Epidural analgesia in labour

In the first stage of labour an epidural analgesia is required to block T8-L5. It should include a block of S2-S4 in the second stage of labour.

Epidural analgesia is indicated in labour for:

• maternal distress as a result of painful uterine contractions which are not being adequately controlled by simple analgesia e.g. pethidine, nitrous oxide
• anaesthesia for a forceps delivery or vacuum extraction
• hypertension: pregnancy-induced and chronic. Epidural analgesia is helpful in lowering blood pressure as well as reducing the amount of sedation required
• caesarian section
• if desired by the woman in labour (1)

NICE (1) note:

• if, after a discussion of the benefits and risks, a woman in labour chooses regional analgesia, support her decision
• either epidural or combined spinal-epidural analgesia is recommended for establishing regional analgesia in labour
• if rapid analgesia is required, combined spinal-epidural analgesia is recommended
• establish combined spinal–epidural analgesia with bupivacaine (or an equivalent local anaesthetic) and fentanyl
• establish epidural analgesia with a low-concentration local anaesthetic and fentanyl solution
  • the initial dose is essentially a test dose, so administer it cautiously to ensure that inadvertent intrathecal or intravascular placement of the epidural catheter has not occurred
• low-concentration local anaesthetic and opioid solutions (0.0625-0.1% bupivacaine or equivalent combined with 2.0 micrograms per ml fentanyl) are recommended for maintaining epidural analgesia in labour
• do not use high concentrations of local anaesthetic solutions (0.25% or above of bupivacaine or equivalent) routinely for either establishing or maintaining epidural analgesia
• either patient-controlled epidural analgesia or intermittent bolus given by healthcare professionals are the preferred modes of administration for maintenance of epidural analgesia

Notes:

• a study of 495,695 births (114,897 with epidural analgesia during labour) found no clinically significant increase in neonatal morbidity, death, or childhood cerebral palsy (2):
  • findings support wider, equitable access to epidural analgesia as a safe component of intrapartum care

Reference:

1. NICE (September 2023).Intrapartum care
2. Kearns R J, Kyzayeva A, Singh S, Lawlor D A, Shaw M, Nelson S et al. Epidural analgesia in labour and neonatal and childhood outcomes: national population based cohort study. BMJ 2026; 394 :e343320.