decrease in the amount of milk produced. Technique Anatomy An epidural is injected into the epidural space, inside the bony spinal canal but just outside the 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. 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. Insertion 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. The person receiving the epidural may be seated, or lying on their side or stomach. 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 termination of the spinal cord. 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 processes. When using a paramedian approach, the tip of the needle passes along a shelf of vertebral bone called the lamina until just before reaching the ligamentum flavum and the epidural space. 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 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. In addition to the loss of resistance technique, direct