Management of the failing epidural during labour epidural analgesia
Labour epidural analgesia reportedly fails in up to 10 to 25% of cases. A joint taskforce of European Society of Anaesthesiology and Intensive Care (ESAIC) experts was created to develop this focused guideline on the management of failing epidural analgesia in a previously well functioning epidural catheter.
Neuraxial analgesia is considered the gold standard for labour analgesia. Although the rate of labour epidural analgesia (LEA) is as high as 90% among women in some European centres, there is significant regional variation. Multiple factors likely contribute to this variation including the availability of adequate information to solve maternal concerns about the safety and reliability of LEA.
In past years, research in labour analgesia has increasingly focused on enhancing the quality and safety of LEA, with a concomitant decrease in complications. Since the landmark COMET study in 2000, preceded by other older studies, low concentrations of local anaesthetics are administered for maintenance of LEA, enabling a reduced motor block and increased parturient mobility during labour. Administration of adjunct neuraxial epidural opioids has contributed to a gradual enhancement in LEA effectiveness. Furthermore, the introduction of innovative administration methods, such as programmed intermittent epidural bolus (PIEB), has further improved the quality of LEA. Finally, advanced techniques such as combined spinal epidural (CSE) analgesia and dural puncture epidural (DPE) techniques have also played a role in refining LEA, paving the way for tailored analgesic approaches.
Given the broad scope of issues associated with failing epidural analgesia, the task force was elected to specifically address, in this focus guideline, the scenario of secondary epidural failure (a failing epidural in parturients who initially received adequate analgesia from a well functioning epidural catheter placed for LEA). Thus, this guideline will specifically exclude issues related to the initiation phase of epidural analgesia, otherwise known as primary failure of LEA.
