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Introduction Epidural analgesia has remained the gold standard for labour analgesia over the past 30 years. Consecutive publications in the field of neuraxial analgesia have progressively improved the safety and reduced side effects of the technique: • The decrease in local anaesthetic concentrations 1 has reduced the risk of obstetric and haemodynamic side effects. • The use of opioid adjuvants, thanks to their synergistic effect with local anaesthetics, has helped to further decrease local anaesthetic concentrations.2 • The introduction of new techniques involving puncture of the dura has allowed a more rapid onset of the block and improved the overall efficacy of epidural analgesia during labour, with no significant side effects or complications.3 4 • The development of maintenance methods using programmed intermittent epidural boluses,5 combined with patient-controlled epidural analgesia (PCEA) rescue boluses has led to better pain control after successful initiation of labour analgesia.6 In fact, the European minimum standards in obstetric anaesthesia recommend adequate management of pain during both vaginal and caesarean delivery, at all stages of the epidural analgesia process.7 A recent study described the protective effect of epidural analgesia on severe morbidity during delivery, especially when the epidural block was indicated for medical reasons and at an early gestational age.8 This finding highlights the importance of epidural analgesia not only for the comfort of parturients but also for their safety. In the last 15 years, while safety concerns have progressively improved, there has been increasing focus on the efficacy of the epidural block, leading to efforts to reduce the incidence of epidural failure. Definitions of Epidural Failure In 2009, Agaram et al.9 were the first to introduce the concept of inadequate pain relief with labour epidural, focusing on the onset of the block. They reported an incidence of 16.9% of inadequate block 30 minutes after epidural catheter placement. They identified cervical dilation >7 cm, opioid tolerance, history of previous failed epidural, and less experienced operators as risk factors for inadequate onset of the epidural block. Hermanides et al.,10 in a narrative review published in 2012, were the first to mention the concept of failed epidural. However, their review presented several limitations: they included studies from various specialties beyond obstetrics; causes of failure varied; criteria for epidural block failure differed between studies; and reported incidence ranged from 5% to more than 40%, depending on the context. In 2013, Thangamuthu et al.11 used a standardized definition and reported an epidural failure rate of 23%, identifying risk factors such as anaesthesiologist experience and the length of catheter inserted into the epidural space. However, their definition encompassed both failure during onset and failure during maintenance. Many authors have evaluated the causes and risk factors for breakthrough pain, as defined by Hess et al.12 as an episode of pain in a previously functional epidural catheter. Prediction tools were developed to help clinicians prevent these breakthrough pain episodes.13 Until now, there has been no clear definition in the literature of what constitutes a failing epidural. This is why a panel of experts in obstetric anaesthesia recently defined the concept as inadequate pain relief in a parturient with a previously functional epidural catheter that does not respond to a single epidural top-up dose.14 Management of a Failing Epidural Despite efforts to prevent and treat onset failure and breakthrough pain episodes, 6% to 9% of patients still experience epidural block failure requiring catheter replacement.15 A recent meta-analysis confirmed the superiority of induction techniques involving dural puncture over conventional epidural analgesia, as well as maintenance techniques combining programmed intermittent epidural boluses with PCEA over continuous epidural infusion with PCEA in preventing breakthrough pain.6 Tan et al.16 recently developed a score to predict breakthrough pain and guide clinicians in applying preventive measures. Other studies have shown a reduced need for epidural catheter replacement when using the Dural Puncture Epidural (DPE) technique during labour.15 Guidance was previously published for managing deficient onset of the epidural block during labour.17 In 2025, a panel of European experts published a focused guideline to help clinicians manage failing epidural analgesia.14 The guideline addressed six clinical questions, covering failing epidural management for vaginal birth and intrapartum caesarean delivery, as well as human resources, organisational, and team training aspects. A systematic review was performed, but due to limited evidence, the panel formulated 11 clinical practice statements and only two formal recommendations. An algorithm (figure 1) was developed, recommending whether to administer a top-up dose or to replace the catheter in three situations: totally ineffective block, partially ineffective block, and lateralised block. For catheter replacement, the consensus recommended using a technique involving dural puncture (CSE or DPE). Detection of a failing epidural is crucial for its management. Despite limited evidence, the panel recommended periodic monitoring of motor and sensory block, pain scores, and clinical status using objective scales. An interval of 2 hours was proposed for high-risk patients, though more flexible intervals could be considered for low-risk parturients. Assessment should include prior epidural function, the number of previous top-ups, motor block, and sympathetic block, using the HELP acronym (How was the Epidural functioning so far, Epidural top-ups administered before, Leg raising capacity, and Place hands on legs to assess temperature differences).14 Regarding human resources, the guideline emphasised the leadership role of anaesthesiologists in managing failing epidurals. However, part of the management can be delegated to trained non-anaesthesiologist healthcare professionals, considering human resource limitations in Europe.18 Maintaining adequate patient safety remains essential, and appropriate training for non-anaesthesiologist staff is recommended. Although there is no specific evidence regarding the optimal training for obstetric teams in handling failing epidurals, evidence from crisis resource management suggests that simulation, teamwork, communication, multidisciplinary training, and fostering a safety and quality culture within departments improve outcomes.19 Consequently, the panel recommended developing local protocols for detecting and managing failing epidurals, alongside simulation-based training to enhance protocol adherence and awareness among healthcare professionals and patients. Management of a Failing Epidural in the Context of Intrapartum Caesarean Delivery To address this scenario, the panel formulated recommendations on converting epidural analgesia to anaesthesia and assessing the block to recognise failed conversion—either before surgery begins or intraoperatively. This guidance aims to assist clinicians in managing such situations. Based on criteria described by Yoon et al.20—including the level of urgency, the prior effectiveness of the epidural block, the time since the last epidural bolus, and maternal condition—an algorithm was created (figure 2). The experts recommended that early and proactive management of a failing epidural facilitates successful conversion of analgesia to anaesthesia for intrapartum caesarean delivery. Conclusion and Future Perspectives The introduction of the ‘failing epidural’ concept during labour represents an important advancement in labour analgesia management. It provides clinicians with a systematic approach to addressing inadequate epidural analgesia. The focused guideline helps differentiate between onset failure, breakthrough pain, and a failing epidural, offering practical guidance for management. However, the lack of robust evidence required the panel to rely on consensus-based clinical practice statements, pending future research to validate these recommendations with stronger clinical evidence.References Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ. Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis. Anaesthesia 2022;77:910–918.Cavens L, Roofthooft E. Neuraxial labor analgesia: is there a place for neuraxial adjuvants beyond opioids. Best Practice & Research Clinical Anaesthesiology 2022;36:31–36.Guasch E, Brogly N, Gilsanz F. Combined spinal epidural for labour analgesia and caesarean section: indications and recommendations. Curr Opin Anaesthesiol. 2020;33:284–290.Singh PM, Monks DT, Bhat AD, et al. Epidural analgesia versus dural puncture epidural analgesia in labouring parturients: a meta-analysis of randomised controlled trials. Br J Anaesth. 2025;134:1402–1414.Tan HS, Zeng Y, Qi Y, et al. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database Syst Rev. 2023;6:CD011344.Wang L, Huang J, Chang X, Xia F. Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: a network meta-analysis. Eur J Anaesthesiol. 2024;41:411–420.Guasch E, Brogly N, Mercier FJ, et al. European minimum standards for obstetric analgesia and anaesthesia departments: an experts’ consensus. Eur J Anaesthesiol. 2020;37:1115–1125.Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ. 2024;385:e077190.Agaram R, Douglas MJ, McTaggart RA, Gunka V. Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors. Int J Obstet Anesth. 2009;18:10–4.Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: causes and management. Br J Anaesth. 2012;109:144–54.Thangamuthu A, Russell IF, Purva M. Epidural failure rate using a standardised definition. Int J Obstet Anesth. 2013;22:310–5.Hess PE, Pratt SD, Lucas TP, et al. Predictors of breakthrough pain during labor epidural analgesia. Anesth Analg. 2001;93:414–8, 4th contents page.Tan HS, Liu N, Sultana R, et al. Prediction of breakthrough pain during labour neuraxial analgesia: comparison of machine learning and multivariable regression approaches. Int J Obstet Anesth. 2021;45:99–110.Brogly N, Valbuena Gomez I, Afshari A, et al. Esaic focused guidelines for the management of the failing epidural during labour epidural analgesia. Eur J Anaesthesiol. 2025;42:96–112.Berger AA, Jordan J, Li Y, Kowalczyk JJ, Hess PE. Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study. Int J Obstet Anesth. 2022;52:103590.Tan HS, Liu N, Tan CW, Sia ATH, Sng BL. Developing the breakthrough pain risk score: an interpretable machine-learning-based risk score to predict breakthrough pain with labour epidural analgesia. Can J Anaesth. 2022;69:1315–1317.Guasch E, Iannuccelli F, Brogly N, Gilsanz F. Failed epidural for labor: what now? Minerva Anestesiol. 2017;83:1207–1213.Guasch E, Ioscovich A, Brogly N, et al. Obstetric anaesthesia manpower and service provision issues (introduction and european perspective). Int J Obstet Anesth. 2023;55:103647.MacLennan K, Minehart RD, Vasco M, Eley VA. Simulation-based training in obstetric anesthesia: an update. Int J Obstet Anesth. 2023;54:103643.Yoon HJ, Do SH, Yun YJ. Comparing epidural surgical anesthesia and spinal anesthesia following epidural labor analgesia for intrapartum cesarean section: a prospective randomized controlled trial. Korean J Anesthesiol. 2017;70:412–419.Array Introduction Epidural analgesia has remained the gold standard for labour analgesia over the past 30 years. Consecutive publications in the field of neuraxial analgesia have progressively improved the safety and reduced side effects of the technique:The decrease in local anaesthetic concentrations1 has reduced the risk of obstetric and haemodynamic side effects.The use of opioid adjuvants, thanks to their synergistic effect with local anaesthetics, has helped to further decrease local anaesthetic concentrations.2 The introduction of new techniques involving puncture of the dura has allowed a more rapid onset of the block and improved the overall efficacy of epidural analgesia during labour, with no significant side effects or complications.3 4 The development of maintenance methods using programmed intermittent epidural boluses,5 combined with patient-controlled epidural analgesia (PCEA) rescue boluses has led to better pain control after successful initiation of labour analgesia.6 In fact, the European minimum standards in obstetric anaesthesia recommend adequate management of pain during both vaginal and caesarean delivery, at all stages of the epidural analgesia process.7 A recent study described the protective effect of epidural analgesia on severe morbidity during delivery, especially when the epidural block was indicated for medical reasons and at an early gestational age.8 This finding highlights the importance of epidural analgesia not only for the comfort of parturients but also for their safety.In the last 15 years, while safety concerns have progressively improved, there has been increasing focus on the efficacy of the epidural block, leading to efforts to reduce the incidence of epidural failure.Definitions of Epidural Failure In 2009, Agaram et al. 9 were the first to introduce the concept of inadequate pain relief with labour epidural, focusing on the onset of the block. They reported an incidence of 16.9% of inadequate block 30 minutes after epidural catheter placement. They identified cervical dilation >7 cm, opioid tolerance, history of previous failed epidural, and less experienced operators as risk factors for inadequate onset of the epidural block.Hermanides et al.,10 in a narrative review published in 2012, were the first to mention the concept of failed epidural. However, their review presented several limitations: they included studies from various specialties beyond obstetrics; causes of failure varied; criteria for epidural block failure differed between studies; and reported incidence ranged from 5% to more than 40%, depending on the context.In 2013, Thangamuthu et al.11 used a standardized definition and reported an epidural failure rate of 23%, identifying risk factors such as anaesthesiologist experience and the length of catheter inserted into the epidural space. However, their definition encompassed both failure during onset and failure during maintenance.Many authors have evaluated the causes and risk factors for breakthrough pain, as defined by Hess et al.12 as an episode of pain in a previously functional epidural catheter. Prediction tools were developed to help clinicians prevent these breakthrough pain episodes.13 Until now, there has been no clear definition in the literature of what constitutes a failing epidural. This is why a panel of experts in obstetric anaesthesia recently defined the concept as inadequate pain relief in a parturient with a previously functional epidural catheter that does not respond to a single epidural top-up dose.14 Management of a Failing Epidural Despite efforts to prevent and treat onset failure and breakthrough pain episodes, 6% to 9% of patients still experience epidural block failure requiring catheter replacement. 15 A recent meta-analysis confirmed the superiority of induction techniques involving dural puncture over conventional epidural analgesia, as well as maintenance techniques combining programmed intermittent epidural boluses with PCEA over continuous epidural infusion with PCEA in preventing breakthrough pain.6 Tan et al.16 recently developed a score to predict breakthrough pain and guide clinicians in applying preventive measures.Other studies have shown a reduced need for epidural catheter replacement when using the Dural Puncture Epidural (DPE) technique during labour.15 Guidance was previously published for managing deficient onset of the epidural block during labour.17 In 2025, a panel of European experts published a focused guideline to help clinicians manage failing epidural analgesia.14 The guideline addressed six clinical questions, covering failing epidural management for vaginal birth and intrapartum caesarean delivery, as well as human resources, organisational, and team training aspects. A systematic review was performed, but due to limited evidence, the panel formulated 11 clinical practice statements and only two formal recommendations.An algorithm (figure 1) was developed, recommending whether to administer a top-up dose or to replace the catheter in three situations: totally ineffective block, partially ineffective block, and lateralised block. For catheter replacement, the consensus recommended using a technique involving dural puncture (CSE or DPE).Detection of a failing epidural is crucial for its management. Despite limited evidence, the panel recommended periodic monitoring of motor and sensory block, pain scores, and clinical status using objective scales. An interval of 2 hours was proposed for high-risk patients, though more flexible intervals could be considered for low-risk parturients. Assessment should include prior epidural function, the number of previous top-ups, motor block, and sympathetic block, using the HELP acronym (How was the Epidural functioning so far, Epidural top-ups administered before, Leg raising capacity, and Place hands on legs to assess temperature differences).14 Regarding human resources, the guideline emphasised the leadership role of anaesthesiologists in managing failing epidurals. However, part of the management can be delegated to trained non-anaesthesiologist healthcare professionals, considering human resource limitations in Europe.18 Maintaining adequate patient safety remains essential, and appropriate training for non-anaesthesiologist staff is recommended.Although there is no specific evidence regarding the optimal training for obstetric teams in handling failing epidurals, evidence from crisis resource management suggests that simulation, teamwork, communication, multidisciplinary training, and fostering a safety and quality culture within departments improve outcomes.19 Consequently, the panel recommended developing local protocols for detecting and managing failing epidurals, alongside simulation-based training to enhance protocol adherence and awareness among healthcare professionals and patients.Management of a Failing Epidural in the Context of Intrapartum Caesarean Delivery To address this scenario, the panel formulated recommendations on converting epidural analgesia to anaesthesia and assessing the block to recognise failed conversion—either before surgery begins or intraoperatively. This guidance aims to assist clinicians in managing such situations. Based on criteria described by Yoon et al. 20 —including the level of urgency, the prior effectiveness of the epidural block, the time since the last epidural bolus, and maternal condition—an algorithm was created (figure 2).The experts recommended that early and proactive management of a failing epidural facilitates successful conversion of analgesia to anaesthesia for intrapartum caesarean delivery.Conclusion and Future Perspectives The introduction of the ‘failing epidural’ concept during labour represents an important advancement in labour analgesia management. It provides clinicians with a systematic approach to addressing inadequate epidural analgesia. The focused guideline helps differentiate between onset failure, breakthrough pain, and a failing epidural, offering practical guidance for management. However, the lack of robust evidence required the panel to rely on consensus-based clinical practice statements, pending future research to validate these recommendations with stronger clinical evidence.Abstract FT02 Figure 1Algorithm for the management of a failing epidural block14Abstract FT02 Figure 2Algorithm for the management of failed conversion of analgesia to anaeReferences Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ. Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis. Anaesthesia 2022;77:910–918.Cavens L, Roofthooft E. Neuraxial labor analgesia: is there a place for neuraxial adjuvants beyond opioids. Best Practice & Research Clinical Anaesthesiology 2022;36:31–36.Guasch E, Brogly N, Gilsanz F. Combined spinal epidural for labour analgesia and caesarean section: Indications and recommendations. Curr Opin Anaesthesiol. 2020;33:284–290.Singh PM, Monks DT, Bhat AD, et al. Epidural analgesia versus dural puncture epidural analgesia in labouring parturients: a meta-analysis of randomised controlled trials. Br J Anaesth. 2025;134:1402–1414.Tan HS, Zeng Y, Qi Y, et al. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database Syst Rev. 2023;6:CD011344.Wang L, Huang J, Chang X, Xia F. Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: a network meta-analysis. Eur J Anaesthesiol. 2024;41:411–420.Guasch E, Brogly N, Mercier FJ, et al. European minimum standards for obstetric analgesia and anaesthesia departments: an experts’ consensus. Eur J Anaesthesiol. 2020;37:1115–1125.Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ. 2024;385:e077190.Agaram R, Douglas MJ, McTaggart RA, Gunka V. Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors. Int J Obstet Anesth. 2009;18:10–4.Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: causes and management. Br J Anaesth. 2012;109:144–54.Thangamuthu A, Russell IF, Purva M. Epidural failure rate using a standardised definition. Int J Obstet Anesth. 2013;22:310–5.Hess PE, Pratt SD, Lucas TP, et al. Predictors of breakthrough pain during labor epidural analgesia. Anesth Analg. 2001;93:414–8, 4th contents page.Tan HS, Liu N, Sultana R, et al. Prediction of breakthrough pain during labour neuraxial analgesia: comparison of machine learning and multivariable regression approaches. Int J Obstet Anesth. 2021;45:99–110.Brogly N, Valbuena Gomez I, Afshari A, et al. Esaic focused guidelines for the management of the failing epidural during labour epidural analgesia. Eur J Anaesthesiol. 2025;42:96–112.Berger AA, Jordan J, Li Y, Kowalczyk JJ, Hess PE. Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study. Int J Obstet Anesth. 2022;52:103590.Tan HS, Liu N, Tan CW, Sia ATH, Sng BL. Developing the breakthrough pain risk score: an interpretable machine-learning-based risk score to predict breakthrough pain with labour epidural analgesia. Can J Anaesth. 2022;69:1315–1317.Guasch E, Iannuccelli F, Brogly N, Gilsanz F. Failed epidural for labor: what now? Minerva Anestesiol. 2017;83:1207–1213.Guasch E, Ioscovich A, Brogly N, et al. Obstetric anaesthesia manpower and service provision issues (introduction and european perspective). Int J Obstet Anesth. 2023;55:103647.MacLennan K, Minehart RD, Vasco M, Eley VA. Simulation-based training in obstetric anesthesia: an update. Int J Obstet Anesth. 2023;54:103643.Yoon HJ, Do SH, Yun YJ. Comparing epidural surgical anesthesia and spinal anesthesia following epidural labor analgesia for intrapartum cesarean section: a prospective randomized controlled trial. Korean J Anesthesiol. 2017;70:412–419.