• Epidural analgesia provides the most effective form of pain relief during labour and birth.
• An epidural may be sited provided that the parturient has been consented, and absolute contra-indications have been ruled out and relative contra-indications have been considered.
• The parturient must have one-to-one midwifery care.
• Any epidural block that is ineffective should be highlighted to the duty anaesthetist at the earliest opportunity to prevent any associated complications or failures.

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Abbreviations

1.1 Epidural analgesia

Epidural analgesia provides the most effective form of pain relief during labour and birth ¹. Epidural analgesia in labour is available at all times to labouring women at Frimley Park Hospital (FPH) and Wexham Park Hospital (WPH).

Epidural analgesia may be chosen by the woman or may be advised by the obstetric team for certain conditions. Information on pain relief in labour is included in maternity notes and has been designed to assist women in making informed choices concerning analgesia during labour and birth. An “Epidural Information Card”, devised by the Obstetric Anaesthetists’ Association (OAA), is available in a range of languages on the OAA website and on the labour ward.

Epidural analgesia is an effective method of pain relief during labour for about 93% of women who have one². About 6-8% find their epidurals only partially effective. All mothers should be informed of the potential advantages and disadvantages of having an epidural. Women in labour who desire regional analgesia should not be denied it. This includes women in severe pain in the latent first stage of labour.

In 2024 the trust changed from PCEA alone, to PIEB with PCEA for labour epidural analgesia. These changes have been made using the latest research in obstetric anaesthesia and are similar to a growing number of other trusts in the United Kingdom. The aim of PIEB with PCEA is to deliver a better analgesic experience to the patient while simultaneously lowering the total local anaesthetic dose and, therefore, reducing the change of local anaesthetic toxicity or other side effects ^{3, 4}.

1.2 Advantages

• Parturients report less pain and are more satisfied with epidural analgesia compared to opioid analgesia⁵.

• There is significantly improved neonatal acid-base status compared to opioid analgesia⁶.

• Epidurals have no effect on breastfeeding in comparison to intrapartum opioids which may delay the establishment of lactation⁷.

1.3 Disadvantages:

• Epidurals are associated with a longer second stage of labour and an increased chance of vaginal instrumental birth⁸.

• Epidurals are associated with an increased risk of raised maternal temperature but are not associated with sepsis or increased need for neonatal antibiotic use.

There are a number of side effects and complications from the use of an epidural which should be discussed with the parturient ideally antenatally or at least prior to its insertion.

Evidence shows that use of epidural analgesia are not associated with long term backache, a longer first stage or increased incidence of caesarean section. ^1,8,9

Analgesia without anaesthesia, proprioceptive block or motor block: Neuraxial blockade should produce a barely perceptible sensory block from T10-S5 with retention of sensation without pain and the maintenance of motor power allowing mobility.

• Patient refusal

• Severe systemic sepsis

• Infection at site of insertion

• Raised intracranial pressure

• Allergy to amide local anaesthetics and/or opioids

• Non-availability of a trained midwife for continuous one-to-one care of the parturient for the duration of the block*

• Neurological disease: if possible, the patient should be seen antenatally. Perform and document a full neurological examination.

• Gross spinal deformity / previous surgery: no contraindications but explain that the success of the procedure is reduced, due to the possibility of poor spread of solutions, particularly in the epidural space.

• Maternal pyrexia: preferable to wait for 1 hour after the first dose of antibiotics has been given.

• Patients with fixed cardiac output states (aortic stenosis, mitral stenosis, HOCM)

• Coagulopathy / thrombocytopenia - pathological / pharmacological.

• Haemorrhage resulting in cardiovascular instability or hypovolaemia.

• Anatomical abnormalities.

In these cases, or if ever in doubt, contact the on-call consultant anaesthetist for advice.

5.1

• Ensure vital signs have been recorded in the 30 minutes before epidural insertion¹⁰.

• Check blood test results if appropriate (e.g., pre-eclampsia).

• Offer the woman the epidural information card to read while waiting for the anaesthetist. This can be found on the labour ward, and downloaded in many languages: http://www.oaa-anaes.ac.uk/

• Site a 16g intravenous cannula. If there are concerns, leave this task for the anaesthetist.

• Call the anaesthetist on bleep 5112 (FPH), bleep 4490 (WPH).

• Remain in the room during epidural insertion to assist the anaesthetist and care for the woman and her partner.

• Once the first dose of drugs is given through the epidural catheter, perform observations of blood pressure every 5 minutes for 20 minutes and record on the patient’s EPIC flowsheet.

• Every 30 minutes, the following should be documented: BP, respiratory rate, pain score, change of position and Waterlow score.

• Every 60 minutes, the level of block and ability to straight leg raise should be documented.

• The block should be tested with ethyl chloride spray or cool metal sticks every hour. The midwife should chart level of block and ability to straight leg raise in the patient’s EPIC notes (see 5.2).

• The block should be up to T10 (umbilicus); if the block is inadequate or rises above T6, stop the infusion and inform the anaesthetist.

• Continuous electronic fetal heart rate monitoring (EFM) should be in place for at least 30 minutes from the time of epidural insertion and following any bolus top up of 10ml or more.1 In the absence of any other indication for continuous EFM intermittent auscultation can be resumed.

• Do not leave the woman unattended during the 20minute period after any bolus. This is the time that most serious complications occur, e.g., hypotension, fetal distress, etc.

• If the BP drops rapidly, or is less than 90mmHg, or patient feels nauseated or faint, put patient in left lateral position, give O2 via a facemask and give a fluid bolus. Call the anaesthetist in this situation. It may be advisable to stop any oxytocin that is running at the time.

• Analgesia should NOT be allowed to wear off in the second stage1.

• Do NOT lie the woman flat on her back10.

• If the pain is predominantly on one side, lie the woman on that side for the top-up (ANAESTHETIST ONLY) and leave her on that side for at least 10 minutes after the top up.

• No epidurals should be done in the Birth Centre (WPH) or Mulberry Unit (FPH).

• The midwife is responsible for removing the epidural catheter on the labour ward. She must check that the tip is complete and record this in the notes. The bag of levo- bupivacaine + fentanyl solution must be disposed of in a safe manner.

5.2 Neurological Monitoring

• Serious neurological lesions such as vertebral canal haematoma are rare after labour epidural, but early detection may be crucial to avoid permanent damage. This may be hindered by the variable and sometimes prolonged recovery after ‘normal’ labour epidural block, such that an underlying lesion may be missed¹².

• It is recommended that the midwife monitors the motor block hourly by assessing the woman’s straight-leg raise (being able to raise the heel off the bed against gravity, even if not sustained). The reason for hourly assessment is that there is a limited time available to salvage serious lesions, and midwives are already required to monitor the sensory block hourly to be compliant with NICE guidance. The recommendation can be applied with a degree of flexibility, e.g. if a low-risk woman with uncomplicated epidural analgesia, with no motor block when assessed at 02:00, is due for her next vaginal examination at 03:30, it would be reasonable to defer the 03:00 test of motor block until 03:30, just before the vaginal examination, to allow her to catch up on sleep.

• The midwife should alert the anaesthetist if a woman is unable to straight-leg raise. This may not require further escalation/management depending on the individual circumstances of the case but should be kept under review. Any woman with profound motor or sensory block should be assessed by the anaesthetist and where there is concern, management should be escalated (see escalation guideline below). Neurological impairment caused by epidural haematoma may become permanent if not detected and managed within 8-12 h.

• Women should be informed of the likely timescale for resolution of their labour epidural block and encouraged to alert staff should this be delayed.

• The Bromage scale is a standardised method used for documentation of the resolution or persistence of motor block.

• Attend as soon as possible, and within 30 minutes of request.¹ If that is not possible, consider the need to call another anaesthetist, including the on-call consultant, and inform the midwife of possible delay. No woman should wait longer than 1 hour save for exceptional circumstances; call for help if the wait is likely to be more than 30 minutes. Record on the labour epidural procedure on EPIC the time you were called and the time you attended the patient.

• Assess the woman including history and examination.

• Take consent. This should usually be documented using the anaesthetic consent form on EPIC. Verbal consent is adequate with documentation of aspects discussed.

• Ensure a 16g intravenous cannula is in situ.

• Site and secure epidural catheter using aseptic technique.

• Consider calling for help after 20 minutes of failed attempts.

• Give a test dose of 10mL “low-dose local anaesthetic mixture’” (0.1% levo-bupivacaine + 2 microgram/ml fentanyl) using the “clinician bolus” function on the epidural pump. After 10 minutes a second 10mL can be given provided there are no signs of intrathecal administration of the test dose.

DRUGS GIVEN DOWN THE EPIDURAL CATHETER SHOULD ONLY BE ADMINISTERED BY THE ANAESTHETIST; THE EPIDURAL INFUSION SHOULD ONLY BE CONNECTED BY AN ANAESTHETIST.

• Document anaesthetic assessment on the pre-procedure assessment document on EPIC, and document the procedure information using the labour epidural procedure note on EPIC (found on the intra-operative tab).

• Ensure that relevant drugs are prescribed on the patient’s ‘Orders’ tab on EPIC, including omeprazole orally.

• Review after 30 minutes to ensure that the epidural is working in a satisfactory manner and prescribe PCIB with PCEA protocol for the continuing management of epidural analgesia.

• Ensure the patient understands when to press the button on the pump, in order to maintain an adequate block.

• If hypotension occurs after a bolus, attend to the patient, and in addition to left lateral position, oxygen and fluids, you may need to administer ephedrine.

• If analgesia is inadequate, take measures to make it adequate. This may mean replacing the epidural if satisfactory analgesia is not achieved within 60 minutes. This is especially important in women who are at risk of caesarean.

• In the event of a dural tap, see ‘Dural Puncture and Dural Puncture Headache’.

• It is vital that any epidurals that are sited in labour are regularly checked by the anaesthetist (every 2-4hrs, or more regularly if there is a problem)¹¹.

7.1 Both labour wards at Frimley Health NHS Foundation Trust have standardised their epidural infusion protocols to utilize the PIEB with PCEA programming as set out below.

7.2 PIEB with PCEA should be started if the parturient is likely to require more than 1 hour of analgesia. Occasionally an extra bolus may be required to maintain completely satisfactory pain relief.

7.3 The following should be carried out by the midwives (FPH) or the anaesthetists (WPH):

7.3.1 Ensure that the woman understands how to use PCEA button

7.3.2 Wait until the epidural is working effectively, then set up a PCEA with PIEB system using a 250ml bag of levo-bupivacaine 0.1% with fentanyl 2microgram/ml delivered via a trust epidural pump set to the labour analgesia protocol

7.3.3 The pump is automatically set to deliver two programs at once:

7.3.3.1 Programmed Intermittent Epidural Bolus (PIEB): a bolus of 7mL of levo-bupivacaine 0.1% with fentanyl 2microgram every 60 minutes

7.3.3.2 Patient Controlled Epidural Analgesia (PCEA): a bolus of 6mL of levo-bupivacaine 0.1% with fentanyl 2microgram up to every 20 minutes when requested by the patient using the PCEA button

7.3.4 If the epidural is not working well, call the anaesthetist before starting the pump protocol.

Call the anaesthetist if: • The pain is not improving • The woman is hypotensive • The block is at or above T6 • The respiratory rate is less than 10/min • Any other concern

Continue the epidural until the end of the third stage or until the patient needs to go to theatre.

8.1 This technique may be chosen by the anaesthetist for a number of reasons, but particularly if rapid analgesia is required.¹ The principles of care are as for epidural insertion.

8.2 A Combined Spinal Epidural (CSE) may be carried out via a needle-through-needle technique or using separate injections. An intrathecal injection of EITHER 2.5ml 0.1% levo-bupivacaine with 2microgram/ml fentanyl OR 1ml of 0.25% bupivacaine +/- 25micrograms fentanyl is administered. An epidural catheter is placed following this spinal injection. The spinal component of the procedure provides rapid analgesia (including excellent sacral analgesia) which lasts around 90 minutes. Once the spinal is wearing off the epidural catheter can be used to deliver low dose bag mix (0.1% levo-bupivacaine with 2microgram/ml fentanyl) via the PIEB with PCEA pump protocol.

8.3 Points to note are:

• Observations following the spinal drugs given should be taken every 5 minutes for 20 minutes and recorded.

• The first dose of epidural medication must be given by an anaesthetist who should be alerted as soon as the analgesia from the spinal shows signs of beginning to wear off.

• The administration of epidural test dosing should be as for a normal epidural.

• Subsequent analgesia will continue using PIEB with PCEA.

9.1 A good sign of an effective block is warm dry feet; this is a very sensitive sign in picking up a unilateral block.

9.2 Inadequate analgesic blocks are never improved by giving more concentrated solutions of local anaesthetic.

The trick with a failing block is to use the same mass of drug, and not to increase the concentration. Try to avoid stronger mixtures, as they do seriously impair mobility, and can lead to prolonged labour, and exacerbate the pain in the unblocked area.

Instead consider the following:

• Re-positioning patient

• Withdrawing catheter by 1-2cm

• Increasing the volume rather than the dosage

• Adding additional opioids

• Re-inserting a new epidural block.

9.3 Intractable back/sacral pain: Often caused by occipito-posterior (OP) position. It may not be attenuated by even the best block. In this situation, 100microgram fentanyl diluted to 10ml and administered epidurally, with the patient sitting upright can help. Consider a low dose spinal injection (ie 2.5mg total bupivacaine) for short term rescue analgesia.

9.4 Unilateral block: check previous top-up has been given in a lateral position (painful side down). Try this if not previously attempted. If this fails and the patient is not too distressed, consider withdrawing catheter 1-2 cm and give one more top-up. If this fails, replace the epidural catheter in a different space.

N.B Missed segments may occur if air is used for loss of resistance; these can be managed similarly to a unilateral block.

9.5 Patchy block: Consider the possibility of a subdural block (characterised by a negative epidural test dose followed by a high sensory block with motor sparing). Manage hypotension with left lateral positioning, fluids and vasoconstrictors if necessary. The anaesthetist should be called if the BP drops rapidly or SBP is <90mmHg. (See ‘Hypotension during Regional Block in Obstetric Patient’ guideline). Reassure the patient and advise patient of likely rapid regression of the high sensory block after 1 hour. Re-site the epidural.

9.6 Do allow the patient to use Entonox, as well as the epidural, especially in the 2nd stage.

9.7 TOP UPS SHOULD ONLY BE GIVEN BY AN ANAESTHETIST.