What are the recommended approaches for labor analgesia?

Recommended Approaches for Labor Analgesia

Neuraxial analgesia techniques are the most effective, commonly used, and versatile methods for labor pain management and should be offered to all eligible parturients who request pain relief during labor.

Neuraxial Analgesia Options

Epidural Analgesia

• Recommended solution: Bupivacaine 0.1-0.125% with fentanyl 2-2.5 μg/ml 1
• Administration methods:
  • Patient-controlled epidural analgesia (PCEA)
  • Programmed intermittent epidural bolus (PIEB)
  • Continuous infusion (typically 1-3 ml/h)
• Benefits:
  • Superior pain relief compared to non-neuraxial methods 2
  • Mother remains alert and participatory in the birth process 3
  • Can be extended for operative delivery if needed 3
  • Reduces physiological stress responses to labor pain 3

Combined Spinal-Epidural (CSE)

• Indications: Particularly beneficial when rapid onset analgesia is needed (e.g., advanced labor ≥6 cm dilation) 4
• Typical intrathecal dose: Sufentanil 5-10 μg ± bupivacaine 2.5 mg 4
• Benefits:
  • Faster onset of analgesia (<5 minutes) 4, 5
  • Better sacral coverage 5
  • Less motor blockade initially 4
  • Higher maternal satisfaction due to rapid pain relief 4

Dural Puncture Epidural (DPE)

• A newer technique that combines benefits of CSE and traditional epidural
• Intentional dural puncture with a spinal needle (without medication administration) followed by epidural catheter placement
• Benefits: Faster onset, greater bilateral spread, and lower failure rates than traditional epidural 5

Intrathecal Catheter (after accidental dural puncture)

• When accidental dural puncture occurs during epidural placement, threading the catheter intrathecally is an option
• Maintenance solution: Same as epidural - bupivacaine 0.1-0.125% with fentanyl 2-2.5 μg/ml 1
• Administration: Either intermittent boluses (up to 2.5 mg) or continuous infusion (1-3 ml/h) 1
• For breakthrough pain: Up to 2 ml bolus of the same solution 1

Monitoring During Neuraxial Analgesia

Vital Signs Monitoring

• Blood pressure every 5 minutes for at least 15 minutes after initial dose and subsequent top-ups 1
• Continuous fetal heart rate monitoring for 30 minutes after initiation 1
• Once stable, hourly blood pressure monitoring 1

Neurological Monitoring

• Motor function: Hourly assessment using straight-leg raise test (ability to raise heel off bed against gravity) 1
  • Alert anesthetist if unable to straight-leg raise 1
• Sensory block: Assess hourly 1

Special Considerations

COVID-19 Patients

• Neuraxial analgesia is preferred over general anesthesia for COVID-19 patients 1
• No reported neurological complications after neuraxial procedures in COVID-19 patients 1
• Standard PPE and infection control measures should be followed 1

Cardiovascular Disease

• Lumbar epidural analgesia is often recommended for patients with cardiovascular disease 1
• Benefits include:
  • Reduces pain-related elevations of sympathetic activity
  • Reduces urge to push
  • Provides anesthesia for surgery if needed
• Caution with regional anesthesia in patients with obstructive valve lesions due to risk of hypotension 1

Complications and Management

Dense or Unexpected Block

• If profound motor and sensory block develops:
  • Discontinue epidural infusion/withhold next top-up
  • Immediate assessment by anesthesiologist 1
  • Consider removing/resiting the epidural 1

Breakthrough Pain

• For epidural: Assess catheter function, consider repositioning or replacement
• For intrathecal catheter: Give up to 2 ml bolus of the same solution 1
• If analgesia remains inadequate after additional bolus, remove catheter and consider alternative analgesia 1

Post-Dural Puncture Headache

• Risk is approximately 52-60% after accidental dural puncture 1
• Intrathecal catheter placement may potentially reduce incidence and severity 1

Non-Pharmacological Methods

• Continuous labor support has been shown to decrease the use of pharmacologic analgesia and shorten labor 2
• Intradermal water injections may decrease back labor pain 2
• These methods can complement but not replace neuraxial analgesia for effective pain relief

Algorithm for Labor Analgesia Selection

1. Assess patient factors:

   • Stage and progress of labor
   • Anticipated mode of delivery
   • Medical comorbidities
   • Coagulation status
   • Patient preference

2. For early labor:

   • Traditional epidural with low-dose local anesthetic/opioid combination

3. For advanced labor (≥6 cm):

   • Consider CSE for rapid onset

4. For patients with anticipated difficult airway:

   • Prioritize early neuraxial placement to avoid general anesthesia if emergency cesarean delivery needed 1

5. After accidental dural puncture:

   • Consider threading catheter intrathecally rather than re-siting 1

Remember that neuraxial analgesia does not increase cesarean delivery rates compared to systemic opioids, though dense blocks may increase instrumental vaginal delivery risk 2.