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Neuraxial analgesia for labor and delivery (including instrumented delivery)

Roulhac d'Arby Toledano, PhD, MD
Lisa Leffert, MD
Section Editor
David L Hepner, MD
Deputy Editor
Marianna Crowley, MD


Neuraxial analgesia is the most effective and most commonly used therapy for pain relief during labor and delivery. Epidural, combined spinal–epidural (CSE), and other central neuraxial techniques, including dural puncture epidural (DPE), single-shot spinal, and continuous spinal, are among the many options available to alleviate the pain of childbirth. In most cases, these techniques provide excellent analgesia with minimal risk to both mother and fetus.

This topic will discuss the indications, common techniques, and drugs used for neuraxial labor analgesia. The pain pathways applicable to labor and delivery, other pharmacologic methods for control of labor pain, neuraxial techniques, and adverse effects of neuraxial block are discussed in detail separately. (See "Pharmacologic management of pain during labor and delivery", section on 'Pain pathways' and "Pharmacologic management of pain during labor and delivery", section on 'Adverse consequences of labor pain' and "Adverse effects of neuraxial analgesia and anesthesia for obstetrics" and "Spinal anesthesia: Technique" and "Epidural and combined spinal-epidural anesthesia: Techniques".)


Neuraxial labor analgesia may be performed to relieve the pain of labor and to provide an in-situ epidural catheter for rapid conversion to surgical anesthesia for operative delivery, should it become necessary.

Pain relief — Neuraxial analgesia is appropriate for laboring women regardless of parity, cervical dilation, and fetal station, unless there is a contraindication [1]. The techniques are usually easily performed, life-threatening complications are rare, and side effects such as pruritus and hypotension are transient or easily treated. The following general considerations apply to neuraxial analgesia for labor:

The American College of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA) concur that maternal request is sufficient indication for pain relief during labor, barring a medical contraindication [1].

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Literature review current through: Nov 2017. | This topic last updated: Jun 27, 2017.
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  1. ACOG Committee Opinion No. 295, Pain Reilief During Labor, July 2004 (replaces No. 231, February 2000; reaffirmed 2015). http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Pain-Relief-During-Labor (Accessed on May 19, 2016).
  2. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016; 124:270.
  3. Bauer ME, Kountanis JA, Tsen LC, et al. Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials. Int J Obstet Anesth 2012; 21:294.
  4. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64.
  5. Perlas A, Chaparro LE, Chin KJ. Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis. Reg Anesth Pain Med 2016; 41:251.
  6. Ansari T, Yousef A, El Gamassy A, Fayez M. Ultrasound-guided spinal anaesthesia in obstetrics: is there an advantage over the landmark technique in patients with easily palpable spines? Int J Obstet Anesth 2014; 23:213.
  7. Heesen M, Van de Velde M, Klöhr S, et al. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. Anaesthesia 2014; 69:64.
  8. Lee S, Lew E, Lim Y, Sia AT. Failure of augmentation of labor epidural analgesia for intrapartum cesarean delivery: a retrospective review. Anesth Analg 2009; 108:252.
  9. Groden J, Gonzalez-Fiol A, Aaronson J, et al. Catheter failure rates and time course with epidural versus combined spinal-epidural analgesia in labor. Int J Obstet Anesth 2016; 26:4.
  10. Booth JM, Pan JC, Ross VH, et al. Combined Spinal Epidural Technique for Labor Analgesia Does Not Delay Recognition of Epidural Catheter Failures: A Single-center Retrospective Cohort Survival Analysis. Anesthesiology 2016; 125:516.
  11. Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2012; 10:CD003401.
  12. American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology 2010; 112:530.
  13. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med 2006; 31:311.
  14. Toledano RD, Tsen LC. Epidural catheter design: history, innovations, and clinical implications. Anesthesiology 2014; 121:9.
  15. Spiegel JE, Vasudevan A, Li Y, Hess PE. A randomized prospective study comparing two flexible epidural catheters for labour analgesia. Br J Anaesth 2009; 103:400.
  16. Mhyre JM, Greenfield ML, Tsen LC, Polley LS. A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement. Anesth Analg 2009; 108:1232.
  17. Sviggum HP, Farber MK. The incidence and management of inability to advance Arrow FlexTip Plus epidural catheters in obstetric patients. Int J Obstet Anesth 2014; 23:113.
  18. Mhyre JM. Why do pharmacologic test doses fail to identify the unintended intrathecal catheter in obstetrics? Anesth Analg 2013; 116:4.
  19. Mulroy MF, Norris MC, Liu SS. Safety steps for epidural injection of local anesthetics: review of the literature and recommendations. Anesth Analg 1997; 85:1346.
  20. Zakowski MI, Ramanathan S. Uteroplacental circulation and respiratory gas exchange. In: Shnider and Levinson's Anesthesia for Obstetrics, 5th ed, Suresh MS, Segal BS, Preston R, et al (Eds), Lippincott, Williams & Wilkins, Philadelphia 2013. p.18.
  21. D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2014; 120:1505.
  22. Lamont RF, Pinney D, Rodgers P, Bryant TN. Continuous versus intermittent epidural analgesia. A randomised trial to observe obstetric outcome. Anaesthesia 1989; 44:893.
  23. Smedstad KG, Morison DH. A comparative study of continuous and intermittent epidural analgesia for labour and delivery. Can J Anaesth 1988; 35:234.
  24. Halpern SH, Carvalho B. Patient-controlled epidural analgesia for labor. Anesth Analg 2009; 108:921.
  25. van der Vyver M, Halpern S, Joseph G. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis. Br J Anaesth 2002; 89:459.
  26. Capogna G, Stirparo S. Techniques for the maintenance of epidural labor analgesia. Curr Opin Anaesthesiol 2013; 26:261.
  27. Sumikura H, van de Velde M, Tateda T. Comparison between a disposable and an electronic PCA device for labor epidural analgesia. J Anesth 2004; 18:262.
  28. Sng BL, Zhang Q, Leong WL, et al. Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia. J Clin Anesth 2015; 27:277.
  29. Lim Y, Sia AT, Ocampo C. Automated regular boluses for epidural analgesia: a comparison with continuous infusion. Int J Obstet Anesth 2005; 14:305.
  30. Fettes PD, Moore CS, Whiteside JB, et al. Intermittent vs continuous administration of epidural ropivacaine with fentanyl for analgesia during labour. Br J Anaesth 2006; 97:359.
  31. Wong CA, Ratliff JT, Sullivan JT, et al. A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia. Anesth Analg 2006; 102:904.
  32. Capogna G, Camorcia M, Stirparo S, Farcomeni A. Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: the effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women. Anesth Analg 2011; 113:826.
  33. Wong CA, McCarthy RJ, Hewlett B. The effect of manipulation of the programmed intermittent bolus time interval and injection volume on total drug use for labor epidural analgesia: a randomized controlled trial. Anesth Analg 2011; 112:904.
  34. Margarido CB, Mikhael R, Arzola C, et al. The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Can J Anaesth 2011; 58:262.
  35. Lee AJ, Ranasinghe JS, Chehade JM, et al. Ultrasound assessment of the vertebral level of the intercristal line in pregnancy. Anesth Analg 2011; 113:559.
  36. Locks Gde F, Almeida MC, Pereira AA. Use of the ultrasound to determine the level of lumbar puncture in pregnant women. Rev Bras Anestesiol 2010; 60:13.
  37. Palmer CM. Continuous spinal anesthesia and analgesia in obstetrics. Anesth Analg 2010; 111:1476.
  38. Arkoosh VA, Palmer CM, Yun EM, et al. A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia. Anesthesiology 2008; 108:286.
  39. Jagannathan DK, Arriaga AF, Elterman KG, et al. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. Int J Obstet Anesth 2016; 25:23.
  40. Suzuki N, Koganemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia. Anesth Analg 1996; 82:1040.
  41. Cappiello E, O'Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg 2008; 107:1646.
  42. Thomas JA, Pan PH, Harris LC, et al. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology 2005; 103:1046.
  43. Ginosar Y, Davidson EM, Firman N, et al. A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction. Int J Obstet Anesth 2010; 19:171.
  44. Christiaens F, Verborgh C, Dierick A, Camu F. Effects of diluent volume of a single dose of epidural bupivacaine in parturients during the first stage of labor. Reg Anesth Pain Med 1998; 23:134.
  45. Lyons GR, Kocarev MG, Wilson RC, Columb MO. A comparison of minimum local anesthetic volumes and doses of epidural bupivacaine (0.125% w/v and 0.25% w/v) for analgesia in labor. Anesth Analg 2007; 104:412.
  46. Polley LS, Columb MO, Naughton NN, et al. Relative analgesic potencies of ropivacaine and bupivacaine for epidural analgesia in labor: implications for therapeutic indexes. Anesthesiology 1999; 90:944.
  47. Lacassie HJ, Columb MO, Lacassie HP, Lantadilla RA. The relative motor blocking potencies of epidural bupivacaine and ropivacaine in labor. Anesth Analg 2002; 95:204.
  48. Beilin Y, Halpern S. Focused review: ropivacaine versus bupivacaine for epidural labor analgesia. Anesth Analg 2010; 111:482.
  49. Grice SC, Eisenach JC, Dewan DM. Labor analgesia with epidural bupivacaine plus fentanyl: enhancement with epinephrine and inhibition with 2-chloroprocaine. Anesthesiology 1990; 72:623.
  50. Hess PE, Snowman CE, Hahn CJ, et al. Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia. J Clin Anesth 2006; 18:29.
  51. Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg 2002; 94:1598.
  52. Roelants F, Lavand'homme P. Clonidine versus sufentanil as an adjuvant to ropivacaine in patient-controlled epidural labour analgesia: A randomised double-blind trial. Eur J Anaesthesiol 2015; 32:805.
  53. Van de Velde M, Berends N, Kumar A, et al. Effects of epidural clonidine and neostigmine following intrathecal labour analgesia: a randomised, double-blind, placebo-controlled trial. Int J Obstet Anesth 2009; 18:207.
  54. Boogmans T, Vertommen J, Valkenborgh T, et al. Epidural neostigmine and clonidine improves the quality of combined spinal epidural analgesia in labour: a randomised, double-blind controlled trial. Eur J Anaesthesiol 2014; 31:190.
  55. Ross VH, Pan PH, Owen MD, et al. Neostigmine decreases bupivacaine use by patient-controlled epidural analgesia during labor: a randomized controlled study. Anesth Analg 2009; 109:524.
  56. Booth JL, Ross VH, Nelson KE, et al. Epidural Neostigmine versus Fentanyl to Decrease Bupivacaine Use in Patient-controlled Epidural Analgesia during Labor: A Randomized, Double-blind, Controlled Study. Anesthesiology 2017; 127:50.
  57. Campbell DC, Camann WR, Datta S. The addition of bupivacaine to intrathecal sufentanil for labor analgesia. Anesth Analg 1995; 81:305.
  58. Wong CA, Scavone BM, Loffredi M, et al. The dose-response of intrathecal sufentanil added to bupivacaine for labor analgesia. Anesthesiology 2000; 92:1553.
  59. Wong CA, Scavone BM, Slavenas JP, et al. Efficacy and side effect profile of varying doses of intrathecal fentanyl added to bupivacaine for labor analgesia. Int J Obstet Anesth 2004; 13:19.
  60. Van de Velde M. Neuraxial analgesia and fetal bradycardia. Curr Opin Anaesthesiol 2005; 18:253.
  61. Nelson KE, Rauch T, Terebuh V, D'Angelo R. A comparison of intrathecal fentanyl and sufentanil for labor analgesia. Anesthesiology 2002; 96:1070.