Association between combined spinal-epidural analgesia and neurodevelopment at 3 years old: The Japan Environment and Children's Study.

AIM: To investigate the association between maternal combined spinal-epidural analgesia during vaginal delivery and neurodevelopment in 3-year-old children. METHODS: Using data from the Japan Environment and Children's Study, a birth cohort study on pregnant women and their offspring, we described the background, perinatal outcomes, and neurodevelopmental outcomes of participants with a singleton pregnancy who received combined spinal-epidural analgesia during vaginal delivery and those who did not. The association between maternal combined spinal-epidural analgesia and abnormalities in five domains of the Ages and Stages Questionnaire, Third Edition, was analyzed using univariable and multivariable logistic regression analyses. Crude and adjusted odds ratios with 95% confidence intervals (95% CI) were calculated. RESULTS: Among 59 379 participants, 82 (0.1%) children (exposed group) were born to mothers who received combined spinal-epidural analgesia during vaginal delivery. In the exposed versus control groups, 1.2% versus 3.7% had communication abnormalities (adjusted odds ratio [95% CI]: 0.30 [0.04-2.19]), 6.1% versus 4.1% exhibited gross-motor abnormalities (1.36 [95% CI: 0.55-3.36]), 10.9% vs. 7.1% had fine-motor abnormalities (1.46 [95% CI: 0.72-2.96]), 6.1% vs. 6.9% showed difficulties with problem-solving (0.81 [95% CI: 0.33-2.01]), and 2.4% vs. 3.0% had personal-social problems (0.70 [95% CI: 0.17-2.85]). CONCLUSIONS: Exposure to combined spinal-epidural analgesia during vaginal delivery was not associated with the risk of neurodevelopmental abnormalities; however, the sample size of our study might not be appropriate for the study design.

Anesthetic Management of Severe Pulmonary Hypertension in Pregnancy.

Pregnancy entails significant changes in maternal physiology that are not well-tolerated in patients with pulmonary arterial hypertension. The profound changes in plasma volume, cardiac output, and systemic vascular resistance can lead to increased strain placed on the right ventricle, leading to right-heart failure and cardiovascular collapse. Given the complex and sometimes opposing physiologic changes, managing these patients can be challenging. As such, these patients have a significantly increased reported maternal mortality rate. This report describes a parturient with newly diagnosed severe pulmonary arterial hypertension and her anesthetic management.

Impact of COVID-19 status on patients receiving neuraxial analgesia during labor: A national retrospective-controlled study.

BACKGROUND: Pregnancy affects a woman's susceptibility to and severity of certain infectious diseases. Central neuraxial block for analgesia during labor is superior to nonneuraxial methods in efficacy, safety, and maternal satisfaction. Although Coronavirus disease (COVID-19) can be vertically transmitted from mother to fetus, little is known about the effects of COVID-19 on pregnant women or about anesthesia management and the risk of adverse effects related to neuraxial techniques in women with untreated COVID-19 during gestation. AIM: This investigation assesses the effects of neuraxial analgesia during labor of COVID-19-positive parturients on their hemodynamic stability. RESULTS: The study was conducted on 64 patients and involved 32 parturients positive for SARS-CoV-2 by polymerase chain reaction (PCR) and a similar number of control "negative" patients. The affected group had an uneventful course during gestation. Seven were positive for ground-glass opacities on chest X-rays, and none underwent computed tomography (CT) scans. Two neonates were PCR-positive for SARS-CoV-2, and all 32 neonates were released from the hospital. No clinical differences were observed between the neonates in the COVID-19 and control groups. Although parturients in both groups were hemodynamically stable, hemodynamic stability was subnormal in the COVID-19 group regarding blood pressure, oxygen saturation, heart rate, and body temperature. None of the women in either group required a vasopressor or oxygen supplementation during delivery. No other clinical differences were observed between the COVID-19 and control groups. CONCLUSION: This is the first case-controlled study testing the anesthetic implications of neuraxial labor analgesia in pregnant, COVID-19-positive women. Although management of neuraxial labor analgesia did not differ in pregnant women positive and negative for COVID-19, their hemodynamic characteristics differed significantly. Therefore, care is required to prevent adverse outcomes in pregnant women positive for COVID-19.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study.

BACKGROUND: No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA). METHODS: NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016. RESULTS: The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05). CONCLUSIONS: Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Comparison of the labor curves with and without combined spinal-epidural analgesia in nulliparous women- a retrospective study.

BACKGROUND: Neuraxial labor analgesia is known to increase the rate of instrumental delivery and prolong the second stage of labor; however, there is no standard method to evaluate the progress of labor under analgesia. Friedman curve is considered the gold standard for evaluating the progress of labor. However, it included not only neuraxial labor analgesia but also labor without analgesia. Thus we compared the labor curves of primiparous women undergoing labor with and without neuraxial labor analgesia, to understand the progress of labor in both groups and to arrive at a standard curve to monitor the progress of labor under neuraxial analgesia. METHODS: Primiparous women with cephalic singleton pregnancies who delivered at term from 2016 to 2017 were included. Two hundred patients who opted for combined spinal-epidural (CSE) labor analgesia were included in the CSE group and 200 patients who did not undergo CSE were included in the non-CSE group. In all, 400 cases were examined retrospectively. The evaluation parameters were cervical dilation and fetal station, and we calculated the average value per hour to plot the labor curves. RESULTS: The labor curve of the non-CSE group was significantly different from the Friedman curve. In the CSE group, the time from 4 cm dilation of the cervix to full dilation was 15 h; in addition, the speed of cervical dilation was different from that in the non-CSE group. The progress of labor in the CSE group was faster than that in the non-CSE group during the latent phase; however, the progress in the CSE group was slower than that in the non-CSE group during the active phase. CONCLUSIONS: Neuraxial labor analgesia results in early cervical dilation and descent of the fetal head; thus, appropriate advance planning to manage the delivery may be essential.

Characteristics of labor-onset hypertension persist after neuraxial labor analgesia.

AIM: This study aimed to investigate the rate of labor-onset hypertension (LOH) under neuraxial labor analgesia and the effect of neuraxial labor analgesia on LOH. METHODS: A retrospective study was conducted in a tertiary university hospital from 2015 to 2016. Patients who were admitted to the hospital for vaginal delivery under combined spinal and epidural anesthesia were selected. LOH was defined as the elevation of systolic blood pressure (BP) to ≥140 mmHg or diastolic BP to ≥90 mmHg for the first time after the onset of labor. Cases of LOH that persisted after neuraxial labor analgesia (prolonged LOH) were further analyzed to determine the hypertension severity and therapeutic intervention rate. RESULTS: Among 775 patients, 213 (28.4%) developed LOH. Prolonged LOH was observed in 30 patients (3.9%). LOH severity and the likelihood of prolonged LOH were positively correlated. Therapeutic intervention was administered only to the patients with prolonged LOH, that is, to 100% of those with emergent hypertension, to 21.1% of those with severe hypertension during labor, and to 36.8% of those with severe hypertension, to 55.6% of those with mild hypertension in the post-partum period. CONCLUSION: The rate of LOH was reduced significantly after neuraxial labor analgesia. Patients with prolonged LOH should be carefully followed up during labor and in the post-partum period because such patients often require antihypertensive therapy.

Childbirth Experience and Pain Control: Expectation, Satisfaction, and Analgesia Myths.

BACKGROUND: In our days, increasing importance has been given to maternal satisfaction as a quality indicator in healthcare services. A positive childbirth experience should meet a woman's personal and sociocultural beliefs and expectations in every setting. This study aimed to evaluate childbirth experience regarding expectations, satisfaction, and myths around epidural analgesia. METHODOLOGY: A cross-sectional survey designed was carried out in the Obstetric Department of a public hospital in Madeira-Portugal. A well-structured questionnaire was applied to 101 post-partum women covering aspects such as sociodemographic details, childbirth expectations, overall satisfaction, and prevailing myths. IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY) was used for data analysis. RESULTS: From the total of 101 participants, 32 (31%) women belonged to the 31-35 age group. Among the respondents, 58 (57%) had attained a high school diploma. The results showed that there was a positive experience with childbirth; out of the total women, 79 (78%) considered it exceeded their expectations. The majority of pregnant women (93, 92%) received neuraxial analgesia for labor, reporting the experience as good or excellent. The overall satisfaction related to the birth experience was good or excellent for 88 (87%) women. Regarding the myths, education level was significantly associated with the myth Epidurals often cause permanent back pain (P < 0.05), since women with higher education don't believe them. CONCLUSIONS: The result of this study proves that, despite the high level of satisfaction with the labor and delivery experience found in our maternity unit, satisfaction remains a complex and dynamic phenomenon.

Sacral sensory blockade from 27-gauge pencil-point dural puncture epidural analgesia or epidural analgesia in laboring nulliparous parturients: a randomized controlled trial.

BACKGROUND: The dural puncture epidural (DPE) technique has been associated with better sacral analgesia compared with a traditional epidural (EPL) technique in laboring parturients. The aim of this study was to investigate whether DPE with a 27-gauge pencil-point needle compared with a traditional EPL technique produces more rapid bilateral sacral blockade in nulliparous parturients. METHODS: Patients were randomized to a DPE or EPL technique. Epidural analgesia in both groups was initiated with ropivacaine 0.1% and sufentanil 0.5 µg/mL (15 mL) and maintained via programmed intermittent epidural boluses. Analgesic blockade was tested bilaterally beginning 10 min after initiation, and then at predefined intervals until delivery. The presence of an S2 blockade at 20 min was the primary outcome. RESULTS: Among 108 (54 per group) patients enrolled, bilateral sacral (S2) blockade at 20 min was significantly more common in the DPE than in the EPL group [47 (87%) vs. 23 (43%), absolute risk reduction (ARR) 44%, 95% CI 28 to 60; P < 0.001]. Time to a numeric pain rating scale score (0-10 scale) ≤ 3 (20 [20,30] min in both groups, HR 1.15, 95% CI 0.77 to 1.15; P = 0.50), number of rescue doses [0 (0, 1) vs 0 (0, 1); P 0.08], and presence of bilateral S2 blockade at delivery were not significantly different between groups. CONCLUSIONS: The DPE technique with a 27-gauge pencil-point spinal needle more often provides bilateral sacral blockade at 20 min following block initiation compared with the EPL technique. The time to adequate analgesia and need for supplemental analgesia did not appear to differ between techniques.

Association Between Epidural Labor Analgesia and Autism Spectrum Disorder in Offspring: A Systematic Review and Meta-Analysis.

Purpose: Many studies have focused on the association between Autism spectrum disorder (ASD) and epidural labor analgesia (ELA), which is the most effective way to manage labor pain. The purpose of this meta-analysis was to summarize the current state of the association between ELA and ASD. Methods: A search of the literature yielded 201 relevant studies, of which 7 cohort studies met our inclusion criteria. Two independent reviewers screened the inclusion results, extracted data, and assessed the risk of bias and quality of evidence. Results: Compared to parturient who did not receive ELA, parturient who received ELA had a slightly increased risk of ASD (adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI], 1.06-1.17; I2, 69%; P < 0.001; seven studies). After excluding one literature (aHR, 1.09; 95% CI, 1.06-1.12; I2, 4%; P < 0.001; six studies). The sensitivity analyses had consistent outcomes with the main analyses involving siblings (aHR 1.11; 95% CI 1.03-1.19), cesarean section and instrumental deliveries (aHR 1.07; 95% CI 1.03-1.10), non-overlapping populations (aHR 1.09; 95% CI 1.05-1.12), full-term birth populations (aHR 1.10; 95% CI 1.06-1.14), and studies assessed to have moderate risk of bias (aHR 1.09; 95% CI 1.02-1.16). Conclusion: This meta-analysis revealed a modest positive association between ELA and ASD, acknowledging a slight potential risk. However, it is important to note that this risk cannot be completely dismissed due to the possibility of bias and this association is based on low-quality evidence. Future studies are required to assess and mitigate different confounding biases and investigate the time-dose-response relationship.

Association between breakthrough labor pain, patient-controlled epidural analgesia use, and numeracy: A pilot observational study.

OBJECTIVE: Labor analgesia can be maintained with a continuous epidural infusion, supplemented by patient-controlled epidural boluses. patient-controlled epidural boluses use and timing require numeric understanding, as patients need to understand when they can administer supplemental boluses, lockout intervals, and total doses. We hypothesized that women with lower numeric literacy have a higher rate of provider-administered supplemental boluses for breakthrough pain because they do not understand the concept behind patient-controlled epidural boluses. DESIGN: Pilot observational study SETTING: Labor and Delivery Suite PARTICIPANTS: Nulliparous, English-speaking patients with singleton, vertex pregnancies admitted for postdates (gestational age ≥ 41 weeks) induction of labor requesting neuraxial labor analgesia. INTERVENTIONS: Combined spinal-epidural labor analgesia was initiated with intrathecal fentanyl and epidural analgesia was maintained using continuous epidural infusion with patient-controlled epidural boluses. MEASUREMENTS AND FINDINGS: Numeric literacy was assessed using the Lipkus 7-item expanded numeracy test. Patients were stratified by whether or not they required supplemental provider-administered analgesia and patient-controlled epidural boluses use patterns were evaluated. A total of 89 patients completed the study. There were no demographic differences between patients who required supplemental analgesia compared with those who did not. Patients that required supplemental analgesia were more likely to request and receive patient-controlled epidural boluses (P<0.001). Hourly bupivacaine requirement was higher in women with breakthrough pain. There were no differences in numeric literacy between the two groups. KEY CONCLUSIONS: Patients who required treatment of breakthrough pain had higher patient-controlled epidural boluses demands-to-delivery ratio. Numeric literacy was not correlated with the need for provider-administered supplemental boluses. IMPLICATIONS FOR PRACTICE: Easy to understand scripts on how to use patient-controlled epidural boluses allows for understanding of patient-controlled epidural boluses use.

Effects of neuraxial labor analgesia on intrapartum maternal fever in full-term pregnancy and its influence on birth outcomes.

Introduction: This study aimed to explore the relationship between neuraxial labor analgesia and intrapartum fever and to demonstrate the influence of maternal fever on perinatal outcomes within 6 weeks after birth. Methods: This was a secondary analysis of a multicenter prospective cohort study that enrolled women with single- and full-term cephalic pregnancy in northern China. Intrapartum maternal fever was defined as the highest axillary temperature during labor ≥37.5°C. Data on baseline characteristics, maternal variables, and neonatal outcomes were all collected. The association between neuraxial labor analgesia and intrapartum maternal fever was analyzed with logistic regression models, and the cutoff point was identified by the receiver operating characteristic curve. Results: Of 577 parturients, 74 (12.8%) developed intrapartum fever. Neuraxial analgesia was associated with an increased risk of maternal intrapartum fever with or without adjusting for confounding factors (adjusted OR = 2.68; 95% CI: 1.32-5.47; p = 0.007). Further analysis showed that neuraxial analgesia of <5 h did not increase the risk of intrapartum fever compared with no analgesia (OR = 1.52; 95% CI: 0.63-3.64; p = 0.35), and longer neuraxial labor analgesia time (over 5 h) significantly increased the risk of fever (OR = 3.38; 95% CI: 1.63-7.01; p = 0.001). Parturients with intrapartum fever suffered more maternal adverse outcomes compared with those without fever (p < 0.001). Neonates of women with intrapartum fever had slightly higher rates of composite adverse neonatal outcomes compared with those without fever; however, the difference was not statistically significant (p = 0.098). Conclusion: In women with low-risk pregnancies, a longer time of neuraxial labor analgesia was associated with an increased risk of intrapartum maternal fever. Intrapartum fever was related to adverse maternal outcomes but did not significantly affect neonatal outcomes within 6 weeks after delivery.

Association between neuraxial labor analgesia and postpartum depression: A meta-analysis.

BACKGROUND: Labor and delivery complications, particularly pain, are important risk factors for postpartum depression (PPD). Neuraxial labor analgesia can effectively relieve labor pain; however, the association between neuraxial labor analgesia and PPD, if any, has not been established. METHODS: PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library were searched. The incidence of PPD was the primary outcome. The secondary outcome was the difference in postpartum Edinburgh Postpartum Depression Scale scores between the neuraxial labor analgesia and control groups. Subgroup analyses and post-hoc meta-regression were performed. RESULTS: Nineteen studies with a total of 8758 parturients were identified. Neuraxial labor analgesia did not decrease PPD risk compared to the control group (OR = 0.84, 95% CI: 0.58-1.23); however, after being stratified by PPD prevalence, neuraxial labor analgesia decreased the risk for PPD in the high prevalence (>14%) subgroup (OR = 0.61, 95% CI: 0.39-0.94) and increased the risk for PPD in the low prevalence (<14%) subgroup (OR = 1.56, 95% CI: 1.16-2.10) compared to the control group. Meta-regression analysis showed that the association between neuraxial labor analgesia and PPD was influenced by PPD prevalence. There was no difference in the postpartum Edinburgh Postpartum Depression Scale scores between the neuraxial labor analgesia and control groups (WMD = -0.11, 95% CI: -0.56-0.34). LIMITATION: Heterogeneity and a limited number of randomized controlled trials may bias the interpretation of the results. CONCLUSION: Neuraxial labor analgesia had a protective effect when administered to parturients in the region with a high prevalence of PPD, but became a risk factor when administered to parturients in the region with a low prevalence of PPD.

Neuraxial labor analgesia: Initiation techniques.

The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. In this review, we outline the unique technical considerations, analgesic characteristics, and side effect profiles for each technique that can ultimately impact the maternal-fetal dyad. The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.

The concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in Japanese parturients.

Background: The accurate identification of an intervertebral lumbar level is essential to avoid neuraxial anesthesia and analgesia-related spinal cord injury. It has been shown that estimation of L3/4 intervertebral lumbar level based on the intercristal line determined by palpation (palpated L3/4) is often inaccurate. However; studies evaluating intervertebral lumbar level concordance based on palpation vs. ultrasonography were conducted in Western populations (i.e. in North America and/or Europe). Radiological studies suggest that the intercristal line intersects at a lower level of the spine in Japanese women than in Western women. Therefore, we hypothesized that differences exist in intervertebral levels based on the palpated intercristal line between Asian and Western women. Herein we present the results of the first study in Japan comparing the concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in pregnant Japanese women.Study objective: The objective of this study was to evaluate the accuracy of palpated L3/4 in Japanese parturients assessed by ultrasonography (US).Design: A prospective, observer-blinded study.Setting: Labor and delivery room at the Kitasato University Hospital, Sagamihara, Kanagawa, Japan.Patients: Sixty-three term parturients underwent induction of labor and requested neuraxial labor analgesia.Interventions: With the patients in the sitting position, an attending anesthesiologist marked the intervertebral space estimated as L3/4 based on intercristal line with palpation. Another attending anesthesiologist who was blinded to the marker performed US to identify L3/4.Results: The overall agreement rate of palpated and US L3/4 was 69.8% (44/63). Palpated L3/4 was US L2/3 in 8/63 (12.7%) and US L4/5 in 11/63 (17.5%). In comparison with women with palpated L3/4 agreed with US L3/4, women with palpated L3/4 agreed with US L2/3 were more frequently multiparous (52 vs. 100%, p < .05) and women with palpated L3/4 identified as L4/5 were younger (36 ± 4 years vs. 33 ± 4 yrs, p < .05) and gained less weight during pregnancy (10 ± 4 kg vs. 7 ± 4 kg, p < .05). The patients whose palpated L3/4 were found to be US L2/3 were all multiparous.Conclusion: The accuracy rate of palpated L3/4 intervertebral lumbar level in pregnant women included in our study was 69.8%. Pregnancy-related weight gain, parity, and maternal age can all influence an estimation of L3/4 intervertebral lumbar level by palpation. In addition, we believe that this is the first study to analyze the correlation between maternal parity and interspace estimation by palpation in pregnant women.

Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial.

BACKGROUND: Breakthrough pain during neuraxial labor analgesia is typically alleviated with additional administration of epidural local anesthetics, with or without adjuvants. Sometimes avoiding neuraxial opioids may be warranted and clonidine is an alternative. In a randomized double-blind trial we compared the efficacy of clonidine versus fentanyl, added to bupivacaine, for the management of breakthrough pain. METHODS: Term parturients (n=98) receiving bupivacaine 0.0625% with fentanyl 2 µg/mL at 12 mL/h, a patient-administered bolus of 5 mL at lockout 6-10 min and a maximum of four boluses per hour, and experiencing breakthrough pain ≥5/10, were randomized to receive a 10 mL bolus containing 12.5 mg bupivacaine and either clonidine 100 µg or fentanyl 100 µg. The primary outcome was 'success' of study drug treatment, defined as a pain score reduction ≥4/10 within 15 min of administration. Maternal hemodynamics and fetal heart rate were documented for two hours after treatment. RESULTS: There was no significant difference between groups in success rates (66.0% after clonidine (n=47) vs 74.5% after fentanyl (n=51), P=0.48) or in the incidence of hypotension (systolic blood pressure ≤80% of baseline or <90 mmHg) or sedation at 15 min, with 2/51 and 1/47 subjects in the fentanyl and clonidine groups, respectively, receiving phenylephrine. CONCLUSION: Epidural clonidine 100 µg was not superior to fentanyl 100 µg for decreasing pain scores within 15 min of co-administration with bupivacaine 0.125% for intrapartum breakthrough pain. The analgesic efficacy and hemodynamic side effects did not significantly differ.

Progress in analgesia for labor: focus on neuraxial blocks.

Neuraxial analgesia is widely accepted as the most effective and the least depressant method of providing pain relief in labor. Over the last several decades neuraxial labor analgesia techniques and medications have progressed to the point now where they provide high quality pain relief with minimal side effects to both the mother and the fetus while maximizing the maternal autonomy possible for the parturient receiving neuraxial analgesia. The introduction of the combined spinal epidural technique for labor has allowed for the rapid onset of analgesia with minimal motor blockade, therefore allowing the comfortable parturient to ambulate. Patient-controlled epidural analgesia techniques have evolved to allow for more flexible analgesia that is tailored to the individual needs of the parturient and effective throughout the different phases of labor. Computer integrated systems have been studied to provide seamless analgesia from induction of neuraxial block to delivery. New adjuvant drugs that improve the effectiveness of neuraxial labor analgesia while decreasing the side effects that may occur due to high dose of a single drug are likely to be added to future labor analgesia practice. Bupivacaine still remains a popular choice of local anesthetic for labor analgesia. New local anesthetics with less cardiotoxicity have been introduced, but their cost effectiveness in the current labor analgesia practice has been questioned.

Why epidurals do not always work.

The overwhelming majority of epidural catheters placed for labor provide satisfactory analgesia. There are, however, times when the catheter is not sited within the epidural space correctly, the patient's neuraxial anatomy is problematic, or a patient's labor progresses more quickly than expected by the anesthesiologist, and the epidural block does not set up on time. In this article, the basics of neuraxial labor analgesia, the causes of its failure, and the strategies anesthesiologists employ to rescue poorly functioning catheters are reviewed.