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:

• women in labour who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labour
• 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
• it is recommended that combined spinal-epidural analgesia is established with bupivacaine and fentanyl
• it is recommended that epidural analgesia is established with a low-concentration local anaesthetic and opioid solution with, for example, 10-15 ml of 0.0625-0.1% bupivacaine with 1-2 micrograms per ml fentanyl. The initial dose of local anaesthetic plus opioid is essentially a test dose and as such should be administered cautiously to ensure that inadvertent intrathecal injection 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
• high concentrations of local anaesthetic solutions (0.25% or above of bupivacaine or equivalent) should not be used 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

Reference:

1. NICE (September 2007).Intrapartum care