View source for Epidural administration

{{Short description|Medication injected into the epidural space of the spine}}
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{{Redirect|Epidural|the anatomical site|Epidural space|other uses|Epidural (disambiguation)}}
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{{Infobox medical intervention
| Name        = Epidural administration
| Image       = Epidural.JPG
| alt         = 
| Caption     = A freshly inserted [[lumbar]] epidural [[catheter]]. The site has been prepared with [[tincture of iodine]], and the [[dressing (medical)|dressing]] has not yet been applied. Depth markings may be seen along the shaft of the catheter.
| ICD10       =
| ICD9        = {{ICD9proc|03.90}}
| ICD9_mult   =
| MeshID      = D000767
| OPS301      = {{OPS301|8-910}}
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| OtherCodes  =
}}

'''Epidural administration''' (from [[Ancient Greek]] ἐπί, "upon" + ''[[dura mater]]'')<ref name="OED">{{cite OED |term=Epidural |access-date=1 November 2020}}</ref> is a [[route of administration|method of medication administration]] in which a medicine is injected into the [[epidural space]] around the [[spinal cord]]. The epidural route is used by physicians and [[nurse anesthetists]] to administer [[local anesthetic]] agents, [[analgesic]]s, [[Laboratory diagnosis of bacteria|diagnostic]] medicines such as [[radiocontrast agent]]s, and other medicines such as [[glucocorticoid]]s. Epidural administration involves the placement of a [[catheter]] into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by the Spanish [[Aragonese people|Aragonese]] military surgeon [[Fidel Pagés]].

Epidural anaesthesia causes a loss of [[Somatosensory system|sensation]], including [[pain]], by blocking the transmission of signals through [[nerve fibres]] in or near the spinal cord. For this reason, epidurals are commonly used for [[pain control]] during [[childbirth]] and [[surgery]], for which the technique is considered safe and effective, and is considered more effective and safer than giving pain medication by mouth or through an [[intravenous line]]. An epidural injection may also be used to administer [[steroids]] for the treatment of [[Inflammation|inflammatory]] conditions of the spinal cord. It is not recommended for people with severe bleeding disorders, low platelet counts, or infections near the intended injection site. Severe complications from epidural administration are rare, but can include problems resulting from improper administration, as well as [[adverse effect]]s from medicine. The most common complications of epidural injections include bleeding problems, [[headache]]s, and inadequate pain control. Epidural analgesia during childbirth may also impact the mother's ability to move during labor. Very large doses of anesthetics or analgesics may result in [[respiratory depression]].

An epidural injection may be administered at any point of the spine, but most commonly the [[lumbar spine]], below the end of the spinal cord. The specific administration site determines the specific [[nerve]]s affected, and thus the area of the body from which pain will be blocked. Insertion of an epidural catheter consists of threading a needle between bones and ligaments to reach the epidural space without going so far as to puncture the ''dura mater''. Saline or air may be used to confirm placement in the epidural space. Alternatively, direct imaging of the injection area may be performed with a [[portable ultrasound]] or [[fluoroscopy]] to confirm correct placement. Once placed, medication may be administered in one or more single doses, or may be continually infused over a period of time. When placed properly, an epidural catheter may remain inserted for several days, but is usually removed when it is possible to use less invasive administration methods (such as oral medication).

== Uses ==
[[file:EDK Pump 1.jpg|thumb|upright|Epidural infusion pump with opioid ([[sufentanil]]) and anesthetic ([[bupivacaine]]) in a locked box]]

=== Pain relief during childbirth ===
Epidural injections are commonly used to provide pain relief ([[analgesia]]) during childbirth.<ref>{{cite journal |last1=Schrock |first1=SD |last2=Harraway-Smith |first2=C |title=Labor analgesia |journal=American Family Physician |date=1 March 2012 |volume=85 |issue=5 |pages=447–54 |pmid=22534222}}</ref> This usually involves epidural injection of a local anesthetic and [[opioid]]s, commonly called an "epidural". This is more effective than oral or [[Intravenous therapy|intravenous]] (IV) opioids and other common modalities of analgesia in childbirth.<ref name="Anim-Somuah2018">{{cite journal |vauthors = Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A |title = Epidural versus non-epidural or no analgesia in labour |journal = The Cochrane Database of Systematic Reviews |volume = 2018 |pages = CD000331 |year = 2018 |issue = 5 |pmid = 29781504 |pmc = 6494646 |doi = 10.1002/14651858.CD000331.pub4}}</ref> After an epidural is administered, the recipient may not feel pain, but may still feel pressure.<ref>{{cite journal |last=Buckley |first=Sarah |title=Epidurals: risks and concerns for mother and baby |journal=Midwifery Today with International Midwife |url=http://sarahbuckley.com/epidurals-risks-and-concerns-for-mother-and-baby#ref |publisher=Mothering No.133 |access-date=April 18, 2014 |date=2014-01-24 |issue=81|pages=21–3, 63–6 |pmid=17447690}}</ref> Epidural [[clonidine]] is rarely used but has been extensively studied for management of analgesia during labor.<ref name=Patel1996>{{cite journal |vauthors=Patel SS, Dunn CJ, Bryson HM |s2cid=72544106 |title=Epidural clonidine: a review of its pharmacology and efficacy in the management of pain during labour and postoperative and intractable pain |journal=CNS Drugs |year=1996 |volume=6 |issue=6 |pages=474–497 |doi=10.2165/00023210-199606060-00007}}</ref>

Epidural analgesia is considered a safer and more effective method of relieving pain in labor as compared to intravenous or oral analgesia. In a 2018 [[Cochrane Collaboration|Cochrane review]] of studies which compared epidural analgesia with [[oral administration|oral]] opioids, some advantages of epidural analgesia versus opioids included fewer instances of [[naloxone]] use in newborns, and decreased risk of maternal hyperventilation.<ref name="Anim-Somuah2018" /> Some disadvantages of epidural analgesia versus opioids included longer labor durations, an increased need for [[oxytocin]] to stimulate [[uterine contraction]]s, and an increased risk of fever, low blood pressure, and muscle weakness.<ref name="Anim-Somuah2018" /> 

However, the review found no difference in overall Caesarean delivery rates between epidural analgesia versus no analgesia. Additionally, there was no difference found on the immediate neonatal health of the child between epidural analgesia versus no analgesia. Furthermore, the occurrence of long-term backache was unchanged after epidural use.<ref name="Anim-Somuah2018" /> Complications of epidural analgesia are rare, but may include headaches, dizziness, difficulty breathing and seizures for the mother. The child may experience a slow heartbeat, decreased ability to regulate temperature, and potential exposure to the drugs administered to the mother.<ref>{{cite web |title=Anesthesia |url=http://search.credoreference.com/content/entry/hupwh/anesthesia/0?searchId=9b195ee2-c732-11e3-b874-0aea1e3b2a47&result=1 |publisher=Harvard University Press |access-date=April 18, 2014}}</ref>

There is no overall difference in outcomes based on the time the epidural is administered to the mother,<ref name="Cochrane2014">{{cite journal |vauthors=Sng BL, Leong WL, Zeng Y, Siddiqui FJ, Assam PN, Lim Y, Chan ES, Sia AT |title = Early versus late initiation of epidural analgesia for labour. |journal = The Cochrane Database of Systematic Reviews |volume = 2014 |issue = 10 |pages = CD007238 |date = October 9, 2014 |pmid = 25300169 |doi=10.1002/14651858.CD007238.pub2|doi-access = free |pmc = 10726979 }}</ref> specifically no change in the rate of caesarean section, [[Childbirth#Management|birth which must be assisted by instruments]], and duration of labor. There is also no change in the [[Apgar score]] of the newborn between early and late epidural administration.<ref name="Cochrane2014" /> Epidurals other than low-dose ambulatory epidurals also impact the ability of the mother to move during labor. Movement such as walking or changing positions may help improve labor comfort and decrease the risk of complications.<ref name=Lothian2009>{{cite journal |vauthors = Lothian JA |title = Safe, healthy birth: what every pregnant woman needs to know |journal = J Perinat Educ |volume = 18 |issue = 3 |pages = 48–54 |year = 2009 |pmid = 19750214 |pmc = 2730905 |doi = 10.1624/105812409X461225 }}</ref>

=== Pain relief during other surgery ===
Epidural analgesia has been demonstrated to have several benefits after other surgeries, including decreasing the need for the use of oral or systemic opioids,<ref name=Block2003>{{cite journal |vauthors=Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL | s2cid = 35260733 | title = Efficacy of postoperative epidural analgesia: a meta-analysis | journal = JAMA | volume = 290 | issue = 18 | pages = 2455–63 | year = 2003 | pmid = 14612482 | doi = 10.1001/jama.290.18.2455 }}</ref> and reducing the risk of postoperative respiratory problems, chest infections,<ref name=Ballantyne1998>{{cite journal |vauthors=Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F | s2cid = 37136047 | title = The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials | journal = Anesth Analg | volume = 86 | issue = 3 | pages = 598–612 | year = 1998 | pmid = 9495424 | doi = 10.1097/00000539-199803000-00032 | doi-access = free }}</ref> [[blood transfusion]] requirements,<ref name=Allman1038/> and [[myocardial infarction]]s.<ref name=Beattie2001>{{cite journal |vauthors=Beattie WS, Badner NH, Choi P | s2cid = 9449275 | title = Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis | journal = Anesth Analg | volume = 93 | issue = 4 | pages = 853–8 | year = 2001 | pmid = 11574345 | doi = 10.1097/00000539-200110000-00010 | doi-access = free }}</ref> Use of epidural analgesia after surgery in place of systemic analgesia is less likely to decrease [[intestinal motility]] which would occur with systemic opioid therapy through blockade of the sympathetic nervous system.<ref name="Allman1038">{{cite book|title=Oxford handbook of anaesthesia|vauthors=Wilson IH, Allman KG|publisher=Oxford University Press|year=2006|isbn=978-0-19-856609-0|location=Oxford|page=1038}}</ref><ref name=Gendall>{{cite journal |vauthors=Gendall KA, Kennedy RR, Watson AJ, Frizelle FA | title = The effect of epidural analgesia on postoperative outcome after colorectal surgery | journal = Colorectal Disease | volume = 9 | issue = 7 | pages = 584–98; discussion 598–600 | year = 2007 | pmid = 17506795 | doi = 10.1111/j.1463-1318.2007.1274.x }}</ref> Some surgeries that spinal analgesia may be used in include lower abdominal surgery, lower limb surgery, cardiac surgery, and perineal surgery.<ref name="Allman1038" /><ref>{{cite journal|last1=Guay|first1=Joanne|last2=Kopp|first2=Sandra|date=2019-03-01|title=Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass|journal=The Cochrane Database of Systematic Reviews|volume=2019|issue=3 |pages=CD006715|doi=10.1002/14651858.CD006715.pub3|issn=1469-493X|pmc=6396869|pmid=30821845}}</ref><ref>{{cite journal|last1=Salicath|first1=Jon H.|last2=Yeoh|first2=Emily Cy|last3=Bennett|first3=Michael H.|date=2018-08-30|title=Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults|url=|journal=The Cochrane Database of Systematic Reviews|volume=8| issue=10 |pages=CD010434|doi=10.1002/14651858.CD010434.pub2|issn=1469-493X|pmc=6513588|pmid=30161292}}</ref>
[[File:Epidural kit in sterile packaging.jpg|thumb|A single-use epidural administration kit in sterile packaging]]

=== Others ===
{{Main|Epidural steroid injection|Epidural blood patch}}

The injection of steroids into the epidural space is sometimes used to treat [[radiculopathy|nerve root pain]], [[radicular pain]] and [[inflammation]] caused by conditions such as [[spinal disc herniation]], [[degenerative disc disease]], and [[spinal stenosis]].<ref name="episteroid" /> The risk of complications from steroid administration is low and complications are usually minor. The specific drug, dose, and frequency of administration impacts the risk for and severity of complications. Complications of epidural steroid administration are similar to the side effects of steroids administered in other manners, and can include higher than normal blood sugar, especially in patients with [[type 2 diabetes]].<ref name="episteroid" />
An [[epidural blood patch]] consists of a small amount of a person's own blood is injected into the epidural space. This is done as a method of sealing a hole or leak in the epidural.<ref name="auto">{{Citation|last1=Tubben|first1=Robert E.|last2=Murphy|first2=Patrick B. |title=Epidural Blood Patch |date=2018 |url= https://www.ncbi.nlm.nih.gov/books/NBK482336/ |work=StatPearls|publisher=StatPearls Publishing|pmid=29493961|access-date=2018-10-31 }}</ref> The injected blood clots at the site of the puncture, closes the leak, and modulates CSF pressure.<ref>White, Benjamin; Lopez, Victor; Chason, David; Scott, David; Stehel, Edward; Moore, William (2019-03-28). [https://www.appliedradiology.com/communities/MR-Community/the-lumbar-epidural-blood-patch-a-primer The lumbar epidural blood patch: A Primer.] ''Applied Radiology''. '''48''' (2): 25–30.</ref><ref>{{cite journal|last1=Nath|first1=Gita|last2=Subrahmanyam|first2=Maddirala|date=2011|title=Headache in the parturient: Pathophysiology and management of post-dural puncture headache|url=http://www.joacc.com/text.asp?2011/1/2/57/93988|journal=Journal of Obstetric Anaesthesia and Critical Care|language=en|volume=1|issue=2|pages=57|doi=10.4103/2249-4472.93988|issn=2249-4472|doi-access=free}}</ref>  This may be used to treat [[post-dural-puncture headache]] and leakage of [[cerebrospinal fluid]] due to dural puncture, which occurs in approximately 1.5% of epidural analgesia procedures.<ref name=":0">{{cite journal|vauthors=Silva M, Halpern SH|date=2010|title=Epidural analgesia for labor: Current techniques|journal=Local and Regional Anesthesia|volume=3|pages=143–53|doi=10.2147/LRA.S10237|pmc=3417963|pmid=23144567 |doi-access=free }}</ref>

== Contraindications ==
The use of epidural analgesia and anesthetic is considered safe and effective in most situations. Epidural analgesia is contraindicated in people who have complications such as [[cellulitis]] near the injection site or severe coagulopathy.<ref name=":0" /> In some cases, it may be contraindicated in people with low platelets, increased [[intracranial pressure]], or decreased [[cardiac output]].<ref name=":0" /> Due to the risk of disease progression, it is also potentially contraindicated in people with preexisting progressive neurologic disease.<ref name=":0" /> Some heart conditions such as [[stenosis]] of the aortic or mitral valves are also a contraindication to the use of epidural administration, as is low blood pressure or [[hypovolemia]].<ref name="episteroid" /> An epidural is generally not used in people who are being administered [[anticoagulant|anticoagulation therapy]] as it increases the risk of complications from the epidural.<ref name="episteroid" />

== Risks and complications ==
In addition to blocking nerves which carry pain signals, local anesthetics may block nerves which carry other signals, though [[sensory nerve|sensory nerve fibers]] are more sensitive to the effects of the local anesthetics than [[motor nerve|motor nerve fiber]]s. For this reason, adequate pain control can usually be attained without blocking the motor neurons, which would cause a loss of muscle control if it occurred. Depending on the drug and dose administered, the effects may last only a few minutes or up to several hours.<ref>{{cite journal|vauthors=Stark P|date=February 1979|title=The effect of local anesthetic agents on afferent and motor nerve impulses in the frog|journal=Archives Internationales de Pharmacodynamie et de Therapie|volume=237|issue=2|pages=255–66|pmid=485692}}</ref> As such, an epidural can provide pain control without as much of an effect on muscle strength. For example, a woman in labor who is being administered continuous analgesia via an epidural may not have impairment to her ability to move. Larger doses of medication are more likely to result in side effects.<ref name=":1">{{cite journal|vauthors=Tobias JD, Leder M|date=October 2011|title=Procedural sedation: A review of sedative agents, monitoring, and management of complications|journal=Saudi Journal of Anaesthesia|volume=5|issue=4|pages=395–410|doi=10.4103/1658-354X.87270|pmc=3227310|pmid=22144928 |doi-access=free }}</ref> Very large doses of some medications can cause paralysis of the [[intercostal muscle]]s and [[thoracic diaphragm]] responsible for breathing, which may lead to respiratory depression or arrest. It may also result in loss of sympathetic nerve input to the heart, which may cause a significant decrease in heart rate and blood pressure.<ref name=":1" /> [[Obese]] people, those who have [[multiparity|given birth prior]], those with a history of opiate use, or those with [[cervical dilation]] of more than 7&nbsp;cm are at a higher risk of inadequate pain control.<ref name="Agaram2009">{{cite journal | vauthors = Agaram R, Douglas MJ, McTaggart RA, Gunka V | title = Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors | journal = Int J Obstet Anesth | volume = 18 | issue = 1 | pages = 10–4 | date = January 2009 | pmid = 19046867 | doi = 10.1016/j.ijoa.2007.10.008 }}</ref>

If the dura is accidentally punctured during administration, it may cause cerebrospinal fluid to leak into the epidural space, causing a post-dural-puncture headache.<ref name="Allman20">{{cite book|title=Oxford handbook of anaesthesia|vauthors=Wilson IH, Allman KG|publisher=Oxford University Press|year=2006|isbn=978-0-19-856609-0|location=Oxford|page=20}}</ref> This occurs in approximately 1 in 100 epidural procedures. Such a headache may be severe and last several days, or rarely weeks to months, and is caused by a reduction in CSF pressure. Mild post-dural-puncture headaches may be treated with caffeine and gabapentin,<ref name="Cochrane database 2015">{{cite journal |url=https://www.cochrane.org/CD007887/SYMPT_drugs-treating-headache-after-lumbar-puncture|title=Drugs for treating headache after a lumbar puncture|issue=7|pages=CD007887|last=Basurto |first= Ona | date=15 July 2015 |journal=The Cochrane Database of Systematic Reviews |volume=2015 |publisher=The Cochrane Library |access-date=16 November 2018 |quote=Caffeine proved to be effective in decreasing the number of people with PDPH and those requiring extra drugs (2 or 3 in 10 with caffeine compared to 9 in 10 with placebo). Gabapentin, theophylline and hydrocortisone also proved to be effective, relieving pain better than placebo|doi=10.1002/14651858.CD007887.pub3|pmid=26176166|pmc=6457875}}</ref> while severe headaches may be treated with an epidural blood patch, though most cases resolve spontaneously with time. Less common but more severe complications include [[subdural hematoma]] and [[cerebral venous thrombosis]]. The epidural catheter may also rarely be inadvertently placed in the subarachnoid space, which occurs in less than 1 in 1000 procedures. If this occurs, cerebrospinal fluid can be freely aspirated from the catheter, and this is used to detect misplacement. When this occurs, the catheter is withdrawn and replaced elsewhere, though occasionally no fluid may be aspirated despite a dural puncture.<ref name="Troop1992">{{cite journal|vauthors=Troop M|year=2002|title=Negative aspiration for cerebral fluid does not assure proper placement of epidural catheter.|journal=AANA J|volume=60|issue=3|pages=301–3|pmid=1632158}}</ref> If dural puncture is not recognized, large doses of anesthetic may be delivered directly into the cerebrospinal fluid. This may result in a high block, or, more rarely, a ''total spinal'', where anesthetic is delivered directly to the brainstem, causing unconsciousness and sometimes [[seizures]].<ref name="Troop1992" />

Epidural administrations can also cause bleeding issues, including "bloody tap", which occurs in approximately 1 in 30–50 people.<ref name="pmid22726899">{{cite journal|vauthors=Shih CK, Wang FY, Shieh CF, Huang JM, Lu IC, Wu LC, Lu DV| year=2012|title=Soft catheters reduce the risk of intravascular cannulation during epidural block—a retrospective analysis of 1,117 cases in a medical center|journal=Kaohsiung J. Med. Sci.|volume=28|issue=7|pages=373–6|doi=10.1016/j.kjms.2012.02.004|pmid=22726899|doi-access=free}}</ref> This occurs when epidural veins are inadvertently punctured with the needle during the insertion. It is a common occurrence and is not usually considered a problem in people who have normal blood clotting. Permanent neurological problems from bloody tap are extremely rare, estimated at less than 0.07% of occurrences.<ref name="pmid9009940">{{cite journal|vauthors=Giebler RM, Scherer RU, Peters J|year=1997|title=Incidence of neurologic complications related to thoracic epidural catheterization|journal=Anesthesiology|volume=86|issue=1|pages=55–63|doi=10.1097/00000542-199701000-00009|pmid=9009940|doi-access=free}}</ref> However, people who have a [[coagulopathy]] may have a risk of epidural hematoma, and those with thrombocytopenia might bleed more than expected. A 2018 Cochrane review found no evidence regarding the effect of [[platelet transfusion]]s prior to a [[lumbar puncture]] or epidural anesthesia for participants that have [[thrombocytopenia]].<ref name=":4" /> It is unclear whether major surgery-related bleeding within 24 hours and the surgery-related complications up to 7 days after the procedure are affected by epidural use.<ref name=":4">{{cite journal|last1=Estcourt|first1=Lise J|last2=Malouf|first2=Reem|last3=Hopewell|first3=Sally|last4=Doree|first4=Carolyn|last5=Van Veen|first5=Joost|date=2018-04-30|editor-last=Cochrane Haematological Malignancies Group|title=Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia|journal=Cochrane Database of Systematic Reviews|volume=2018|issue=4 |pages=CD011980|language=en|doi=10.1002/14651858.CD011980.pub3|pmid=29709077|pmc=5957267}}</ref>

Rare complications of epidural administration include formation of an [[epidural abscess]] (1 in 145,000)<ref name="ox">{{cite web|url=http://www.medicine.ox.ac.uk/bandolier/band159/b159-3.html|title=Epidurals and risk: it all depends|archive-url=https://web.archive.org/web/20120218151943/http://www.medicine.ox.ac.uk/bandolier/band159/b159-3.html|archive-date=18 February 2012|url-status=dead|df=mdy-all}}</ref> or [[epidural hematoma]] (1 in 168,000),<ref name="ox" /> neurological injury lasting longer than 1 year (1 in 240,000),<ref name="ox" /> [[paraplegia]] (1 in 250,000),<ref name="Allman21">{{cite book|title=Oxford handbook of anaesthesia|vauthors=Wilson IH, Allman KG|publisher=Oxford University Press|year=2006|isbn=978-0-19-856609-0|location=Oxford|page=21}}</ref> and [[arachnoiditis]].<ref name="Rice2004">{{cite journal | vauthors = Rice I, Wee MY, Thomson K | title = Obstetric epidurals and chronic adhesive arachnoiditis | journal = Br J Anaesth | volume = 92 | issue = 1 | pages = 109–20 | date = January 2004 | pmid = 14665562 | doi = 10.1093/bja/aeh009 | citeseerx = 10.1.1.532.6709 }}</ref> Rarely, an epidural may cause death (1 in 100,000).<ref name="Allman21" /> In circumstances where contraindications exist, there are numerous fascial plane blocks that may be provided instead of an epidural.<ref>{{cite journal |last1=Pawa |first1=Amit |last2=King |first2=Christopher |last3=Thang |first3=Christopher |last4=White |first4=Leigh |title=Erector spinae plane block: the ultimate 'plan A' block? |journal=British Journal of Anaesthesia |date=February 2023 |volume=130 |issue=5 |pages=497–502 |doi=10.1016/j.bja.2023.01.012|pmid=36775671 |s2cid=256805767 |doi-access=free |hdl=10072/429314 |hdl-access=free }}</ref>

===Medication-specific===
If bupivacaine, a medication commonly administered via epidural, is inadvertently administered into a vein, it can cause excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures as well as [[central nervous system depression]], loss of consciousness, respiratory depression and apnea. Bupivacaine intended for epidural administration has been implicated in cardiac arrests resulting in death when accidentally administered into a vein instead of the epidural space.<ref name="Rosenblatt2006">{{cite journal|vauthors = Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB |s2cid=40214528|year=2006|title=Successful Use of a 20% Lipid Emulsion to Resuscitate a Patient after a Presumed Bupivacaine-related Cardiac Arrest|journal=Anesthesiology|volume=105|issue=7|pages=217–8|pmid=16810015|doi=10.1097/00000542-200607000-00033|doi-access=free}}</ref><ref name="Mulroy2002">{{cite journal|author=Mulroy MF|year=2002|title=Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures.|journal=Reg Anesth Pain Med|volume=27|issue=6|pages=556–61|pmid=12430104|doi=10.1053/rapm.2002.37127|s2cid=36915462}}</ref> The administration of large doses of opioids into the epidural space may cause [[pruritus|itching]] and respiratory depression.<ref name="Jacobson1988">{{cite journal|vauthors=Jacobson L, Chabal C, Brody MC|year=1988|title=A dose-response study of intrathecal morphine: efficacy, duration, optimal dose, and side effects|journal= Anesthesia & Analgesia|volume=67|issue=11|pages=1082–8|doi=10.1213/00000539-198867110-00011|pmid=3189898|doi-access=free}}</ref><ref name="Wust1987">{{cite journal|vauthors=Wüst HJ, Bromage PR|year=1987|title=Delayed respiratory arrest after epidural hydromorphone|journal=Anaesthesia|volume=42|issue=4|pages=404–6|doi=10.1111/j.1365-2044.1987.tb03982.x|pmid=2438964|s2cid=37237552|doi-access=free}}</ref> The sensation of needing to urinate is often significantly diminished or completely absent after administration of epidural local anesthetics or opioids.<ref name=":2">{{cite journal|vauthors=Baldini G, Bagry H, Aprikian A, Carli F|date=May 2009|title=Postoperative urinary retention: anesthetic and perioperative considerations|journal=Anesthesiology|volume=110|issue=5|pages=1139–57|doi=10.1097/ALN.0b013e31819f7aea|pmid=19352147|doi-access=free}}</ref> Because of this, a [[urinary catheterization|urinary catheter]] is often placed for the duration of the epidural infusion.<ref name=":2" />

In many women given epidural analgesia during labor oxytocin is also used to augment uterine contractions. In one study which examined the rate of breastfeeding two days following epidural anesthesia during childbirth, epidural analgesia used in combination with oxytocin resulted in lower maternal oxytocin and prolactin levels in response to breastfeeding on the second day following birth.<ref name="Jonas2009">{{cite journal|vauthors=Jonas K, Johansson LM, Nissen E, Ejdebäck M, Ransjö-Arvidson AB, Uvnäs-Moberg K|year=2009|title=Effects of Intrapartum Oxytocin Administration and Epidural Analgesia on the Concentration of Plasma Oxytocin and Prolactin, in Response to Suckling During the Second Day Postpartum|journal=Breastfeed Med|volume=4|issue=2|pages=71–82|doi=10.1089/bfm.2008.0002|pmid=19210132}}</ref> The lower maternal oxytocin level negatively affects the baby’s feeding rooting reflex, decreasing the amount of milk produced. The consequence of these effects from epidural analgesia is higher weight loss.<ref name="Takahashi2021">{{cite journal|vauthors=Takahashi Y, Uvnäs-Moberg K, Nissen E, Lidfors L, Ransjö-Arvidson AB, Jonas W|year=2021|title=Epidural Analgesia With or Without Oxytocin, but Not Oxytocin Alone, Administered During Birth Disturbs Infant Pre-feeding and Sucking Behaviors and Maternal Oxytocin Levels in Connection With a Breastfeed Two Days Later|journal=Frontiers in Neuroscience|volume=15|doi=10.3389/fnins.2021.673184|doi-access=free |pmid=34267623|pmc=8276259 }}</ref>

== Technique ==
=== Anatomy ===
[[File:Epiduraldiagram.png|thumb|[[Sagittal]] section of the spinal column (not drawn to scale). ''Yellow'': spinal cord; ''blue'': [[pia mater]]; ''red'': arachnoid; ''light blue'': [[subarachnoid space]]; ''pink'': [[dura mater]]; ''pale green'': epidural space; ''taupe'': vertebral bones; ''teal'': interspinous ligaments.]]
{{Main|Epidural space}}
An epidural is injected into the epidural space, inside the bony [[spinal canal]] but just outside the [[dura mater|dura]]. In contact with the inner surface of the dura is another membrane called the [[arachnoid mater]], which contains the cerebrospinal fluid. In adults, the spinal cord terminates around the level of the disc between L1 and L2, while in neonates it extends to L3 but can reach as low as L4.<ref name="episteroid">{{cite journal |last1=Schneider |first1=Byron |last2=Zheng |first2=Patricia |last3=Mattie |first3=Ryan |last4=Kennedy |first4=David J. |title=Safety of epidural steroid injections |journal=Expert Opinion on Drug Safety |date=2 August 2016 |volume=15 |issue=8 |pages=1031–1039 |doi=10.1080/14740338.2016.1184246|pmid=27148630 |s2cid=27053083 }}</ref> Below the spinal cord there is a bundle of nerves known as the [[cauda equina]] or "horse's tail". Hence, lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural space without puncturing the layer immediately below containing CSF under pressure.<ref name="episteroid" />

=== Insertion ===
[[File:Epidural needle insertion between the spinous processes of the lumbar vertebrae.jpg|thumb|Simulation of the insertion of an epidural needle between the spinous processes of the lumbar vertebrae. A syringe is connected to the epidural needle and the epidural space is identified by a technique to assess loss of resistance.]]
Epidural administration is a procedure which requires the person performing the insertion to be technically proficient in order to avoid complications. Proficiency may be trained using bananas or other fruits as a model.<ref name="Raj2013">{{cite journal|vauthors=Raj D, Williamson RM, Young D, Russell D|year=2013|title=A simple epidural simulator: a blinded study assessing the 'feel' of loss of resistance in four fruits.|journal=Eur J Anaesthesiol|volume=30|issue=7|pages=405–8|doi=10.1097/EJA.0b013e328361409c|pmid=23749185|s2cid=2647529|doi-access=free}}</ref><ref name="Leighton1989">{{cite journal|author=Leighton BL|year=1989|title=A greengrocer's model of the epidural space.|journal=Anesthesiology|volume=70|issue=2|pages=368–9|doi=10.1097/00000542-198902000-00038|pmid=2913877|doi-access=free}}</ref>

The person receiving the epidural may be seated, or lying on their side or stomach.<ref name="episteroid" /> The level of the spine at which the catheter is placed depends mainly on the site of intended operation – based on the location of the pain. The [[iliac crest]] is a commonly used anatomical landmark for lumbar epidural injections, as this level roughly corresponds with the fourth lumbar vertebra, which is usually well below the [[conus medullaris|termination of the spinal cord]].<ref name="episteroid" /> The [[Tuohy needle]], designed with a 90-degree curved tip and side hole to redirect the inserted catheter vertically along the axis of the spine, may be inserted in the midline, between the [[spinous process]]es. When using a paramedian approach, the tip of the needle passes along a shelf of vertebral bone called the [[Lamina of the vertebral arch|lamina]] until just before reaching the [[Ligamenta flava|ligamentum flavum]] and the epidural space.<ref name="tuohy">{{cite journal |last1=Nagel |first1=Sean J. |last2=Reddy |first2=Chandan G. |last3=Frizon |first3=Leonardo A. |last4=Holland |first4=Marshall T. |last5=Machado |first5=Andre G. |last6=Gillies |first6=George T. |last7=Howard |first7=Matthew A. |title=Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation: INTRATHECAL THERAPEUTICS REVIEW |journal=Neuromodulation: Technology at the Neural Interface |date=October 2018 |volume=21 |issue=7 |pages=625–640 |doi=10.1111/ner.12693|pmid=28961351 |s2cid=25494914 }}</ref>

Along with a sudden loss of resistance to pressure on the plunger of the syringe, a slight clicking sensation may be felt by the operator as the tip of the needle breaches the ligamentum flavum and enters the epidural space. [[saline (medicine)|Saline]] or air may be used to identify placement in the epidural space. A systematic review from 2014 showed no difference in terms of safety or efficacy between the use of saline and air for this purpose.<ref>{{cite journal|last1=Antibas|first1=Pedro L|last2=do Nascimento Junior|first2=Paulo|last3=Braz|first3=Leandro G|last4=Vitor Pereira Doles|first4=João|last5=Módolo|first5=Norma SP|last6=El Dib|first6=Regina|date=2014-07-17|title=Air versus saline in the loss of resistance technique for identification of the epidural space|journal=Cochrane Database of Systematic Reviews| volume=2015 |issue=7|pages=CD008938|doi=10.1002/14651858.cd008938.pub2|pmid=25033878|pmc=7167505|issn=1465-1858}}</ref> In addition to the loss of resistance technique, direct imaging of the placement may be used. This may be conducted with a [[portable ultrasound]] scanner or [[fluoroscopy]] (moving X-ray pictures).<ref name="Rapp2005">{{cite journal |vauthors=Rapp HJ, Folger A, Grau T | s2cid = 17614330 | title = Ultrasound-guided epidural catheter insertion in children | journal =  Anesthesia & Analgesia| volume = 101 | issue = 2 | pages = 333–9, table of contents | year = 2005 | pmid = 16037140 | doi = 10.1213/01.ANE.0000156579.11254.D1 | doi-access = free }}</ref> After placement of the tip of the needle, a catheter or small tube is threaded through the needle into the epidural space. The needle is then withdrawn over the catheter. The catheter is generally inserted 4–6&nbsp;cm into the epidural space, and is typically secured to the skin with adhesive tape, similar to an [[Intravenous therapy|intravenous line]].<ref name="Beilin1995">{{cite journal |vauthors=Beilin Y, Bernstein HH, Zucker-Pinchoff B | title = The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space | journal = Anesth Analg | volume = 81 | issue = 2 | pages = 301–4 | year = 1995 | pmid = 7618719 | doi = 10.1097/00000539-199508000-00016 | s2cid = 26405808 | doi-access = free }}</ref>

=== Use and removal ===
If a short duration of action is desired, a single dose of medication called a [[Bolus (medicine)|bolus]] may be administered. Thereafter, this bolus may be repeated if necessary provided the catheter remains undisturbed. For a prolonged effect, a continuous infusion of medication may be used. There is some evidence that an automated intermittent bolus technique may provide better pain control than a continuous infusion technique even when the total doses administered are identical.<ref name="Lim2005">{{cite journal |vauthors=Lim Y, Sia AT, Ocampo C | title = Automated regular boluses for epidural analgesia: a comparison with continuous infusion | journal = Int J Obstet Anesth | volume = 14 | issue = 4 | pages = 305–9 | year = 2005 | pmid = 16154735 | doi = 10.1016/j.ijoa.2005.05.004 }}</ref><ref name="Wong2006">{{cite journal |vauthors=Wong CA, Ratliff JT, Sullivan JT, Scavone BM, Toledo P, McCarthy RJ | title = A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia | journal = Anesthesia & Analgesia| volume = 102 | issue = 3 | pages = 904–9 | year = 2006 | pmid = 16492849 | doi = 10.1213/01.ane.0000197778.57615.1a | s2cid = 36635329 | doi-access = free }}</ref><ref name="Sia2007">{{cite journal |vauthors=Sia AT, Lim Y, Ocampo C | title = A comparison of a basal infusion with automated mandatory boluses in parturient-controlled epidural analgesia during labor | journal =  Anesthesia & Analgesia| volume = 104 | issue = 3 | pages = 673–8 | year = 2007 | pmid = 17312228 | doi = 10.1213/01.ane.0000253236.89376.60 | s2cid = 38626333 | doi-access = free }}</ref> Typically, the effects of the epidural block are noted below a specific [[Dermatome (anatomy)|level or portion of the body]], determined by the site of injection. A higher injection may result in sparing of nerve function in the lower [[spinal nerve]]s. For example, a thoracic epidural performed for upper abdominal surgery may not have any effect on the [[perineum|area surrounding the genitals]] or pelvic organs.<ref name="Basse2000">{{cite journal |vauthors=Basse L, Werner M, Kehlet H | title = Is urinary drainage necessary during continuous epidural analgesia after colonic resection? | journal = Reg Anesth Pain Med | volume = 25 | issue = 5 | pages = 498–501 | year = 2000 | pmid = 11009235 | doi = 10.1053/rapm.2000.9537 | s2cid = 21296374 }}</ref>

=== Combined spinal-epidural techniques ===
{{Main|Combined spinal and epidural anesthesia}}

For some procedures where both the rapid onset of a [[spinal anaesthesia|spinal anesthetic]] and the post-operative analgesic effects of an epidural are desired, both techniques may be used in combination. This is called [[combined spinal and epidural anesthesia]] (CSE). The spinal anesthetic may be administered in one location, and the epidural at an adjacent location. Alternatively, after locating the epidural space with the Tuohy needle, a spinal needle may be inserted through the Tuohy needle into the [[subarachnoid space]].<ref name="episteroid" /> The spinal dose is then given, the spinal needle withdrawn, and the epidural catheter inserted as normal. This method, known as the "needle-through-needle" technique, may be associated with a slightly higher risk of placing the catheter into the subarachnoid space.<ref name="cochraneCSE">{{cite journal |last1=Simmons |first1=Scott W |last2=Dennis |first2=Alicia T |last3=Cyna |first3=Allan M |last4=Richardson |first4=Matthew G |last5=Bright |first5=Matthew R |title=Combined spinal-epidural versus spinal anesthesia for caesarean section |journal=Cochrane Database of Systematic Reviews |date=10 October 2019 |volume=10 |issue=10 |pages=CD008100 |doi=10.1002/14651858.CD008100.pub2|pmid=31600820 |pmc=6786885 }}</ref>

== Recovery ==
Epidural analgesia is generally well tolerated, with recovery time quick after administration is complete and the epidural is removed. The epidural catheter is usually removed when it is possible to safely switch to oral administration of medications, though catheters can safely remain in place for several days with little risk of bacterial infection,<ref name="Kost1998">{{cite journal |vauthors=Kost-Byerly S, Tobin JR, Greenberg RS, Billett C, Zahurak M, Yaster M | title = Bacterial colonization and infection rate of continuous epidural catheters in children | journal = Anesth Analg | volume = 86 | issue = 4 | pages = 712–6 | year = 1998 | pmid = 9539589 | doi = 10.1097/00000539-199804000-00007 | s2cid = 22716908 | doi-access = free }}</ref><ref name="Kostopanagiotou2002">{{cite journal |vauthors=Kostopanagiotou G, Kyroudi S, Panidis D, Relia P, Danalatos A, Smyrniotis V, Pourgiezi T, Kouskouni E, Voros D | title = Epidural catheter colonization is not associated with infection | journal = Surgical Infections | volume = 3 | issue = 4 | pages = 359–65 | year = 2002 | pmid = 12697082 | doi = 10.1089/109629602762539571 }}</ref><ref name="Yuan2008">{{cite journal |vauthors=Yuan HB, Zuo Z, Yu KW, Lin WM, Lee HC, Chan KH | title = Bacterial colonization of epidural catheters used for short-term postoperative analgesia: microbiological examination and risk factor analysis | journal = Anesthesiology | volume = 108 | issue = 1 | pages = 130–7 | year = 2008 | pmid = 18156891 | doi = 10.1097/01.anes.0000296066.79547.f3 | doi-access = free }}</ref> particularly if the skin is prepared with a [[chlorhexidine]] solution.<ref name="Kinirons2001">{{cite journal |vauthors=Kinirons B, Mimoz O, Lafendi L, Naas T, Meunier J, Nordmann P | s2cid = 20016232 | title = Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial | journal = Anesthesiology | volume = 94 | issue = 2 | pages = 239–44 | year = 2001 | pmid = 11176087 | doi = 10.1097/00000542-200102000-00012 | doi-access = free }}</ref> Subcutaneously tunneled epidural catheters may be safely left in place for longer periods, with a low risk of infection or other complications.<ref name="Aram2001">{{cite journal |vauthors=Aram L, Krane EJ, Kozloski LJ, Yaster M | s2cid = 21017121 | title = Tunneled epidural catheters for prolonged analgesia in pediatric patients | journal = Anesth Analg | volume = 92 | issue = 6 | pages = 1432–8 | year = 2001 | pmid = 11375820 | doi = 10.1097/00000539-200106000-00016 }}</ref><ref name="Bubeck2004">{{cite journal |vauthors=Bubeck J, Boos K, Krause H, Thies KC | title = Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters | journal = Anesthesia & Analgesia| volume = 99 | issue = 3 | pages = 689–93, table of contents | year = 2004 | pmid = 15333395 | doi = 10.1213/01.ANE.0000130023.48259.FB | s2cid = 31939386 | doi-access = free }}</ref> Regardless of the length of use, the effects of a medicine administered epidurally, including numbness if used for analgesia, usually wear off within a few hours of the epidural being stopped, with full recovery of normal function within 24 hours.<ref>{{cite web |title=Epidural |url=https://www.nhs.uk/conditions/epidural/ |website=NHS |publisher=UK [[National Health Service]] |access-date=2 December 2020 |language=en |date=11 March 2020}}</ref>

The use of epidural analgesia during a birth does not have any effect on whether a caesarean section must be performed during future births. Epidural analgesia during childbirth also generally has no negative effects on the long-term health of the mother or child.<ref name="Anim-Somuah2018" /> Use of epidural analgesia versus oral analgesia or no analgesia has no effect on the normal length of hospital stay after childbirth, the only difference being that care must be performed around the epidural insertion site to prevent infection.<ref>{{cite book |last1=Cassanova |first1=Robert |title=Beckmann and Ling's obstetrics and gynecology |date=2018 |publisher=Wolters Kluwer |location=Philadelphia |isbn=978-1-4963-5309-2 |pages=120–126 |edition=8th}}</ref> Following epidural analgesia used for gastrointestinal surgery, the time to recovery of normal gastrointestinal function is not significantly different from recovery time after intravenous analgesia.<ref>{{cite journal |last1=Shi |first1=W.-Z. |last2=Miao |first2=Y.-L. |last3=Yakoob |first3=M. Y. |last4=Cao |first4=J.-B. |last5=Zhang |first5=H. |last6=Jiang |first6=Y.-G. |last7=Xu |first7=L.-H. |last8=Mi |first8=W.-D. |title=Recovery of gastrointestinal function with thoracic epidural vs. systemic analgesia following gastrointestinal surgery: Analgesia and gastrointestinal function |journal=Acta Anaesthesiologica Scandinavica |date=September 2014 |volume=58 |issue=8 |pages=923–932 |doi=10.1111/aas.12375|pmid=25060245 |s2cid=27573664 }}</ref> The use of epidural analgesia during cardiac surgeries may shorten the amount of time a person requires ventilator support following surgery, but it is unknown whether it shortens the overall post-surgery hospital stay overall.<ref>{{cite journal |last1=Jakobsen |first1=Carl-Johan |title=High Thoracic Epidural in Cardiac Anesthesia: A Review |journal=Seminars in Cardiothoracic and Vascular Anesthesia |date=March 2015 |volume=19 |issue=1 |pages=38–48 |doi=10.1177/1089253214548764|pmid=25201889 |s2cid=24662760 }}</ref>

== History ==
{{Main|History of neuraxial anesthesia}}
[[File:Fidel Pagés visiting an injured person in Melilla in the 1909 campaign.gif|thumb|Spanish doctor [[Fidel Pagés]] visiting injured soldiers at the Docker Hospital in Melilla in 1909]]

The first record of an epidural injection is from 1885, when American neurologist James Corning of [[Acorn Hall]] in Morristown, New Jersey, used the technique to perform a [[neuraxial blockade]]. Corning inadvertently injected 111&nbsp;mg of cocaine into the epidural space of a healthy male volunteer,<ref name=Corning1885>{{cite journal|last=Corning|first=JL|title=Spinal anaesthesia and local medication of the cord|journal=New York Medical Journal|volume=42|pages=483–5|year=1885}}</ref> although at the time he believed he was injecting it into the subarachnoid space.<ref name=Marx1994>{{cite journal|last=Marx |first=GF |title=The first spinal anesthesia. Who deserves the laurels? |journal=Regional Anesthesia |volume=19 |issue=6 |pages=429–30 |year=1994 |pmid=7848956}}</ref> Following this, in 1901 Fernand Cathelin first reported intentionally blocking the lowest sacral and coccygeal nerves through the epidural space by injecting local anesthetic through the [[sacral hiatus]].<ref name=":0"/> The loss of resistance technique was first described by Achile Dogliotti in 1933, following which Alberto Gutiérrez described the hanging drop technique. Both techniques are now used to identify when the needle has correctly been placed in the epidural space.<ref name=":3" /><ref name=":0"/>

In 1921 [[Fidel Pagés]], a military surgeon from Spain, developed the technique of "single-shot" lumbar epidural anesthesia,<ref name=Pages1921>{{cite journal|last=Pagés|first=F|author-link=Fidel Pagés|title=Anestesia metamérica|language=es|journal=Revista de Sanidad Militar|volume=11|pages=351–4|year=1921}}</ref> which was later popularized by Italian surgeon Achille Mario Dogliotti.<ref name=Dogliotti1933>{{cite journal|vauthors=Dogliotti AM |title=Research and clinical observations on spinal anesthesia: with special reference to the peridural technique |journal=Current Researches in Anesthesia & Analgesia |volume=12 |issue=2 |pages=59–65 |year=1933}}</ref> Later, in 1931 [[Eugen Aburel]] described using a continuous epidural catheter for pain relief during childbirth.<ref>{{cite journal|vauthors=Curelaru I, Sandu L |title=Eugen Bogdan Aburel (1899–1975). The pioneer of regional analgesia for pain relief in childbirth |journal=Anaesthesia |volume=37 |issue=6 |pages=663–9 |date=June 1982 |pmid=6178307 |doi=10.1111/j.1365-2044.1982.tb01279.x|s2cid=23183413 |doi-access=free }}</ref><ref name=":3">{{cite journal|vauthors=Goerig M, Freitag M, Standl T |date=December 2002 |title=One hundred years of epidural anaesthesia—the men behind the technical development |journal=International Congress Series |volume=1242 |pages=203–212 |doi=10.1016/s0531-5131(02)00770-7}}</ref> In 1941, Robert Hingson and Waldo Edwards recorded the use of continuous caudal anesthesia using an indwelling needle,<ref name="Edwards1942">{{cite journal|vauthors=Edwards WB, Hingson RA |title=Continuous caudal anesthesia in obstetrics |journal=American Journal of Surgery |volume=57 |issue=3 |pages=459–64 |year=1942 |doi=10.1016/S0002-9610(42)90599-3}}</ref> following which they described the use of a flexible catheter for continuous caudal anesthesia in a woman in labor in 1942.<ref name="HingsonJAMA1943">{{cite journal| vauthors=Hingson RA, Edwards WE |title=Continuous Caudal Analgesia in Obstetrics |journal=Journal of the American Medical Association |volume=121 |issue=4 |pages=225–9 |year=1943 |doi=10.1001/jama.1943.02840040001001}}</ref> In 1947, Manuel Curbelo described placement of a lumbar epidural catheter,<ref name=Curbelo1949>{{cite journal|last=Martinez Curbelo |first=M |title=Continuous peridural segmental anesthesia by means of a ureteral catheter |journal= Current Researches in Anesthesia & Analgesia|volume=28 |issue=1 |pages=13–23 |year=1949  |pmid=18105827 |doi=10.1213/00000539-194901000-00002}}</ref> and in 1979, Behar reported the first use of an epidural to administer narcotics.<ref name=Behar1979>{{cite journal|last1=Behar|first1=M|last2=Olshwang|first2=D|last3=Magora|first3=F|last4=Davidson|first4=J|s2cid=37432948|title=Epidural morphine in treatment of pain|journal=The Lancet|volume=313|issue=8115|pages=527–529|year=1979|pmid=85109|doi=10.1016/S0140-6736(79)90947-4}}</ref>

==Society and culture==
Some people continue to be concerned that women who are administered epidural analgesia during labor are more likely to require a cesarean delivery, based on older observational studies.<ref name="Seyb1999">{{cite journal|vauthors=Seyb ST, Berka RJ, Socol ML, Dooley SL|year=1999|title=Risk of cesarean delivery with elective induction of labour at term in nulliparous women|journal=Obstet Gynecol|volume=94|issue=4|pages=600–607|doi=10.1016/S0029-7844(99)00377-4|pmid=10511367}}</ref> However, evidence has shown that the use of epidural analgesia during labor does not have any statistically significant effect on the necessity to perform a cesarean delivery. A 2018 Cochrane review found no increase in the rate of Caesarean delivery when epidural analgesia was employed.<ref name="Anim-Somuah2018" /> However, epidural analgesia does lengthen the second stage of labor by 15 to 30 minutes, which may increase the risk a delivery must be assisted by instruments.<ref name="Liu2004">{{cite journal|vauthors=Liu EH, Sia AT|date=June 2004|title=Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review |journal=BMJ |volume=328 |issue=7453 |page=1410 |doi=10.1136/bmj.38097.590810.7C |pmc=421779 |pmid=15169744}}</ref><ref name="Halpern2004">{{cite journal|vauthors=Halpern SH, Muir H, Breen TW, Campbell DC, Barrett J, Liston R, Blanchard JW|date=November 2004|title=A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor|journal= Anesthesia & Analgesia|volume=99|issue=5|pages=1532–8; table of contents|doi=10.1213/01.ANE.0000136850.08972.07|pmid=15502060|s2cid=42337310|doi-access=free}}</ref>

In the United States in 1998, it was reported that over half of childbirths involved the use of epidural analgesia,<ref>{{cite journal |last1=Vincent RD |first1=Jr |last2=Chestnut |first2=DH |title=Epidural analgesia during labor. |journal=American Family Physician |date=15 November 1998 |volume=58 |issue=8 |pages=1785–92 |pmid=9835854}}</ref> and by 2008 this had increased to 61% of births.<ref name=CDC2008>{{cite report |vauthors=Osterman M, Martin JA |date= 6 April 2011 |title= Epidural and Spinal Anesthesia Use During Labor: 27-state Reporting Area, 2008 |url=https://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_05.pdf |publisher=[[Centers for Disease Control and Prevention]] |access-date=1 November 2020}}</ref> In the United Kingdom, epidurals have been offered through the [[National Health Service]] for all women during childbirth since 1980. By 1998, epidural analgesia was used in the UK for almost 25% of childbirths.<ref>{{cite journal |last1=Burnstein |first1=R. |last2=Buckland |first2=R. |last3=Pickett |first3=J. A. |title=A survey of epidural analgesia for labour in the United Kingdom: Epidural analgesia for labour in the UK |journal=Anaesthesia |date=July 1999 |volume=54 |issue=7 |pages=634–640 |doi=10.1046/j.1365-2044.1999.00894.x|pmid=10417453 |s2cid=39476161 |doi-access=free }}</ref> In Japan, most childbirths take place in primary or secondary hospitals in which epidural analgesia is not offered.<ref>{{cite journal |last1=Suzuki |first1=R |last2=Horiuchi |first2=S |last3=Ohtsu |first3=H |title=Evaluation of the labor curve in nulliparous Japanese women. |journal=American Journal of Obstetrics and Gynecology |date=September 2010 |volume=203 |issue=3 |pages=226.e1–6 |doi=10.1016/j.ajog.2010.04.014 |pmid=20494329}}</ref>

In some developed countries, over 70% of childbirths involve epidural analgesia.<ref>{{cite journal |last1=Bucklin |first1=BA |last2=Hawkins |first2=JL |last3=Anderson |first3=JR |last4=Ullrich |first4=FA | title=Obstetric anesthesia workforce survey: twenty-year update. |journal=Anesthesiology |date=September 2005 |volume=103 |issue=3 |pages=645–53 |doi=10.1097/00000542-200509000-00030 |pmid=16129992|doi-access=free }}</ref> Other studies have shown that minority women and immigrants are less likely to receive epidural analgesia during childbirth.<ref>{{cite journal |last1=Glance |first1=LG |last2=Wissler |first2=R |last3=Glantz |first3=C |last4=Osler |first4=TM |last5=Mukamel |first5=DB |last6=Dick |first6=AW |title=Racial differences in the use of epidural analgesia for labor. |journal=Anesthesiology |date=January 2007 |volume=106 |issue=1 |pages=19–25 |doi=10.1097/00000542-200701000-00008 |pmid=17197841|s2cid=22643036 |doi-access=free }}</ref> Even in countries with universal healthcare coverage such as Canada, socioeconomic factors such as race, financial stability, and education influence the rate at which women receive epidural analgesia.<ref>{{cite journal |last1=Liu |first1=N |last2=Wen |first2=SW |last3=Manual |first3=DG |last4=Katherine |first4=W |last5=Bottomley |first5=J |last6=Walker |first6=MC |title=Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system. |journal=American Journal of Obstetrics and Gynecology |date=March 2010 |volume=202 |issue=3 |pages=273.e1–8 |doi=10.1016/j.ajog.2009.10.871 |pmid=20045506}}</ref> One survey in 2014 found that over half of pregnant women in a Nigerian antenatal clinic (79.5%) did not know what epidural analgesia was or what it was used for, while 76.5% of them would utilize epidural analgesia if offered after it was explained to them.<ref>{{cite journal |last1=Okojie |first1=NQ |last2=Isah |first2=EC |title=Perception of Epidural Analgesia for Labour Among Pregnant Women in a Nigerian Tertiary Hospital Setting |journal=Journal of the West African College of Surgeons |date=October 2014 |volume=4 |issue=4 |pages=142–62 |pmid=27182515|pmc=4866730 }}</ref>

== References ==

{{reflist}}

== Further reading ==

* Boqing Chen and Patrick M. Foye, UMDNJ: New Jersey Medical School, ''Epidural Steroid Injections: Non-surgical Treatment of Spine Pain'', eMedicine: Physical Medicine and Rehabilitation (PM&R), August 2005. Also [http://www.emedicine.com/pmr/topic223.htm available online].
* {{cite journal |vauthors=Leighton BL, Halpern SH | title = The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review | journal = Am J Obstet Gynecol | volume = 186 | issue = 5 Suppl Nature | pages = S69–77 | year = 2002 | pmid = 12011873 | doi = 10.1067/mob.2002.121813 }}
* {{cite journal |vauthors=Zhang J, Yancey MK, Klebanoff MA, Schwarz J, Schweitzer D | title = Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment | journal = Am J Obstet Gynecol | volume = 185 | issue = 1 | pages = 128–34 | year = 2001 | pmid = 11483916 | doi = 10.1067/mob.2001.113874 }}

== External links ==
{{commons category|Epidural anaesthesia}}
* [https://medlineplus.gov/ency/patientinstructions/000484.htm MedlinePlus Encyclopedia]

{{Anesthesia}}
{{Dosage forms|state=expanded}}

{{Authority control}}
{{Use mdy dates|date=September 2016}}

[[Category:Childbirth]]
[[Category:Regional anesthesia]]
[[Category:Obstetrical procedures]]
[[Category:Dosage forms]]
[[Category:Spanish inventions]]