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The majority of patients achieve effective relief of labor pain with a standard infusion of a low-concentration local anesthetic and opioid mixture with a patient-controlled bolus option; however, some patients present with refractory pain. Determining the underlying reason for refractory pain is critical to guide effective treatment, and most cases can be resolved with appropriate intervention.

Refractory pain can be a sign of dysfunctional labor. Inherently in this subset of patient population, they have increased incidence of intrapartum cesarean delivery.1 Prompt management of refractory pain is important to improve maternal satisfaction and ensure the successful conversion of labor epidural analgesia to anesthesia for subsequent cesarean section.


  • To provide a framework for determining the etiology of refractory pain in a patient receiving labor epidural analgesia

  • To describe interventions corresponding to each root factor underlying refractory pain


There are two major categories of scenario in which refractory labor pain occurs: epidural catheter failure versus analgesia failure.

Catheter Failure

It is characterized by failure to achieve or maintain a bilateral sensory block. The catheter may provide effective analgesia after a bolus, but regresses to an inadequate level between boluses. This is usually because the infusion is not targeting the epidural space due to one of the scenarios listed in Table 42-1.

TABLE 42-1Causes and Treatments of Epidural Catheter Failure

Analgesia Failure

It is characterized by presence of refractory pain despite bilateral sensory block. Refractory pain in the setting of a functioning epidural that generates bilateral sensory block can be due to any of the scenarios listed in Table 42-2.

TABLE 42-2Causes and Treatments of Labor Analgesia Failure

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