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Providing pain relief during labour is a fundamental human right and can benefit both mother and foetus. Epidural analgesia remains the 'gold standard', providing excellent pain relief, as well as the facility to convert to anaesthesia should operative intervention be required. While maternal well-being remains the primary focus, epidural analgesia may also have implications for the foetus. Data from meta-analyses finds that epidural compared with systemic opioids in labour is associated with reduced neonatal respiratory depression. Clinically relevant neonatal outcomes such as Apgar score <7 at 5 min, neonatal resuscitation and need for admission to a neonatal unit are reassuring, with the benefits of epidural analgesia for both mother and neonate outweighing any potential risks. Recent concerns regarding an association of epidural with the development of autism spectrum disorder in childhood appear to be unfounded, with several large observational studies refuting this association. This review discusses the evidence relating to maternal neuraxial analgesia in labour, implications for the foetus in utero , and childhood outcomes both in the immediate peripartum period and longer term. [ABSTRACT FROM AUTHOR]

Epidurals were introduced for labour analgesia in the 1940s, and since then they have become the gold standard for analgesia in delivery units globally. Although some controversy remains with regards to the effect of neuraxial blockade on the fetus, it is now established that the benefits are significant. As a result of the introduction of low-dose concentration local anaesthetic mixtures, issues surrounding cardiovascular effects and toxicity have become much less of a concern. The profound motor block found with traditional regimens is much less of a problem resulting in improved maternal satisfaction, although the advent of mobile epidurals has not yet been fully established. Research continues to develop new technologies to provide safer and more individualized neuraxial analgesia tailored to the labouring parturient that seek more control and autonomy over their delivery. No modern technique can emulate the theoretical ideal; however, women can experience safe and effective analgesia with minimal risk to both themselves and their babies. [ABSTRACT FROM AUTHOR]

Since the introduction of epidurals for labour analgesia in 1946 it has become the gold standard on delivery units throughout the world. Controversy remains as to the effects of neuraxial block upon the fetus; however, it is now widely accepted that there are beneficial and not just detrimental effects. With the introduction of low-dose anaesthetic solutions the major cardiovascular effects and concerns with toxicity have become much less prominent and the lack of profound motor block associated with traditional dosing has resulted in greater maternal satisfaction, although not the mobile revolution which was once anticipated. As research continues to search for the ideal labour analgesia, newer technologies are evolving making epidurals ever safer, individualized and tailored to the modern women in the delivery suite, as they demand greater control and autonomy over their deliveries. No current method has been able to emulate these ideals, but in the mean time women can enjoy safe and effective analgesia with minimal risks to either themselves or their babies. [ABSTRACT FROM AUTHOR]

Turner's syndrome, one of the most common sex chromosome abnormalities in females, is caused by loss of part or all of an X chromosome. We report a case of mosaic Turner's syndrome, posted for elective cesarean delivery under low-dose sequential combined spinal-epidural anesthesia. The unique features of this case were the combination of an anticipated difficult airway and both short stature and scoliosis in the lumbar region. A titrated combined spinal-epidural technique was performed in order to avoid hemodynamic instability, which could have been exacerbated in the presence of cardiovascular deformities that accompany this syndrome in many cases. The patient was managed successfully under regional anesthesia, which is generally a preferred technique to general anesthesia, to avoid sympathetic stimulation during intubation and emergence. Further, this technique may avoid potential complications associated with difficult airway management. [ABSTRACT FROM AUTHOR]

Since the introduction of epidurals for labour analgesia in 1946, it has become the gold standard on delivery units throughout the world. Controversy remains as to the effects of neuraxial block upon the fetus, however it is now widely accepted that there are beneficial and not just detrimental effects. With the introduction of low-dose anaesthetic solutions the major cardiovascular effects and concerns with toxicity have become much less prominent and the lack of profound motor block associated with traditional dosing has resulted in greater maternal satisfaction, although not the mobile revolution which was once anticipated. As research continues to search for the ideal labour analgesia, newer technologies are evolving making epidurals ever safer, individualized and tailored to the modern women on the delivery suite, as they demand greater control and autonomy over their deliveries. No current method has been able to emulate these ideals, but in the meantime women can enjoy safe and effective analgesia with minimal risks to either themselves or their babies. [ABSTRACT FROM AUTHOR]

Renal tubular acidosis, associated with hypothyroidism, is rare. We present the case of a woman with known renal tubular acidosis and treated hypothyroidism who underwent emergency cesarean delivery under uneventful combined spinal-epidural anesthesia. The rationale for choosing the anesthetic technique and the potential risks associated with anesthesia and renal tubular acidosis are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Labour epidural analgesia underwent marked changes from the mid-1980s. The addition of opioids, such as fentanyl, to local anaesthetics reduced motor block as well as improving analgesia and maternal satisfaction. The introduction of new techniques such as combined spinal epidural analgesia and patient-controlled epidural analgesia has further enhanced regional techniques. Dense motor block, historically associated with labour epidural analgesia, has now been reduced to a level where some mothers can mobilize safely out of bed during their labour. Research continues to focus on finding the ideal technique and combination of drugs to provide reliable analgesia with minimal motor block. No one technique has become universally popular, and the introduction of the new levo- or s-enantiomer local anaesthetics has not had a major impact on labour analgesia practice. Currently, women can enjoy safe, reliable epidurals for labour analgesia with reduced or minimal motor blockade. [Copyright &y& Elsevier]

Abstract: Background: The limited duration of spinal labour analgesia combined with problems associated with maintenance of epidural analgesia, have prompted the search for combinations that could prolong spinal analgesia. A randomised, double-blind trial was carried out to test the hypotheses (a) that initial spinal labour analgesia is prolonged by administering clonidine and neostigmine epidurally whilst (b) the hourly local anaesthetic consumption is reduced. Methods: Seventy labouring patients received spinal analgesia with ropivacaine and sufentanil. Fifteen minutes after spinal injection, 10mL of study solution was administered epidurally. The study solution was plain saline or neostigmine 500μg combined with clonidine 75μg. Outcome parameters were duration of spinal analgesia, local anaesthetic consumption and number of patients delivering without additional epidural analgesia. Results: Epidural clonidine and neostigmine significantly prolonged initial analgesia: 144 (105–163)min vs. 95 (70–120)min in the placebo group and reduced hourly ropivacaine consumption: 7.5 (3.0–11.9)mg vs. 12.7 (9.6–16.9)mg. More patients in the experimental group delivered before the first request for additional analgesia (9 vs. 2). Conclusion: Epidural administration of neostigmine 500μg and clonidine 75μg, following the intrathecal injection of ropivacaine and sufentanil, prolongs analgesia and reduces hourly ropivacaine consumption. [Copyright &y& Elsevier]

Background: The aim of the present study was to compare the efficacy of patient-controlled epidural analgesia after initiation with either epidural or combined spinal-epidural analgesia. Methods: Forty ASA I parturients at 37-42 weeks’ gestation and cervical dilatation <6 cm were randomly allocated to receive either epidural analgesia (group EA) or combined spinal-epidural analgesia (group CSEA). Analgesia was initiated with a 7-mL epidural bolus 0.1% bupivacaine containing fentanyl 50 μg (group EA, n =20) or with intrathecal fentanyl 20 μg (group CSEA, n =20). In both groups, analgesia was provided by a 5-mL bolus on demand via PCEA with a 10-min lock-out interval and a 15-mL/h limit. Results: No significant differences were observed in the rate of cervical dilatation, delivery type or duration of delivery between the groups. The time to first analgesic demand was shorter in the CSEA than in the EA group. Total bupivacaine dose was comparable in both groups, but total fentanyl dose in group CSEA was significantly lower than that of group EA because of the initial dose used for the induction of EA and CSEA. The incidence of pruritus in group CSEA was significantly higher than in group EA. Conclusion: Both regional analgesia techniques followed by demand-only PCEA provided efficient pain relief for labor without changing the duration of labor or rate of cesarean section. [Copyright &y& Elsevier]

Summary: We describe the anaesthetic management of a spontaneous vaginal delivery at 39 weeks’ gestation in a 22-year-old patient with congenital long QT syndrome. With a strong family history of sudden deaths, the patient had an initial QT interval corrected for rate (QTc) of >600 ms. Following a once-daily 50-mg dose of atenolol over the previous 11 months, her QTc remained prolonged at 560 ms. To minimise any increase in catecholamine levels and consequent risk of malignant ventricular arrhythmias, a combined spinal-epidural technique was selected using intrathecal diamorphine and levobupivacaine, with intravenous and oral magnesium and potassium supplementation. Levobupivacaine was substituted for routine racemic bupivacaine to decrease the risk of drug-induced cardiotoxicity. Delivery outcome was successful and uneventful. We outline the pathophysiology, risks and treatments of long QT syndrome, and discuss the analgesic management of this patient in labour with congenital long QT syndrome. [Copyright &y& Elsevier]

Background: Intermittent epidural bolus dosing is a method of drug delivery that can prolong the duration of labour analgesia induced by a combined spinal epidural (CSE). In this randomized, double-blinded study, we compared the analgesic efficacy of two drug delivery systems: regular intermittent epidural boluses and continuous epidural infusion and assessed the incidence of breakthrough pain after CSE. Methods: With the approval of the Hospital Ethics Committee, we recruited 60 parturients into this randomized controlled trial. A CSE was performed with intrathecal fentanyl 25 μg in all patients. The parturients were then randomly allocated into two groups. The infusion group received a continuous epidural infusion of levobupivacaine 0.1% with fentanyl 2 μg/mL at a rate of 10 mL/h. The bolus group received 5-mL epidural boluses every half hour. The sample size was computed to detect a 40% reduction in the rate of breakthrough pain. Results: The bolus group had a lower incidence of breakthrough pain than the infusion group (10% vs. 37%, P <0.05). The bolus group also had significantly higher satisfaction scores for labour analgesia: 97±8 (mean±SD) vs. 89±7 (P <0.05). Conclusion: Automated regular bolus delivery of epidural analgesia when compared with continuous infusion decreased the incidence of breakthrough pain and increased maternal satisfaction. In a busy obstetric unit, this may also serve to decrease the anesthetists’ workload. [Copyright &y& Elsevier]

Summary: A 36-year-old patient with a history of previous back surgery, asthma, latex allergy and achondroplasia presented for urgent cesarean delivery at 31 weeks’ gestation for worsening nonimmune fetal hydrops. The fetus was diagnosed with trisomy 21 and achondroplasia. Because of the urgent clinical situation, the patient was given a spinal anesthetic, which required supplemental intravenous sedation after delivery of the fetus. This case report discusses the controversies in anesthetic management of this complicated patient and compromised fetus regarding general anesthesia, epidural, spinal and combined spinal-epidural anesthesia. [Copyright &y& Elsevier]

Abstract: Regional anaesthesia is the technique of choice for caesarean sections, with single-shot spinal most commonly used. Preoperative assessment must be undertaken in all women, and informed consent is mandatory. Antacid premedication should be given to both elective and emergency cases. Maternal obesity is a risk factor for failed regional anaesthesia. Light-touch is the most reliable way of assessing the block, and the level should be documented prior to surgery. Inadequate block is a frequent cause of litigation, and all women should be offered general anaesthesia. Good communication with the parturient and the obstetricians and detailed documentation are essential if this occurs. Management options include repeating or supplementing the block, nitrous oxide, opiates, ketamine or resorting to general anaesthesia. All caesarean sections require follow-up postoperatively. [Copyright &y& Elsevier]

Abstract: Almost 90% of caesarean sections in the UK are performed under regional anaesthesia. Preoperative assessment should include airway assessment, and informed consent should be documented in detail. Antacid prophylaxis and an appropriate fasting period are mandatory. Both maternal and fetal monitoring should be undertaken during induction of anaesthesia. Maternal hypotension and vena-caval compression are minimized by careful maternal positioning and use of vasopressors. The sensory block should be tested to light touch and the level documented prior to surgery. Pain during surgery is a frequent cause of litigation. If possible surgery should be halted. Management options include nitrous oxide, intravenous opioids or ketamine, epidural ‘top-up’ and local infiltration. Most importantly general anaesthesia must always be offered and this documented. All women having a caesarean should be followed up within 24 hours by the anaesthetic team. [ABSTRACT FROM AUTHOR]

Abstract: Almost 90% of caesarean sections in the UK are carried out under regional anaesthesia. Preoperatively, women should be assessed and given adequate information regarding the regional technique. Antacid premedication and, in elective cases, an appropriate starvation period are mandatory. Regional anaesthesia should be established in the operating theatre, with both maternal and fetal monitoring in progress. Single-shot spinal is currently the most popular technique. Before surgery starts, assessment and documentation of the block are essential. Sensory block to light touch, and/or cold, should be measured. Surgery should be halted, if possible, if there is pain. Analgesic options include Entonox, intravenous opioids or ketamine, epidural ‘top-up’ and local infiltration; however, general anaesthesia should always be offered. All women should be followed up within 24 hours by the anaesthetic team. [Copyright &y& Elsevier]

Abstract: Labour epidural analgesia underwent marked changes from the mid 1980s to the 1990s. The addition of opioids, such as fentanyl, to local anaesthetic reduced motor block and improved analgesia and maternal satisfaction. The introduction of new techniques such as combined spinal epidural analgesia and patient-controlled epidural analgesia further enhanced regional techniques. Dense motor block, historically associated with labour epidural analgesia, has now been reduced to a level where some mothers can choose to mobilize safely out of bed during their labour. In the past decade, research has focused on finding the ideal technique and combination of drugs to provide reliable analgesia with minimal motor block. No one technique has become universally popular, and the introduction of the new levo or s- enantiomer local anaesthetic has not had a major impact on labour analgesia practice. Currently, women can enjoy safe, reliable epidurals for labour analgesia with reduced or minimal motor blockade. The decisions are based on two decades of published research. [Copyright &y& Elsevier]