What are the guidelines for labor analgesia?

Guidelines for Labor Analgesia

Neuraxial analgesia is the preferred method for labor pain management due to its effectiveness, safety profile, and ability to be rapidly converted to surgical anesthesia if needed. 1

Neuraxial Analgesia Options

Epidural Analgesia

• Standard technique: Most commonly used method for labor analgesia
• Medication regimen:
  • Bupivacaine 0.1-0.125% with fentanyl 2-2.5 μg/ml is recommended 1
  • Can be administered via continuous infusion (1-3 ml/h) or intermittent boluses
  • Patient-controlled epidural analgesia (PCEA) is an effective option

Intrathecal (Spinal) Analgesia

• Used in specific situations or as part of combined spinal-epidural technique
• For maintenance via intrathecal catheter (after inadvertent dural puncture):
  • Use bupivacaine 0.1-0.125% with fentanyl 2-2.5 μg/ml 1
  • Can be given as intermittent boluses (up to 2.5 mg) or continuous infusion (1-3 ml/h)
  • For breakthrough pain, give up to 2 ml of the same solution 1

Combined Spinal-Epidural (CSE)

• Provides rapid onset of analgesia with ability to extend duration
• May allow more rapid motor recovery than spinal anesthesia alone 1
• Particularly useful for advanced labor

Monitoring Requirements

During Labor with Neuraxial Analgesia

• Blood pressure monitoring every 5 minutes for at least 15 minutes after initial dose and subsequent top-ups 1
• Hourly monitoring once stable:
  • Sensory level of block
  • Motor function (straight-leg raise test)
  • Blood pressure
• An anaesthetist should remain with the patient for at least 10 minutes after initial bolus 1

Post-Procedure Monitoring

• Straight-leg raising should be used to assess motor block recovery 1
• If unable to straight-leg raise at 4 hours after the last dose, the anaesthetist should be called to assess 1
• Women should be informed about expected resolution timeframes and encouraged to report delayed recovery 1

Special Considerations

Management of Breakthrough Pain

• For continuous infusion: give up to 2 ml of the same solution used for maintenance 1
• If analgesia remains inadequate after an additional bolus, consider:
  • Removing the catheter
  • Re-siting the epidural
  • Using alternative forms of analgesia 1

COVID-19 Considerations

• Neuraxial analgesia should be maintained as the preferred method even during COVID-19 pandemic 1
• Check platelet count before epidural placement in symptomatic COVID-19 patients due to potential thrombocytopenia 1
• Avoid nitrous oxide for labor analgesia during COVID-19 pandemic due to aerosolization risk 1

Complications and Safety

• Each maternity unit should have guidelines for escalation of care if neurological concerns arise 1
• Unexpectedly dense or persistent motor block may indicate serious complications requiring urgent assessment 1
• Serious neurological complications are rare but require early detection to prevent permanent harm 1

Alternative Methods

• Patient-controlled intravenous analgesia (PCIA) with opioids
• Non-pharmacological methods (breathing techniques, water immersion, etc.)
• Nitrous oxide (except during COVID-19 pandemic)

The evidence strongly supports neuraxial techniques as the most effective methods for labor pain management, with epidural analgesia being the gold standard. Proper monitoring protocols are essential to ensure safety and early detection of rare but serious complications.