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Epidural

Extracted from Myles Textbook for Midwives 15th Edition. Diane M. Fraser, Margaret A. Cooper (Eds). London; Churchill Livingstone: 2009. Courtesy Elsevier.

Epidural or regional analgesia can provide effective pain relief during labour. Pain relief from an epidural is obtained by blocking the conduction of impulses along sensory nerves as they enter the spinal cord. The procedure is usually carried out by an experienced obstetric anaesthetist under strict aseptic conditions. A local anaesthetic is injected into the epidural space of the lumbar region, usually between vertebrae L1 and L2, or L2 and L3, or between L3 and L4.  

 

Continuous infusion of local anaesthetic (bupivacaine) and opioids (usually fentanyl) is administered via a syringe pump. Midwives top up the epidural block by giving a further dose as prescribed by the anaesthetist. The midwife is personally responsible for ensuring she is competent to carry out the procedure, and should be aware of possible complications and their immediate treatment. Complications may include:

 

  • Dural puncture and consequent headache
  • Total spinal block leading to respiratory arrest
  • Local anaesthetic toxicity leading to cardiac arrest
  • Fetal compromise (resulting from hypotension or local analgesic toxicity
  • Increased need for assisted vaginal birth
  • Neurological sequelae (serious damage is extremely rare; weakness/sensory loss is uncommon but soon resolves)

Further reading

National Institute for Health and Clinical Excellence (NICE) (2014). Intrapartum care for health women and babies. CG190. Available at: https://www.nice.org.uk/guidance/cg190/chapter/1-recommendations

Royal College of Anaesthetists Faculty of Pain Medicine (2010). Best practice in the management of epidural analgesia in the hospital setting. Available at: https://www.aagbi.org/sites/default/files/epidural_analgesia_2011.pdf

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