TROUBLESHOOTING LABOUR EPIDURALS

Maximum doses over 4 hours – Levobupivacaine 2mg/kg, Fentanyl 200 micrograms

•Where is the pain or discomfort? •Is there good sacral coverage?
If called to top-up an epidural, •What is the height of the block? Check this yourself! •How far has mother progressed through labour?
•Is it equal on the left and right? •What is the orientation of the fetal head?
perform a full assessment: •Are there any missed segments? •Always ask yourself if pain could be related to a full bladder!

POOR SACRAL COVERAGE

MISSED SEGMENT

UNILATERAL BLOCK
NO BLOCK; LOW BLOCK

Give 10-20ml ‘bag solution’ with Is it a true missed segment? This is Suspect this if the mother is Check if feet are warm and dry. Does
mother in normal position. Recheck frequently diagnosed when unilateral describing groin/vaginal/rectal or this correspond to the pain?
block at 20 minutes. block is present. Should be managed as perineal pain.
per unilateral block (initially with 10- Put patient in lateral position sore side
If block still not high enough then 20ml ‘bag solution’). Check lateral aspect of feet for S1/S2 down. Give 10ml ‘bag solution’, pull
consider resiting epidural at different coverage. back epidural catheter by 1-2cm
interspace. If a true missed segment then give 7- (always leave at least 3cm in epidural
10ml 0.25% Levobupivacaine and 50 Give 10-20ml ‘bag solution’ with space, 4cm if obese), and then give
2 strikes consider resite micrograms Fentanyl. If worse on one mother sitting upright. Recheck block another 10ml ‘bag solution’. Recheck
side then position mother sore side at 20 minutes. block at 20 minutes.
down. Recheck block at 20 minutes.
BACK PAIN/’RECTAL PRESSURE’ If sacral coverage remains inadequate If still sore on affected side, then give
This is more likely in the later stages of labour If block still inadequate then consider then resite epidural at different 7-10ml 0.25% Levobupivacaine with
(8-10cm dilation) with descent of the fetal head. resiting epidural at different interspace. (preferably lower) interspace. 50 micrograms Fentanyl with sore side
Particularly common with OP head position. Consider CSE for labour down. Recheck block at 20 minutes.
If block range is adequate (above T10, good sacral coverage) then denser block is required.
Warn mother that complete relief of discomfort/pressure may not be achievable. If sacral coverage now appears to be If block still inadequate then consider
adequate on ethyl chloride testing but resiting epidural at different
Give 7-10ml 0.25% Levobupivacaine and 50 micrograms Fentanyl. Recheck block and response at 20 minutes.
If discomfort or pressure is still distressing mother, then 75micrograms Clonidine can help – always discuss with mother is still sore then follow back interspace.
consultant before administering this. Be aware of risk of fetal bradycardia and maternal hypotension. pain/’rectal pressure’ section.