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  • Initial analgesia provided by intrathecal administration of an analgesic (or mixture)
  • Labor analgesia is maintained using analgesic(s) delivered via an epidural catheter

See Chapters 121, 122, 123, and 124 for Figures.

  • Epidural space accessed using an epidural needle
  • A long spinal needle is passed through the epidural needle into the intrathecal compartment
  • The spinal analgesic is administered and the spinal needle is withdrawn:
    • Most common intrathecal doses are: 2–2.5 mg isobaric 0.25% bupivacaine or 0.2% ropivacaine with 10–20 μg fentanyl or 2–2.5 mg sufentanil
  • An epidural catheter is passed via the epidural needle, aspirated, and secured as usual
  • An epidural infusion is started as usual:
    • Testing of the epidural catheter is not common:
      • Careful aspiration for blood and CSF usually reveals intravascular or intrathecal catheter placement in multiorifice catheters
      • Spinal effects are hard to differentiate from the original spinal dose
      • Intravascular catheter placement testing with diluted epinephrine is notoriously poor in obstetrical patients:
        • Heart rate variability at baseline is considerable due to periods of pain
        • There is no EKG monitoring to assess T-wave amplitude
      • Response to epidural infusion often reveals concealed intrathecal or inadvertent intravascular catheter position:
        • Currently used dilute concentrations of epidural infusions are unlikely to produce rapid, dangerous cephalad spread of neuraxial blockade
        • Do not bolus an “untested” catheter with a full bolus dose immediately after a CSE dose (i.e., without an infusion running for 15–20 minutes) without testing for intrathecal and intravascular placement first as it may produce inadvertent high blocks or local anesthetic toxicity
    • Starting an epidural infusion straightaway allows onset of epidural analgesia by the time the spinal dose wears off
    • Adjust inadequate level of initial analgesia by bolusing the epidural catheter:
      • Initial doses may need to be reduced by about half
      • After about 30–45 minutes, usual “top-up” boluses should have the same effect as with a routine labor epidural

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Comparison with Epidural Analgesia for Labor Pain
Combined spinal epiduralEpidural
Rapid onsetSlower onset
Good or excellent initial analgesia in most casesInitial analgesia good or satisfactory in most cases
Overall satisfaction with labor analgesia is the same
Good option in late first stage of laborSacral spread is poor; may not provide analgesia in patients presenting in advanced labor
Clear end point on insertion (CSF)Placement is determined on subjective “feel”
Fewer failed epidural catheters in less experienced hands
Postdural puncture headache incidence is ˜0.5–1%Postdural puncture headache incidence is ˜1%
There have been recent reports of meningitis cases in healthy pregnant womenMeningitis in healthy pregnant women is exceedingly rare (no large-volume study has included cases of healthy pregnant women until now)
Maintenance of a sterile technique with cap/mask on everyone present in the room is important
Fetal bradycardia incidence increases with dose of intrathecal narcotic (use ≤20 μg fentanyl or ≤2.5 μg sufentanil)Fetal bradycardia with epidural narcotics has been observed
Rapid onset of sympathectomy; increased use of ...

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