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Introduction Labour epidural analgesia can be initiated using a classical epidural insertion technique, a dural puncture epidural (DPE) or combined spinal epidural (CSE). Once the lumbar epidural catheter is in situ, and the test dose has been given with no obvious signs of intrathecal or intravascular placement, the catheter is assumed to be in the epidural space. Maintenance of lumbar epidural labour analgesia, as opposed to a single shot epidural injection or a caudal catheter technique, has been around since the 1960s. 1 The aims of labour epidural analgesia include satisfying the wish of parturients to have a pain-free delivery or one where the pain intensity is significantly controlled; mitigating the effects of labour on pre-existing maternal medical conditions, for example pre-eclampsia2 or modified WHO 3 and WHO 4 heart disease3; and ensuring optimal labour epidural function in case conversion to epidural anaesthesia is required in the peripartum period. This last aim requires regular epidural objective monitoring and proactive management, which remains the responsibility of the supervising anaesthesiologist, though may be delegated to other healthcare professionals.4 Patient Expectations The World Federation of Societies of Anaesthesiologists (WFSA) has published a Declaration on Labour Analgesia which emphasizes the right of every pregnant patient to receive analgesia for labour pain upon request. 5 When a patient asks for labour epidural analgesia, there is a spectrum of expectations as to what that may imply. Some request to ‘feel nothing’ while others prefer to receive what is known as a ‘mobile’ or ‘walking’ epidural where mobility is somewhat retained. It is important that patient wishes are clarified and that the consent process clearly outlines what epidurals can reasonably be expected to provide, as well as the associated outcomes. When patients’ expectations are met, this is associated with increased patient satisfaction.6 Parturients undergoing labour have opted for vaginal delivery, and thus, labour epidural analgesia maintenance should be designed to facilitate this.Evidence-Based Maintenance Regimes An extensive systematic review and network meta-analysis from 2023 including 73 trials overall compared several modalities of labour epidural analgesia, namely continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), and patient controlled epidural bolus (PCEA) among others, alone or in combination. 7 Co-primary outcomes were maternal satisfaction and the need for rescue analgesia. In their conclusion, the authors interpret their overall findings as suggesting that PIEB + PCEA is the optimal mode for maintenance of labour epidural analgesia. This is supported by results showing improved analgesic efficacy of PIEB versus CEI; of PCEA having a reduced incidence of lower limb motor block, an increased rate of spontaneous vaginal delivery and a reduced caesarean section rate compared to CEI; and PIEB + PCEA compared to CEI + PCEA demonstrating lower consumption of local anaesthetics, lower incidence of lower limb motor block, increased rate of spontaneous vaginal delivery and increased maternal satisfaction.Similarly, a Cochrane systematic review published in the same year, including 18 studies and 4590 participants, found that automated mandatory boluses were associated with a lower incidence of breakthrough pain and reduced local anaesthetic consumption, when compared to a basal infusion.8 However, this review found no significant difference in the incidence of caesarean delivery, instrumental delivery, duration of labour analgesia, and neonatal Apgar scores.8 When considering the local anaesthetic to be used, most studies report on bupivacaine, levobupivacaine and/or ropivacaine for labour epidural analgesia maintenance.7 9 These are preferred over other local anaesthetics due to their relatively longer duration of action, and favourable sensory to motor block ratio.9 In relation to local anaesthetic concentration, a systematic review and network meta-analysis compared ultra-low, low, and high concentration local anaesthetics for maintenance of labour epidural analgesia.10 This included 32 studies and 3665 participants. Ultra-low concentration was defined as ≤0.08% bupivacaine or equivalent; low concentration as >0.08% to ≤0.1% bupivacaine or equivalent; and high concentration as >0.1% bupivacaine or equivalent.10 The authors concluded that similar or better maternal and neonatal outcomes were obtained with ultra-low concentrations of local anaesthetics in labour epidurals, as compared to the other concentrations, albeit with lower local anaesthetic consumption. These outcomes included shorter duration of the first and second stages of labour, less motor block, and higher rates of spontaneous vaginal delivery10 when ultra-low concentrations of local anaesthetics were used.Together with local anaesthetics, adjuvants are recommended for the maintenance of labour epidural analgesia. Most commonly, lipophilic opioids8–11 are used in solutions prepared for use for labour epidural analgesia maintenance, such as fentanyl (1–3 μg/mL) and sufentanil (0.2–1 μg/mL), due to their synergistic effects. This increases safety as lower local anaesthetic doses are used.12 Other adjuvants that have been studied include the α2-receptors agonists clonidine and dexmedetomidine especially for breakthrough pain9 11–13; epinephrine9 11–13; and neostigmine.11–13 Mainly due to associated adverse effects, these are not recommended for routine use.Troubleshooting Labour Epidural AnalgesiaAn important aspect of labour epidural analgesia maintenance is troubleshooting when things do not go according to plan. If the epidural was working well, and later fails with the parturient presenting with pain, this may be the consequence of a block that is absent, too low, patchy, or unilateral. In these cases, the flowchart outlined in the ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia can be followed.4 Re-siting of a failing epidural is recommended using DPE/CSE if pain persists despite additional boluses.4 On the other hand, if the epidural block is too high or too dense, then it is relevant to exclude catheter migration into the intrathecal space. If so, the relevant guidance from the Obstetric Anaesthetists’ Association can be consulted.14 If not, the labour epidural analgesia maintenance regime should be amended, for example, using smaller PIEB volumes, or asking the patient to refrain from pressing the PCEA within a PIEB+PCEA protocol.Additional Considerations During labour epidural analgesia maintenance, regular monitoring of the patient’s clinical status should be performed and documented, 4 ideally on a modified obstetric early warning score chart to identify clinical deterioration early.15 Vigilance must also be maintained for significant anaesthetic or obstetric complications, such as local anaesthetic systemic toxicity or uterine rupture with breakthrough pain, respectively.At an institutional level, governance through regular audit and data analysis, will enhance understanding of current local protocols and outcomes, and will allow comparison with international practices.Conclusion Labour epidural analgesia maintenance involves a significant amount of time and attention from anaesthesiologists to be performed safely and effectively; to enhance maternal satisfaction; and to be prepared in case of the need for conversion to epidural anaesthesia. PIEB + PCEA seems to be the optimal mode for maintenance of labour epidural analgesia while utilizing ultra-low dose local anaesthetic with adjuvant lipophilic opioid solutions.References Callahan EC, Lim S, George RB. Neuraxial labor analgesia: maintenance techniques. Best Practice & Research Clinical Anaesthesiology 2022;36(1):17–30.Siddiqui MM, Banayan JM, Hofer JE. Pre-eclampsia through the eyes of the obstetrician and anesthesiologist. International Journal of Obstetric Anesthesia 2019;40:140–8.National Institute for Health and Care Excellence (Great Britain). Intrapartum care for women with existing medical conditions or obstetric complications and their babies. National Institute for Health and Care Excellence (NICE); 2019.Brogly N, Gómez IV, Afshari A, Ekelund K, Kranke P, Weiniger CF, Lucas N, Dewandre PY, Arevalo EG, Ioscovich A, Kollmann A. ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia. European Journal of Anaesthesiology| EJA. 2025;42(2):96–112.WFSA Obstetric Anaesthesia Committee. Declaration on Patients’ Rights to Labour Analgesia. Accessed in June 2025: https://wfsahq.org/wp-content/uploads/WFSA-Declaration-on-Patients-Rights-to-Labour-Analgesia-2.pdfMei JY, Afshar Y, Gregory KD, Kilpatrick SJ, Esakoff TF. Birth plans: what matters for birth experience satisfaction. Birth 2016;43(2):144–50.Wydall S, Zolger D, Owolabi A, Nzekwu B, Onwochei D, Desai N. Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 2023;70(3):406–42.Tan HS, Zeng Y, Qi Y, Sultana R, Tan CW, Sia AT, Sng BL, Siddiqui FJ. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database of Systematic Reviews 2023, Issue 6. Art. No.: CD011344. DOI: 10.1002/14651858.CD011344.pub3. Accessed 29 June 2025.Callahan EC, Lim S, George RB. Neuraxial labor analgesia: maintenance techniques. Best Practice & Research Clinical Anaesthesiology 2022 May 1;36(1):17–30.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(8):910–8.Vanderheeren MC, Van de Velde M, Roofthooft E. Initiation and maintenance of neuraxial labour analgesia: a narrative review. Best practice & research. Clinical Anaesthesiology 2024;38(3):168–75.Halliday L, Nelson SM, Kearns RJ. Epidural analgesia in labor: a narrative review. International Journal of Gynecology & Obstetrics 2022;159(2):356–64.Javed UE, Bhatia K. Neuraxial analgesia in labour-initiation and maintenance techniques. Anaesthesia & Intensive Care Medicine 2025.Griffiths SK, Russell R, Broom MA, Devroe S, Van de Velde M, Lucas DN. Intrathecal catheter placement after inadvertent dural puncture in the obstetric population: management for labour and operative delivery. Guidelines from the Obstetric Anaesthetists’ Association. Anaesthesia 2024;79(12):1348–68.Umar A, Ameh CA, Muriithi F, Mathai M. Early warning systems in obstetrics: a systematic literature review. PloS one. 2019;14(5):e0217864.