There is huge cultural variation - Japan is <5%, France is 80%

This will be presented as 'what are the contraindications to epidural analgesia' if asked by an examiner.

Most people can have an epidural, but there are a few important contraindications.

Absolute

• Informed patient refusal*
• Severe unmanage clotting abnormality
• Genuine allergy to local anaesthetic solution
• Infection over insertion site
• Raised intracranial pressure with concern of coning

Relative

• Systemic infection
• Lumbar spine pathology - spina bifida, anatomical abnormality
• Previous spinal surgery
• Neurological disease
• Anticoagulant drugs

*Many patients will be very hesitant about the idea of an epidural, especially after spending any time on social media, but after a proper informed discussion may well gladly agree to some proper pain relief.

Usually yes.

Scoliosis makes it more difficult to locate the epidural space, and may increase the risk of a patchy or ineffective block, but does not contraindicate an epidural in its own right.

If a patient has undergone complex scoliosis surgery with implanted lumbar metalwork then it all gets more complicated and these patients need a proper individualised anaesthetic assessment to establish their risk profile.

They may still be able to have neuraxial anaesthesia, but it needs a proper informed discussion about the risks and benefits.

However mild or asymptomatic scoliosis with no additional contraindications to neuraxial block shouldn't prevent someone from having an epidural.

Getting pretty niche here.

Genuine allergy to local anaesthetic is very rare, but possible.

You can theoretically still have an epidural injection of opioid that will provide effective analgesia for the first stage of labour, but I haven't seen this done in practice.

Absolutely, at any point.

Clearly if an intramuscular injection of morphine has just been given, you can't then take that out again, but you're allowed to change your mind on what you'd like to try next at any point.

If you have had an epidural sited, there's no obligation to keep using it, so if you decide you no longer want it, we can simply stop administering the local anaesthetic solution, or remove the catheter entirely.