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BACKGROUND

Neuraxial analgesia is the most effective modality for pain control during labor and delivery and is used in ∼70% of laboring women in the United States.1,2 Compared to other pharmacologic and nonpharmacologic analgesic modalities, neuraxial analgesia provides better pain relief during the first and second stages of labor, improves patient attentiveness and cooperation, offers anesthesia for assisted vaginal delivery or cesarean delivery if necessary, and avoids the potentially negative maternal and neonatal respiratory effects of systemic opioid administration.3 Over the past several decades, neuraxial options for labor analgesia have expanded from the standard epidural to include combined spinal epidural (CSE) and dural puncture epidural (DPE).

NEURAXIAL PROCEDURES

Neuraxial procedures for labor are typically placed in the L3-4, L4-5, or L5-S1 interspace.3 The epidural space is commonly identified using the loss of resistance technique, a catheter is threaded into the space to allow for longer-term analgesia. If a CSE or DPE technique will be used, a small gauge spinal needle (usually 25-27 G) is inserted through the epidural needle (“needle-thru-needle” technique) until a “pop” is felt, and cerebrospinal fluid returns through the spinal needle. If spinal medication is desired, a small dose of local anesthetic medication (e.g., bupivacaine or ropivacaine) usually combined with a small dose of opioid (e.g., fentanyl or sufentanil) is injected into the intrathecal space. Then the spinal needle is removed, and a catheter is threaded into the epidural space to allow for longer-term analgesia.1 A test dose should be administered to ensure that the epidural catheter is not intravenous or intrathecal. If no spinal medication was injected, the epidural catheter should be induced with a bolus of medication. We use 15 mL of the Beth Israel Deaconess standard solution (0.04% bupivacaine, fentanyl 1.67 µg/mL, epinephrine 1.67 µg/mL).

MAINTENANCE OF ANALGESIA

There are several techniques used to provide epidural analgesia. Continuous epidural infusion (CEI) using a set rate on an infusion pump allows for stable analgesia. When using the CEI technique, clinician bolus doses are administered when necessary to improve labor analgesia, or to provide additional analgesia for episiotomy, assisted vaginal delivery, repair of perineal tears after delivery, or to provide anesthesia for cesarean delivery.3

Patient-controlled epidural analgesia (PCEA) involves a patient self-administering preprogrammed boluses from an automated pump. This technique yields lower total local anesthetic dose, reduced number of clinician boluses, and decreased motor block compared to CEI.1,3 Some studies also suggest higher patient satisfaction, possibly due to increased perceived control over the analgesic process.1,3 The PCEA technique can be combined with CEI, in which a patient receives a basal infusion and can be given additional self-administered boluses with a set lockout interval.1,3 This combined CEI-PCEA technique provides improved analgesia and fewer clinician boluses compared to PCEA alone, although higher total doses of local anesthetic are administered.1

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