Anaes · Obstetric anaesthesia
Labour analgesia: epidural, CSE, and non-neuraxial alternatives
Also known as Labour epidural · Combined spinal epidural labour · COMET trial mobile epidural · Remifentanil PCA labour
Fellowship coverage of labour neuraxial analgesia: consent, epidural and CSE technique, low-dose mobile solutions, COMET trial findings, PCEA, breakthrough pain, complications, and alternatives including remifentanil PCA and nitrous oxide.
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Target exams
Red flags
- Never top up a questionable epidural for category-1 caesarean without assessing block and having GA readiness.
- High/total spinal after CSE or accidental dural puncture is an ABC emergency.
- LAST after epidural top-up — stop injection, call help, lipid emulsion.
- Remifentanil PCA requires continuous monitoring for sedation and apnoea.
- Coagulopathy and infection over the site are hard contraindications until resolved.
Meet the patient
A nulliparous woman at 4 cm is contracting hard and asking for an epidural. She is anxious, coherent, and wants to know what she is signing up for at 3am. The midwife has run a normal CTG and cannulated her.[1]
Two questions frame the whole topic: how do I consent her and place a low-dose mobile epidural that keeps her comfortable and mobile?, and if she needs theatre, how do I convert it to surgical anaesthesia — or walk away to general anaesthesia without gambling on a weak block? Name COMET for the first, name the conversion rule for the second, and the rest follows.[1]
References4ShowHide
- [1]COMET Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial Lancet, 2001.PMID 11454372
- [2]Melber AA et al. Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010-2015) Int J Obstet Anesth, 2019.PMID 30685299
- [3]Ngan Kee WD et al. Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery Anesth Analg, 2004.PMID 14980943
- [4]Mushambi MC et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics Anaesthesia, 2015.PMID 26449292