Guideline for the Management of Epidural Analgesia in Labour

Document Control:
The care of women in labour requiring epidural analgesia
For Use In:
Delivery suite, Maternity Services
Search Keywords Labour, analgesia, epidural, regional anaesthesia, neuraxial
Document Author: Dr Joanna Walker, Consultant Anaesthetist
Document Owner: Women and Children Division
Maternity Clinical Guidelines Committee
Approved By:
Clinical Guidelines Assessment Panel
Ratified By: Clinical Safety and Effectiveness Sub-board
Date to be
reviewed by:
This document
Approval Date: 13th June 2023 remains current 13th June 2026
after this date
but will be
under review
Implementation Date: N/A

Reference Number: 1305

Version History:
Version Date Author Reason/Change
Dr Jonathon Francis,
V4.0 02/02/2018 Consultant
Anaesthetist
Updated: responsibilities for set-up,
indications/contraindications,
PIEB/PCEA prescription regimes,
Dr Joanna Walker.
recommended observations,
V5.0 26/05/2023 Consultant
trouble-shooting ineffective
Anaesthetist
epidurals and guidance on
neurological monitoring with labour
epidural have been added.

Previous Titles for this Document:

Previous Title/Amalgamated Titles Date Revised
N/A N/A

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 1 of 25
Guideline for the Management of Epidural Analgesia in Labour

Distribution Control
Printed copies of this document should be considered out of date. The most up to
date version is available from the Trust Intranet.

Consultation
The following were consulted during the development of this document: Consultant
Obstetric Anaesthetist Group, Consultant Obstetrician Group, Practice Development
Midwife Group.

Monitoring and Review of Procedural Document

The document owner is responsible for monitoring and reviewing the effectiveness of
this Procedural Document. This review is continuous however as a minimum will be
achieved at the point this procedural document requires a review e.g. changes in
legislation, findings from incidents or document expiry.

Relationship of this document to other procedural documents

This document is a clinical guideline applicable to Norfolk and Norwich University
Hospital Trust please refer to local Trust’s procedural documents for further
guidance, as noted in Section 5.

Inclusivity
Within this document we use the terms pregnant women, her/she. However, It is
important to acknowledge that it is not only people who identify as women for whom
it is necessary to access care. Maternity services and delivery of care must therefore
be appropriate, inclusive and sensitive to the needs of those individuals whose
gender does not identity does not align with the sex they were assigned at birth.

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 2 of 25
Guideline for the Management of Epidural Analgesia in Labour

Contents Page
Quick reference ..........................................................................................................5
1.Introduction .............................................................................................................6
1.1.Rationale ...........................................................................................................6
1.2.Objective ...........................................................................................................6
1.3.Scope .................................................................................................................6
1.4.Glossary ............................................................................................................6
2.Responsibilities and Roles.....................................................................................7
2.1.Anaesthetists.....................................................................................................7
2.2.Midwives............................................................................................................7
2.3.Delivery Suite Co-Ordinator.............................................................................7
3.Processes to be followed .......................................................................................8
3.1.Indications ........................................................................................................8
3.1.1.Absolute Indication:......................................................................................8
3.1.2.Relative Indication:.......................................................................................8
3.2.Contraindications..............................................................................................8
3.2.1.Absolute Contraindications:..........................................................................8
3.2.2.Relative Contraindications (discuss with Consultant Anaesthetist):............8
3.3.Patient Consent.................................................................................................9
3.4.Insertion of an Epidural....................................................................................9
3.4.1.Midwife Actions:............................................................................................9
3.4.2.Anaesthetists Actions:................................................................................10
3.5.Setting up the epidural infusion pump.........................................................11
3.6.Establishing epidural analgesia for labour analgesia.................................11
3.7.Maintenance and monitoring of epidural for labour analgesia..................12
3.8.Changing the Epidural Bag............................................................................14
3.9.Patient Controlled Epidural Analgesia (PCEA) ...........................................15
3.10.Review of Patients with Epidurals During Labour....................................15
3.11.Trouble-Shooting Ineffective Epidurals......................................................15
3.12.Management of Complications of Epidural Analgesia..............................16
3.13.Emergency Drugs to be available on delivery suite at all times..............17
3.14.Mobilisation and positioning ......................................................................17
3.15.Caesarean sections and assisted deliveries in theatre............................17
3.16.Removal of epidural catheter.......................................................................17
3.17.Care of Epidural Related Equipment..........................................................18
3.17.1.Epidural trolleys........................................................................................18
3.17.2.Epidural pumps.........................................................................................18
3.18.Anaesthetic Follow-up .................................................................................18

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 3 of 25
Guideline for the Management of Epidural Analgesia in Labour

3.19.Serious Complications – Post Epidural......................................................19

4.Related Documents ..............................................................................................19
5.References .............................................................................................................19
6.Monitoring Compliance of the service to be delivered .....................................20
7.Appendices.............................................................................................................21
7.1.Appendix A: Obstetric Neuraxial Analgesia Chart......................................21
7.2.Appendix B: Troubleshooting Labour Epidural Quick Reference Guide. 23
7.3.Appendix C: Neurological Monitoring After Epidural.................................24
8.Equality Impact Assessment (EIA) .....................................................................25

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 4 of 25
Guideline for the Management of Epidural Analgesia in Labour

Quick reference
1. Confirm indication/contraindication for epidural analgesia (see page 8)
2. Patient has read the Epidural information card
3. Check with Midwife in charge regarding safe staffing levels and provision of
one-to-one care
4. Informed verbal consent taken by Anaesthetist
 Complete epidural anaesthetic chart (Appendix A)
5. Patent wide bore IV cannula (16-18G) in-situ
6. Midwife to establish adequate CTG monitoring and assess foetal wellbeing
(see Trust guideline for the use of Fetal Monitoring and Blood Sampling Trust
Doc ID 840)
7. Anaesthetist to insert epidural, prescribe, set up pump and connect to patient
 Levobupivacaine 0.1% plus fentanyl 2micrograms/ml is the standard
infusion mix for labour analgesia
8. Ensure an anti-emetic and omeprazole are prescribed, with oxygen as
required
9. Ensure the following are available in the room:
 Hartmann’s solution, emergency pre-filled syringe of ephedrine
10.Anaesthetist must be present for initial or ‘test-dose’ and first blood pressure
11.Midwife to record observations on epidural anaesthetic chart
 Blood Pressure and Heart Rate: Every 5 minutes after initial dose for
20 minutes. Thereafter dependent on PIEB/PCEA regime (see page 11
Table 2: Epidural regime prescription and HR/BP monitoring)
 Motor Score (straight leg raise): Every 1 hour
 Sensory Score (upper and lower levels of sensation to cold): Every 1
hour
 Pain Score: Every 1 hour
 Any concerns with observations or epidural efficacy should be
escalated to the anaesthetist
12.A urinary catheter should be inserted following epidural placement (see Trust
guideline Bladder Care in Labour and Postnatally Trust Doc ID 12617)
13.Anaesthetist to review patient 30 minutes after insertion to ensure effective
analgesia achieved and if required further appropriate management
14.After insertion, anaesthetist to complete
http://nnvmpatweb01/obsaudit/2008/login.asp to facilitate patient follow-up
15.Refer to Appendix B for troubleshooting labour epidurals
16.Refer to page 16 for immediate management of labour epidural complications
17. Document epidural catheter removal on epidural chart, ensure appropriate
LMWH timings (if relevant) and continue neurological monitoring for resolution
of motor block (see page 16 and Appendix C)

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 5 of 25
Guideline for the Management of Epidural Analgesia in Labour

1. Introduction
1.1. Rationale
Epidural analgesia is a well-established technique to reduce pain in labour.

This guideline aims to ensure effective and safe use of epidural analgesia on the
Delivery Suite; delivered via a closed system using BD Bodyguard epidural pumps.

The pumps can be programmed to deliver an automated hourly bolus (Programmed

Intermittent Epidural Bolus – PIEB) with the patient also able to administer bolus
doses herself via the attached handset (Patient Controlled Epidural Analgesia-
PCEA).

Within this guideline the recommendations for monitoring women receiving epidural
analgesia for labour are based on those within the NICE Guideline (190) ‘Intrapartum
care for healthy women and babies: Pain relief’ and the OAA/AoA Safety Guideline:
‘Neurological monitoring after obstetric neuraxial blockade’.

1.2. Objective
The objective of this guideline is to:
 Provide a clear explanation and guidance for the safe set-up, initiation,
maintenance and discontinuation of epidurals for labour analgesia in the
Delivery Suite.
 Detail the management strategy for ineffective epidural analgesia,
complications, or side effects.
 Clarify the responsibilities and roles of the multi-professional team in the
provision of epidural analgesia.

1.3. Scope
For use by Anaesthetists, Midwives and Obstetricians caring for women in labour
requiring epidural analgesia in the Delivery Suite only.

1.4. Glossary
The following terms and abbreviations have been used within this document:

Term Definition
AoA Association of Anaesthetists
BP Blood pressure
BMI Body mass index
OAA Obstetric Association of Anaesthetists
PCEA Patient Controlled Epidural Analgesia
PIEB Programmed Intermittent Epidural Bolus
SBP Systolic blood pressure
SLR Straight leg raise

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 6 of 25
Guideline for the Management of Epidural Analgesia in Labour

2. Responsibilities and Roles

2.1. Anaesthetists
 The time from the anaesthetist being informed of a request for epidural
analgesia until being able to attend should be within 30 minutes
 If the obstetric anaesthetist anticipates a longer delay, they should co-ordinate
with other available anaesthetists or Delivery Suite Co-ordinator (to escalate
to the 4th on Anaesthetic registrar or Consultant Obstetric Anaesthetist). Our
aim is to attend in all cases within 1 hour from request
 Give appropriate explanation and obtain informed consent
 Establish effective epidural analgesia
 Prescribe the local anaesthetic mixture (bag and any top-ups) on the epidural
anaesthetic chart
 Prepare the infusion pump and connect the line
 Review the epidural 30 minutes after insertion, regularly thereafter and after
handovers to ensure patient is comfortable
 Troubleshoot epidural analgesia issues (see Appendix C) in a timely manner

2.2. Midwives

 Inform the anaesthetist without delay, when an epidural has been requested
(or advised during consultation in antenatal care e.g. raised BMI)
 Establish CTG monitoring (see Trust guideline for the use of Fetal Monitoring
and Blood Sampling Trust Doc ID 840)
 Clinical care and monitoring of the patient receiving the epidural as described
within this guideline
 Administer antacid (omeprazole 40mg) prophylaxis 12 hourly for duration of
epidural analgesia
 Insert urinary catheter (see guideline Bladder Care in Labour and Postnatally
Trust Doc ID 12617)
 Check patient pressure areas every 2 hours
 Recognise and escalate concerns or complications
 Complete appropriate documentation on the epidural anaesthetic chart

2.3. Delivery Suite Co-Ordinator

 Epidural analgesia must only be considered where one to one midwifery care
can be provided by a midwife who has been assessed as competent
 Facilitate escalation to another anaesthetist if delays from request to
attendance (>30 min) are anticipated

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 7 of 25
Guideline for the Management of Epidural Analgesia in Labour

3. Processes to be followed
3.1. Indications
3.1.1. Absolute Indication:

 Maternal request

3.1.2. Relative Indication:

An epidural considered early in labour may be beneficial for:
1. Obstetric reasons:
 labour augmentation
 twin pregnancy
 pre-eclampsia (without severe thrombocytopenia or coagulopathy)
2. Medical co-morbidities:
 high Body Mass Index (see guideline for Management of Women with
Obesity during Pregnancy Trust Docs ID 880)
 cardiovascular disease
 respiratory disease
3. Other risk factors for general anaesthetic (e.g. anticipated difficult airway)

3.2. Contraindications
3.2.1. Absolute Contraindications:

 Patient Refusal
 Administration of LMWH (prophylactic dose within the last 12 hours,
therapeutic dose within the last 24 hours)
 Severe coagulopathy
 Thrombocytopenia – Platelet < 80 109/L (with Platelet count <100 109/L check
coagulation and fibrinogen level)
 Localised sepsis over insertion site
 Hypovolaemia /cardiovascular instability
 Raised intracranial pressure

3.2.2. Relative Contraindications (discuss with Consultant Anaesthetist):

 Systemic infection
 Mild coagulopathy
 Pre-existing abnormalities of the vertebral column (e.g. previous spinal
surgery)
 Pre-existing central or peripheral neurological conditions

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 8 of 25
Guideline for the Management of Epidural Analgesia in Labour

3.3. Patient Consent

Patients should be provided with an epidural patient information leaflet, counselled
on the benefits and risks (Table 1) of the procedure by an anaesthetist and have the
opportunity to process the information and ask questions.

A summary of the informed consent discussion should be documented in the

patients notes or on the anaesthetic chart by the anaesthetist.

Patients should be advised once an epidural is running, they will have reduced
mobility, greater levels of monitoring and a diet of still isotonic drinks or water only
(see guideline Maternity Clinical Guideline for Intrapartum Care Trust Doc ID:850)

Table 1: Risks of having an epidural to reduce labour pain

Type of Risk Frequency of Risk
Common
Nausea and vomiting
Pyrexia
Itching 1 in 3
Epidural not effective enough in labour 1 in 10
requiring further attention
Epidural failure in labour requiring 1 in 20
replacement/re-site
Significant drop in blood pressure 1 in 50
Headache 1 in 100
Not linked to long-term backache
Rare
Nerve damage (e.g. numb patch on leg Temporary: 1 in 1000
or foot) Permanent: 1 in 13,000
Severe (including paralysis) 1 in
250,000
Abscess in the spine or site of epidural 1 in 50,000
Meningitis 1 in 100,000
Haematoma (blood clot) in the spine at 1 in 170,000
the site of epidural
Obstetric Implications
Increase in 2nd stage of labour
Increased risk of instrumental delivery
Not linked to an increased chance of having a caesarean section

3.4. Insertion of an Epidural

3.4.1. Midwife Actions:

 Contact the anaesthetist on bleep 0011 or via Alertive without delay once the
patient has requested an epidural.
 Collect the equipment and drugs required:
o Epidural trolley (containing sterile pack, sterile gown/gloves/hat,
chlorhexidine 0.5% in 70% alcohol, epidural mini-pack, ‘lock-it’ or device
to secure catheter, occlusive clear dressing, Mefix tape and emergency
pre-filled syringe of ephedrine).

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 9 of 25
Guideline for the Management of Epidural Analgesia in Labour

o Epidural pump with patient control button and charger.

o Epidural infusion mixture: pre-prepared low-dose levobupivacaine (0.1%)
solution combined with fentanyl (20mcg/ml). The pre-mixed infusion bag
should be checked by two midwives in accordance with the Trust
Medicines policy and is kept in the controlled drug cupboard on delivery
suite.
 Prepare the patient
o Dress in a hospital gown with two patient ID labels.
o Insert an IV cannula (if not done), which must stay in place until the end
of the labour.
o Take required blood tests (FBC, G&S and others as indicated. Any
women with pre-eclampsia should have a FBC in the preceding 6 hours
before siting an epidural).
o Record baseline blood pressure, maternal and foetal heart rate.
o Arrange adequate foetal monitoring pre-insertion.
o Prime pump to commence an infusion of Hartmann’s solution, with the
designated giving set. The anaesthetist or obstetrician will prescribe the
appropriate rate.
o Position the patient sitting evenly on the bed, with feet resting on a
support/stool (or as per anaesthetists request if they prefer an alternative
position such as lateral).

3.4.2. Anaesthetists Actions:

 Ensure the patient is not at risk of coagulopathy (including recent LMWH; if

administered antenatally an epidural may only be inserted >12hrs after
prophylactic dose and >24hrs after a treatment dose).
 Consider using ultrasound pre-procedure to mark the mid-line, level and
estimated depth to epidural space.
 If the procedure is deemed difficult, request assistance from the Emergency
theatre ODP (bleep 1023) who can help with patient positioning, or
equipment; or from a Senior Anaesthetist.
 Follow a strict aseptic technique and wear a facemask, hat, sterile gown and
sterile gloves.
 Clean patients’ skin with chlorhexidine spray 0.5% left to dry x2, taking care
not to contaminate any needles to be used during the procedure.
 Site epidural with loss of resistance to saline technique.
 Secure catheter with 3-5cm of catheter within the epidural space; if the patient
has a BMI>35 consider leaving up to 6cm.
 Document the procedure and any complications on the Epidural Analgesia
Chart.
 Prescribe antacid prophylaxis and prescribe/set the pump regime (see
Options A-C below).

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 10 of 25
Guideline for the Management of Epidural Analgesia in Labour

 Assess the epidural block 20-30 minutes after establishing pain relief (pain
scores, sensory level and SLR), at every shift change or at the request of the
midwife.

3.5. Setting up the epidural infusion pump

 Levobupivacaine 0.1% plus fentanyl 2micrograms/ml is the standard infusion

mix for labour analgesia
 Load the bag (0.1% levobupivacaine plus fentanyl 2micrograms/mL) into the
epidural pump and prime with the designated yellow giving set.
 The infusion should be connected to the epidural filter by a midwife and an
anaesthetist together.
 Administer a ‘test dose’ of 10ml of 0.1% levobupivacaine plus fentanyl
2micrograms/mL (‘bag mix’) via the epidural pump (also see Section 3.6 for
alternative options).
 The current regime options on the pump are for use with pre-filled bags of
Levobupivacaine 0.1% plus fentanyl 2 micrograms/ml:
Option A: PCEA (10ml boluses/10min lock out, maximum 20ml/hr)
Option B: PCEA + PIEB (6ml bolus/20min + 7ml/hr automatic bolus)
Option C: PCEA + PIEB (8ml bolus/25min + 8ml/hr automatic bolus)

3.6. Establishing epidural analgesia for labour analgesia

1) After a ‘test dose’ of 10ml of 0.1% levobupivacaine plus fentanyl
2micrograms/mL (‘bag mix’) via the epidural pump and confirmation of a
satisfactory response, consider a further 5-15ml clinician bolus of bag mix
(0.1% levobupivacaine with 2 micrograms/mL fentanyl) via the epidural pump.
This is the preferred method of ‘test’ and ‘loading’ doses - as also noted in
section 3.5)
Alternative Options:
2) A manually administered 3-4ml 0.25% levobupivacaine* test dose followed by
a cautious further 6-7ml of 0.25% levobupivacaine loading dose*. Depending
on response this may be followed by 10ml of the standard epidural mix
through the pump. Monitor closely for hypotension with this option. (*0.2%
ropivacaine may be used instead of 0.25% levobupivacaine.)
3) Manually administered incremental injections of 0.1% levobupivacaine with 2
micrograms/mL fentanyl. A 10 mL pre-prepared ampoule can be used. Do not
puncture the 100 mL bag of pre-mix 0.1% levobupivacaine plus fentanyl
that is intended for use through the pump. These bags do not contain
preservative and there is a risk of infection if subjected to multiple punctures.
If the 10 mL ampoules are unobtainable a new, separate 100 mL pre-mix bag
should be used and then discarded.
4) In some cases where pain is intense or labour is advanced the anaesthetist
may chose to perform an intrathecal injection of 1-1.25 mL 0.25% plain
levobupivacaine mixed with up to 25 micrograms fentanyl OR 3 mL of the
0.1% levobupivacaine with 2 micrograms/mL fentanyl (Combined Spinal
Epidural, CSE)

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 11 of 25
Guideline for the Management of Epidural Analgesia in Labour

3.7. Maintenance and monitoring of epidural for labour analgesia

The Midwife caring for the patient should have no other clinical duties.

First 30 minutes following insertion and initial (test-dose) bolus:

 Measure and record BP and HR every 5 minutes
 Continuous CTG monitoring
 Document sensory block height to cold (bilaterally) at 20 minutes
 Midwife to remain in the patient’s room
 If maternal analgesia remains unsatisfactory after two consecutive bolus
doses (or if a woman is not pain free 30 minutes after any bolus) then the
anaesthetist should be contacted and the epidural reviewed

For duration of epidural analgesia:

1. Foetal heart rate monitoring: Continuous (see Trust guidelines for the Use
of Fetal Monitoring and Blood Sampling Trust Doc ID 840)
2. Blood Pressure and Heart Rate:

Table 2: Epidural regime prescription and appropriate HR/BP monitoring required

Regime At PCEA PIEB Clinician
insertion Patient Controlled Programmed Bolus
Epidural Analgesia Intermittent Epidural
Bolus
Monitor Regime Monitor Regime Monitor
A Every 10ml/10min Every N/A
5min for lockout 5min for
20min patient 20min
controlled after
bolus every
bolus
B Every 6ml/20min *Not Automatic Hourly Every 5
5min for lock-out unless 7ml/hr min for
20min patient concerne bolus 15 min
controlled d
bolus
C Every 8ml/25min *Not Automatic Hourly Every 5
5min for lock-out unless 8ml/hr min for
20min patient concerne bolus 15 min
controlled d
bolus

*Bolus is less than 10mls therefore there is no need to monitor BP unless concerns

The woman should be observed during and after each bolus and verbal contact
maintained.

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 12 of 25
Guideline for the Management of Epidural Analgesia in Labour

3. Degree of Motor Block

 Perform a straight leg raise every hour and document the degree of motor
block on the epidural chart

Bromage Motor Score Degree of motor block

1 Complete block, unable to
move feet of knees

2 Able to move feet only

3 Just able to flex knees, free

movement of feet

4 No block, full movement of

knees and feet

4. Degree of Sensory Block

 Test the upper and lower level of the block bilaterally every hour by:
o Touching an ice-cube (or Coolstix) on the patients shoulder to
establish ‘cold’
o Run ice from the little toe up the leg to the groin; then from the groin
up the abdomen to the chest on one side. Repeat on the opposite
side.
o Record the upper level (right and left side) AND the lower level (right
and left side) on the epidural chart

Key Levels:

T4 – Nipple

T6 – Xiphoid

T8 – Midpoint between
the umbilicus and xiphoid

T10 – Umbilicus

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 13 of 25
Guideline for the Management of Epidural Analgesia in Labour

L1 – Groin

S1 - Little toe

*Block to the level of T8-10 is ideal

** If block is higher than T6, remove

patient handset and asked for
anaesthetic review**

5. Pain Score
 Ask the patient to rate her current pain every hour, on a scale of 0 (no pain)
to 10 (severe pain) and document on epidural chart

6. Pressure Areas and Epidural Insertion site

 Check pressure areas every 2 hours
 Sit patient forward and check integrity of epidural dressing and any
dislodgement of epidural catheter intermittently every 2-3 hours

7. Local Anaesthetic Administered

 Record the total volume (ml) given (cumulative) every hour on the epidural
chart

3.8. Changing the Epidural Bag

 It is the responsibility of the mid-wife to monitor when a new pre-filled bag of

Levobupivacaine 0.1% plus fentanyl 2 micrograms/ml is required.
 When ‘Near End’ alarm is activated on the pump, press the ‘Stop’ key.
 Enter the Level 1 code to access the menu and select ‘Change Bag’.
 Attach new pre-filled bag, ensuring there is no air in the giving set.
 Press the start key to confirm settings and start pump.

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 14 of 25
Guideline for the Management of Epidural Analgesia in Labour

3.9. Patient Controlled Epidural Analgesia (PCEA)

Patient Controlled Epidural Analgesia should only be instituted when satisfactory
epidural analgesia has been established and maternal observations and the foetal
heart rate are satisfactory. Satisfactory maternal observations include absence of
symptomatic maternal hypotension and ability to straight leg raise both legs.

The woman needs to be instructed in how to use the Remote Dose Cord and when
to administer a bolus dose. The midwife should supervise the woman administer the
first two doses.
 All boluses should be administered with the woman sitting on the bed.
 The woman should only administer a bolus dose when she is sitting or lying
down on her side.
 The bolus will be administered by using the Remote Dose Cord.

The woman should be asked to tell her midwife when she has administered a bolus
dose and asked to inform the midwife of any light-headedness, nausea, dizziness,
breathlessness or marked weakness of the legs. If the woman has any of these
symptoms, the midwife should remove the Remote Dosing Cord from the woman
and lay the woman in the left lateral position. The IV infusion rate should be
increased to give a fluid bolus of 250 mLs. The anaesthetist should be called to
attend. Maternal blood pressure and block height should be recorded and maternal
leg weakness assessed (see Section 3.11 Management of complications of epidural
analgesia).

3.10. Review of Patients with Epidurals During Labour

Women with epidurals during labour should be reviewed regularly to ensure that the
epidural is working well and they are satisfied with their analgesia. Be proactive in
this and do not solely rely on midwives to escalate issues.

As a minimum the epidural block should be assessed by an Anaesthetist 20-30

minutes after establishing pain relief (pain scores, sensory level and SLR), at every
shift change or at the request of the midwife. This should allow early identification of
problems and a chance to rectify them.

3.11. Trouble-Shooting Ineffective Epidurals

If an epidural is not giving adequate analgesia and attempts by the midwife to
improve analgesia (e.g. patient positioning, top-ups) haven’t helped, the woman
should be reviewed by an anaesthetist (see Appendix B)
Disconnection from pump: If the disconnection is witnessed, wrap the end of the
epidural catheter in a sterile swab and call anaesthetist immediately. The catheter
end can be cut and re-sterilised. If the timing of the disconnection is unclear, the
catheter may have to be removed.
Inadequate analgesia: This can be treated by giving additional top-ups through the
pump, or, if the block is deemed to be not dense enough an additional bolus of
0.25% levobupivacaine can be administered by hand. Sometimes additional fentanyl
(50mcg) can be useful in increasing the effectiveness of the analgesia, especially
during the second stage when perineal pain can be difficult to cover with the epidural
block.

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 15 of 25
Guideline for the Management of Epidural Analgesia in Labour

Unilateral Block or Missed Segment: The patient should be positioned on their

side with the “unblocked” side down before giving a top-up bolus. This often helps
the local anaesthetic spread with gravity to the downward side and improves the
effectiveness.

If this proves ineffective then it can help to withdraw the catheter by 1cm, thus
altering the catheter position within the epidural space hopefully allowing the
anaesthetic to spread more effectively. Any adjustment of the catheter position must
only be done by an anaesthetist who should wear sterile gloves and a facemask.
The epidural catheter should be aspirated to check for blood/CSF before re-securing.
The epidural site must be kept as clean as possible and new clean dressings must
be applied afterwards.

Re-siting: If none of the above measures improve the effectiveness of the epidural
then it may be appropriate to remove the epidural and site another one. In this
scenario the woman needs to be made aware that although this is likely to improve
their pain relief there is a chance that the second epidural may fail as well. It may be
appropriate to discuss alternative options such as remifentanil PCA.

Rescue Combined Spinal Epidural (CSE): If an epidural is being re-sited consider

performing a combined spinal-epidural. Women are often very distressed with pain at
these times and the more rapid onset of analgesia provided by CSE can be
advantageous. However, CSEs should only be performed by anaesthetists who are
competent in the technique.

3.12. Management of Complications of Epidural Analgesia

Problem Action
Hypotension If the woman feels unwell after a bolus or exhibits signs of
maternal hypotension (faintness, nausea, dizziness) or develops
sudden marked motor weakness of the legs (unable to straight
leg raise either leg) then no further boluses should be given.

Turn women into left lateral position.

IV fluid infusion should be increased to give a fluid bolus of 250
ml.
Check maternal blood pressure: if SBP<90 pull buzzer and call
anaesthetist to attend.
High or Check SLR after initial dose and hourly thereafter.
Dense Block
Contact the anaesthetist urgently if the patient develops very
heavy legs (unable to lift legs off bed) or the numbness reaches
beyond the chest.

If a high/dense block occurs rapidly: think could this be a total

spinal emergency?

Manage as for hypotension above.

Maternal Pyrexia is common in labour with a multitude of causes.
Pyrexia
Follow the Trust Guideline for the Management of Peripartum

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 16 of 25
Guideline for the Management of Epidural Analgesia in Labour

Pyrexia and Sepsis Trust Docs ID 855

Nausea/ Check maternal blood pressure and exclude hypotension.
vomiting Administer an anti-emetic and ensure adequate hydration.
Respiratory Do not allow further boluses. Consider oxygen if conscious level
rate <10/minute decreased. Call anaesthetist, locate Naloxone.

3.13. Emergency Drugs to be available on delivery suite at all times

 Ephedrine
 Phenylephrine
 Naloxone
 Atropine
 Adrenaline
 20% lipid emulsion (i.e. Intralipid 20% emulsion, Fresenius Kabi AB)

3.14. Mobilisation and positioning

The patient may mobilise if:
 The midwife and the partner are available in the room to assist.
 The degree of motor block of the legs has been assessed and the power is
deemed sufficient to allow the patient to stand. This should be assessed prior
to mobilisation and be recorded by the midwife in the notes.

If the mother wishes and feels able to do so she should be encouraged to adopt
upright positions (see Trust guideline A Maternity Clinical Guideline for Intrapartum
Care Trust Docs ID 850)

3.15. Caesarean sections and assisted deliveries in theatre

When a decision is made for a patient to go to theatre, no further boluses should be
given without discussing with the anaesthetist beforehand. The anaesthetists will
then administer their own top-ups manually.

3.16. Removal of epidural catheter

Once the 3rd stage of labour is complete and there is no concern regarding perineal
tears or PPH, then the epidural catheter can be removed.

If the patient has been to theatre, the epidural catheter is usually removed by the
anaesthetist; it may remain in situ if there are concerns with coagulopathy.

Check for contraindications to epidural catheter removal:

 LMWH within previous 12 hours
 Platelets < 75
 Severe PPH or HELLP with last FBC/Platelet count > 4-6 hours ago
 EBL > 1500 ml (or less if < 60kg)
 Clotting disorder

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 17 of 25
Guideline for the Management of Epidural Analgesia in Labour

 Any other concerns

If any present: DO NOT remove the epidural catheter until discussed with the
anaesthetist.
If there are no concerns:
1. Using an aseptic technique, remove dressing and remove epidural catheter
with gentle traction. If resistance is encountered, do not persist and contact
the anaesthetist.
2. Apply appropriate small dressing to the area.
3. Record the time and that the catheter was ‘intact’ (presence of the blue tip) on
the epidural anaesthetic chart.
4. Complete a thromboembolic risk assessment. If LMWH is indicated, ensure it
is prescribed for > 4hrs after epidural catheter is removed.
5. Inform the patient of the expected time of return of bilateral straight leg raise
(approximately 4 hours after last epidural local anaesthetic dose).
6. The patient should not attempt to mobilise until it is recorded that full motor
power has returned.
7. Disposal of the remaining ‘bag mix’ solution should be made by two midwives
and documented on the epidural chart

3.17. Care of Epidural Related Equipment

3.17.1. Epidural trolleys

 These should be restocked daily by a Midwifery Support Worker

 A stock list can be found in the top drawer of the trolley with the appropriate
type and number of equipment needed
 After use, the Midwife should clean the top of the trolley and return to the
Delivery Suite corridor.

3.17.2. Epidural pumps

 When an epidural pump is in use, the number of the pump must be clearly
marked next to the patients name on the delivery suite board.
 When the pump is no longer in use it should be cleaned and returned to the
equipment cupboard and plugged in to recharge.

3.18. Anaesthetic Follow-up

All women receiving regional analgesia or anaesthesia should be reviewed the
following day, including weekends. This should be documented on the electronic
Obstetric Anaesthetic database including:
 Headache
 Back pain
 Any residual neurological deficit
 Any concerns regarding their anaesthetic care

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 18 of 25
Guideline for the Management of Epidural Analgesia in Labour

3.19. Serious Complications – Post Epidural

Contact the anaesthetist urgently if following the removal of an epidural catheter, the
following occur:
 Numbness or weakness that is not improving over 2-4 hours after epidural
analgesia cessation
 The patient is unable to straight leg raise bilaterally 4 hours after epidural
analgesia cessation
 Severe headache (or photophobia, neck stiffness, drowsiness)
 Back pain
 Leg pain

Further escalation will be according to the Trust guidelines on the Management of

Maternal Postnatal Neurology Injuries (Trust ID 12793) and the Management of
Inadvertent Dural Puncture and Post Dural Puncture Headache in Obstetrics (Trust
Doc ID 1306).

All concerns should be escalated to the Obstetric Anaesthetic Consultant.

4. Related Documents

Trust Guidelines: Trustdocs ID:

Bladder care and Fluid Balance, Antenatal, Intrapartum and 12617
Postnatal
Use of Fetal Monitoring and Blood Sampling 840
Intrapartum Care 850
Management of Maternal Pyrexia in Labour 855
Management of Maternal Postnatal Neurology Injuries 12793
Management of Inadvertent Dural Puncture and Post Dural 1306
Puncture Headache in Obstetrics
Management of Women with Obesity during Pregnancy or 880
Post Bariatric Surgery

5. References

 Agarwala R, Millar CM, Campbell JP. Haemostatic disorders in pregnancy.

BJA Education. 2020 May;20(5):150-157.

 Faculty of Pain Medicine. Best Practice in the Management of Epidural

Analgesia in the Hospital Setting. London: Royal College of Anaesthetists,
2020 https://fpm.ac.uk/sites/fpm/files/documents/2020-09/Epidural-AUG-
2020-FINAL.pdf (accessed 12/04/2023)

 National Institute for Health and Care Excellence. Clinical guideline [CG190]:
Intrapartum care for healthy women and babies, 2014 (revised 201) London:
NICE, 2017 https://www.nice.org.uk/guidance/cg190 (accessed 12/04/2023)

 Purva M, Russell IF, Kinsella M Caesarean section anaesthesia: technique

and failure rate. In: Colvin JR, Peden CJ, eds. Raising the Standard: a

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 19 of 25
Guideline for the Management of Epidural Analgesia in Labour

Compendium of Audit Recipes, 3rd edition London: Royal College of

Anaesthetists. https://www.rcoa.ac.uk/system/files/CSQ-ARB2012-SEC8.pdf
(accessed 12/04/2023)

 Royal College of Anaesthetists, Royal College of Nursing, Association of

Anaesthetists of Great Britain and Northern Ireland, British Pain Society,
European Society of Regional Anaesthesia. Good practice in the
management of continuous epidural in the hospital setting. (2004)

 Yentis, S.M., Lucas, D.N., Brigante, L., Collis, R., Cowley, P., Denning, S.,
Fawcett, W.J. and Gibson, A. (2020), Safety guideline: neurological
monitoring associated with obstetric neuraxial block 2020. Anaesthesia, 75:
913-919. https://doi.org/10.1111/anae.14993

6. Monitoring Compliance of the service to be delivered

Compliance with the process will be monitored through the following:
Key elements Process for By Whom Responsible Frequency
Monitoring (Individual / Governance of
group Committee monitoring
/committee) /dept
Neurological monitoring Review of epidural Obstetric Dept of Annual
with labour epidural as observation chart on Anaesthetist Anaesthesia
per guidance follow-up Group
Response time from Midwifery survey Obstetric Dept of Bi-Annual
request to anaesthetist Anaesthetist Anaesthesia
attendance for epidural Group
insertion
Rate of Epidural blood Review of ORSOS Obstetric Dept of Annual
patch Anaesthetist Anaesthesia
Group

The audit results are to be discussed at relevant governance meetings (Anaesthesia

and Maternity) to review the results and recommendations for further action.
Anaesthetic and Maternity governance teams will ensure that the actions and
recommendations are suitable and sufficient.

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 20 of 25
Guideline for the Management of Epidural Analgesia in Labour

7. Appendices
7.1. Appendix A: Obstetric Neuraxial Analgesia Chart

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 21 of 25
Guideline for the Management of Epidural Analgesia in Labour

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 22 of 25
Guideline for the Management of Epidural Analgesia in Labour

7.2. Appendix B: Troubleshooting Labour Epidural Quick Reference Guide

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 23 of 25
Guideline for the Management of Epidural Analgesia in Labour

7.3. Appendix C: Neurological Monitoring After Epidural

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 24 of 25
Guideline for the Management of Epidural Analgesia in Labour

8. Equality Impact Assessment (EIA)

Type of function or policy Existing

Division Women’s and Children’s Department Maternity

Name of person
J Walker/ V Maxey Date 19/05/23
completing form

Potential Impact Which groups Full Impact

Equality Area are affected Assessment
Negative Positive Impact Required
Impact YES/NO
Race No No N/A No
Pregnancy & No No N/A No
Maternity
Disability No No N/A No
Religion and No No N/A No
beliefs
Sex No No N/A No
Gender No No N/A No
reassignment
Sexual No No N/A No
Orientation
Age No No N/A No
Marriage & Civil No No N/A No
Partnership
Not impact
EDS2 – How does this change
impact the Equality and Diversity
Strategic plan (contact HR or see
EDS2 plan)?

A full assessment will only be required if: The impact is potentially discriminatory
under the general equality duty
 Any groups of patients/staff/visitors or communities could be potentially
disadvantaged by the policy or function/service
 The policy or function/service is assessed to be of high significance
IF IN DOUBT A FULL IMPACT ASSESSMENT FORM IS REQUIRED
The review of the existing policy re-affirms the rights of all groups and clarifies the
individual, managerial and organisational responsibilities in line with statutory and best
practice guidance.

Author: Dr Joanna Walker, Consultant Anaesthetist

Approval Date: June 2023 Next Review: June 2026
Ref: 1305 Page 25 of 25