Review Note

SS_OB 1.23 Describe the selection of agents and route of administration in providing neuraxial analgesia for labour and delivery

• Ropivicaine generally preferred for labour epidural as it has reduced cardiotoxicity and less motor block
• Bupivacaine preferred for spinal as longer duration of action and block density/motor block
• 2% lignocaine may be used for epidural top ups as fast onset (but shorter duration), or 0.75% ropivicaine +/- adrenaline
• Low dose LA typically used for labour epidural once established, 0.125% or 0.0625% Bupivicaine + 2mcg/ml fentanyl

• Fentanyl 5-25mcg (15mcg for spinals where I’ve worked) intrathecal, 50-150mcg epidural
• Morphine 100mcg intrathecal, 3mg epidural
• Sufentanil can also be used 3-10mcg intrathecal, 10-20mcg epidural

Failed Epidural top up for LSCS

• Top up well working epidurals : bilateral signs, warm legs, good labour analgesia 
• Catheter in same place, same depth as when placed 

1. Remove epidural and place new epidural 
2. Remove epidural and do spinal 
3. Remove epidural and do CSE 
4. Remove epidural and do GA 

Failed spinal Anaesthetic 

• Careful technique, aspiration through hyperbaric 
• Landmarks (generally higher than we think we are) 

• Timing : wait 
• From ~10 mins about at peak of effectiveness. 
• Tilt the patient 
• Unknown how much to tilt, how long for, density of block 
• Frequently used but not studies 
• Tilt the almost perfect block - no movement in legs. 
• Cancel / delay 
• If GA very unsafe, and situation allowed may cancel and return 
• GA
• Repeat spinal 
• Not working at all : 
• Repeat normal spinal : likely not in correct space 
• Block ~50-60% 
• ~3ml maximum dose you can use 
• If given 2.2ml could happily give 0.8ml 
• Epidural 
• CSE 
• Gives you options 
• Further spinal dose 
• Back up 
• If CSE for labour consider 2-4mg of 0.5% bupivacaine + 10-15mcg fentanyl