DOI: 10.1111/tog.

12196

2015;17:14755

The Obstetrician & Gynaecologist

Review

http://onlinetog.org

Analgesia for labour: an evidence-based insight for

the obstetrician
Djavid I Alleemudder MRCS(Ed) MRCOG BSc,a,* Yemi Kuponiyi MRCOG,b Charlotte Kuponiyi RM BSc(Hons) SOM MSc,c
Alan McGlennan FRCA,d Shaun Fountain FRCOG,e Ramanathan Kasivisvanathan FRCAf
a

ST7 Obstetrics and Gynaecology, Salisbury NHS Trust, Odstock Road, Salisbury SP2 8BJ, UK
Locum Consultant in Obstetrics and Gynaecology, Chelsea & Wesminister Hospital, 369 Fulham Road, London SW10 9NH, UK
c
Consultant Midwife and Supervisor of Midwives, Princess Royal University Hospital, Farnborough Common, Orpington, Kent BR6 8ND, UK
d
Consultant in Anaesthesia, Royal Free NHS Foundation Trust, Pond Street, London NW3 2QG, UK
e
Consultant in Obstetrics and Gynaecology, Salisbury NHS Trust, Odstock Road, Salisbury SP2 8BJ, UK
f
ST7 Anaesthesia, The Royal Free NHS Foundation Trust, Pond Street, London NW3 2QG, UK
*Correspondence: Djavid I Alleemudder. Email: Djavid@hotmail.co.uk
b

Accepted on 6 March 2015

Key content

Learning objectives

The rising trend in levels of advanced care for women in labour has
prompted the recommendation for the development of safe and
effective alternatives to regional analgesia.
 The most powerful influence on a womans satisfaction with pain
relief appears to be the attitude and behaviour of her caregiver.
 Despite the continued lack of any high-powered randomised
controlled trials, there are a number of simple and safe nonpharmacological options available for pain relief.
 Evidence suggests that intramuscular diamorphine is a better
analgesic than intramuscular pethidine.
 Remifentanil patient-controlled analgesia has emerged as an alternative
to regional anaesthesia but there are concerns with its safety.
 Epidural analgesia remains the most effective form of pain relief
for labour.

To provide an overview of the different types of analgesia available

for labour.
 To understand the mechanism of action, dosages and adverse effect
profiles of pharmacological analgesics.
 To discuss regional analgesia and their indications
and contraindications.
Ethical issues


Should regional analgesia be offered on request to women who are

at or near full dilatation?
 Should all women with a raised body mass index be encouraged to
have an early epidural in labour?
 What is an acceptable time to wait for an epidural in labour?
Keywords: anaesthesia / analgesia / labour

Please cite this paper as: Alleemudder DI, Kuponiyi Y, Kuponiyi C, McGlennan A, Fountain S, Kasivisvanathan R. Analgesia for labour: an evidence-based insight
for the obstetrician. The Obstetrician & Gynaecologist 2015;17:14755.

Introduction
Childbirth is a normal life event yet it is considered one of the
most painful experiences of a womans life. A womans ability to
cope with labour pain appears to be influenced by her parity,
complex psychosocial factors such as fear and anxiety, prior
experience of labour, culture, ethnicity, emotional support,
antenatal class attendance and educational attainment.1
Pain originates from different sites during labour and
childbirth. In the first stage of labour, pain is transmitted via
the spinal nerves of T10L1 and results from uterine
contractions and dilatation of the cervix. In the second
stage, stretching of the pelvic ligaments causes pain via the
pudendal nerve originating from the S2S4 nerve roots.2
There has been a rising trend in the levels of advanced care
for women in labour, primarily due to an increase in births
occurring in non-UK nationals, an increased incidence of
comorbidities such as obesity, and greater maternal

2015 Royal College of Obstetricians and Gynaecologists

expectations. This has prompted a number of

recommendations for analgesia in labour,3 as well as the
development of evidence-based guidelines for analgesia in
labour, the most recent of which is the National Institute for
Health and Care Excellence guidance on intrapartum care.4
These are all particularly important since it is reported that
healthcare professionals often underestimate the intensity of
pain experienced by women in labour and overestimate the
relief offered by the analgesia provided during labour.5
Pain management strategies for women in labour include
non-pharmacological, pharmacological and regional analgesia.
This article aims to provide the obstetrician with an overview of
analgesic options in labour with reference to current evidence.

Non-pharmacological methods
Non-pharmacological methods of analgesia may be useful for
mild labour pain or as an adjunct to severe labour pain. They

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Analgesia for labour

are intended to reduce the medicalisation of labour and

reduce the loss of control often experienced following
pharmacological or regional analgesia.6 They are generally
inexpensive, easy to institute and low risk; however, there is
only poor-quality evidence supporting their effectiveness in
reducing moderate to severe labour pain.

Continuous one-to-one support and the care

provider
Evidence suggests that pain perception is strongly influenced
by the attitude and behaviour of the womans caregiver,
which is probably the single most important factor in a
womans perception of pain during labour and childbirth.4 A
designated midwife during labour is associated with a lower
analgesic requirement, reduced instrumental delivery and
lower rates of dissatisfaction with childbirth.7 Women in
labour can also self-fund a companion (or doula) to provide
non-medical care.

Prenatal information
Providing women with prenatal information about the
labour experience including analgesic options has been
shown to reduce pain levels during labour.8 All care
providers are expected to provide appropriate resources to
women through documented information or the availability
of specialists such as obstetric anaesthetists. The Obstetric
Anaesthetists Association has produced a number of
information resources about pain relief and related topics
for patients and their carers in a web portal
(LabourPains.com). The resources are free of charge and
available in a number of languages.9 The National Childbirth
Trust runs classes and seminars nationally that provide
information and practical sessions for women on topics
including pain relief during labour.

Music
It has been proposed that music reduces anxiety levels and
catecholamine production and provides distraction to pain
during labour.10 A meta-analysis of 22 studies in a broad
range of populations showed that music and music-assisted
relaxation techniques significantly reduce arousal due to
stress.11 Many maternity units in the UK offer facilities such
as iPod docking stations so that women can easily listen to
their preferred choice of music during labour.

Aromatherapy
Aromatherapy is the application of essential oils to the skin
or inhalation of the scents of essential oils and their use in
labour is increasing in popularity.12 It is postulated that
essential oils can increase the production of the bodys
sedative, stimulant and relaxing neurotransmitters. Level 3
evidence suggests that aromatherapy also improves
psychological wellbeing for hospital inpatients.13

148

A meta-analysis of two trials (n=535) found that

aromatherapy provided no benefit in reduction of labour
pain.14 However, a 2014 randomised controlled trial (RCT)
(n=160) demonstrated a reduction in pain intensity in those
using lavender aromatherapy with no adverse maternal or
fetal effects, and no impact on the duration of labour or
Apgar scores.15

Acupuncture and acupressure

Acupuncture and acupressure involves the insertion of fine
needles or application of pressure to specific areas of the
body. It is widely believed that these techniques work
through the stimulation of touch fibres, which block pain
impulses at the pain gates within the spinal cord and the
modification of endorphin release, which alters
pain perception.2
A major limitation of the evidence available for the use of
acupuncture in labour is the high risk of bias due to an
inability to blind participants and evaluators. A systematic
review of ten RCTs (n=2038) showed that acupuncture was
not superior to sham acupuncture (where acupuncture
needles are inserted into non-acupuncture points) in
reducing labour pain at 1 hour or at 2 hours. Acupuncture
did, however, reduce pain by 11% compared with placebo for
the first 30 minutes of labour.16 Despite the limited and
mainly level 4 evidence, many national maternity units still
provide an acupuncture service.

Birthing balls and posture

A birthing ball is an air-filled rubber ball (approximately
60 cm in diameter), which a woman can sit on during
labour, assisting her to adopt an upright position, and
allowing a rocking movement during labour. One RCT
(n=188) demonstrated a 3040% reduction in labour pain
following the implementation of a birthing ball exercise
programme in labour. Women in the birthing ball group also
had a shorter first stage of labour, less epidural requirement
and fewer caesarean sections.17 There is, however, limited
evidence on the use of birthing balls to prevent severe labour
pain and some institutions in the UK have not supported
their use because of safety concerns.
A Cochrane systematic review18 (n=5218) also supported
adopting an upright position during labour, showing a
reduction in analgesic requirements, a shorter first stage of
labour of 1 hour 20 minutes and a reduction in the rate of
caesarean sections. Additionally, upright positions also
appear to shorten the second stage of labour, reduce
instrumental delivery rates and episiotomies, but increase
blood loss.19

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) is the
application of low-voltage electrical impulses to the lower

2015 Royal College of Obstetricians and Gynaecologists

Alleemudder et al.

back. In labour, it is most often applied at the vertebral levels

T10 to S2, where nerve pathways from the uterus, vagina and
perineum enter the spinal cord. It is a popular nonpharmacological form of analgesia because it has the
potential to allow women in labour to control their pain
relief through changing the frequency and intensity of the
electrical impulses delivered. The mechanism of action is
poorly understood but electrical pulses are believed to block
the transmission of pain impulses within the spinal cord. A
secondary benefit is thought to be the release of endorphins,
which mediate pain perception.5
A Cochrane review of 17 studies (n=1466)20 demonstrated
that women using TENS had similar pain scores to a control
group. In four studies where TENS machines were compared
with inactive placebo machines, 63% of women in the TENS
group reported they would use TENS in future labours,
however, 41% of the placebo group also reported wanting to
use the placebo again. This perhaps suggests the device itself
and an element of control may be more of a benefit than the
physiological impact of the intervention.20 The analgesic
effect of TENS in the latent phase of labour remains unclear.4

Sterile water injections

Based on the gate control theory, sterile water injected
subcutaneously or intracutaneously into the area of the
lumbosacral spine is believed to inhibit the transmission of
pain by stimulating large afferent nerve fibres.21 Four to six
injections of water (0.1 ml) can be administered over the
painful area and the therapy can be repeated with minimal
adverse effects.22
Several systematic reviews of RCTs have indicated that this
therapy can significantly reduce pain in labour.23 Pain scores
are reduced by as much as 60% and can last for up to 2
hours.4 One study found that those receiving sterile water
injections experienced less labour pain than those using
acupuncture.22 This practice has not, however, been routinely
adopted in the UK.

The temperature of the pool should be checked hourly to

ensure the woman is comfortable and not becoming pyrexial.
The water temperature should also not exceed 37.5C.4 There
is a lack of evidence on the timing of water use in labour and
on hygiene measures for water birth.4

Hypnosis
During labour, hypnosis (or hypnobirthing) can be used to
focus attention on calm and comforting influences, increase a
womans receptivity to positive suggestions and reduce the
awareness of external stimuli. It may help to relieve pain but
also to enhance feelings of relaxation, safety and control.25 It
is proposed that hypnosis affects the anterior cingulate gyrus
of the limbic system and can suppress the neural activity
between the sensory cortex and the amygdalalimbic system.2
Hypnosis can be delivered by a practitioner-led method or
by self-hypnosis with audio instruction. It should be noted
that when a woman is hypnobirthing, she is more susceptible
to suggestion and therefore staff involved in her care should
be made aware and endeavour to use positive or
hypnobirthing terminology where possible (Table 1).
Meta-analyses disagree over the effectiveness of hypnosis;
one meta-analysis involving five RCTs showed that hypnosis
was associated with a reduction in the use of pharmacological
pain relief and the need for labour augmentation,4 while
another (seven RCTs, n=1213) reported no difference in pain
scores or maternal satisfaction between hypnosis and
control groups.25

Biofeedback
Biofeedback is a form of behavioural therapy aimed at
training women in labour to recognise various body signals
such as changes in heart rate, muscle tension or temperature
and to change their body responses with the aid of electronic
instruments. A review of four studies (n=186) assessing
mainly electromyographic biofeedback for muscle tension
failed to reach a conclusion on whether this form of therapy
was effective in labour.26

Water immersion
Warm water immersion has a long history of use in labour,
being used during any stage of labour and for any duration of
time. The proposed mechanism of pain relief is a
physiological increase in uterine perfusion, which may
promote endorphin and oxytocin release, thus increasing
maternal satisfaction.5
A meta-analysis of 12 trials (n=3243) demonstrated that
women using water immersion experienced less pain than
those not labouring in water.24 There was also a reduction in
duration of the first stage of labour and those randomised to
labour in water also required less subsequent neuraxial
analgesia than women in the control group. There was no
difference in assisted vaginal delivery, caesarean section, the
use of oxytocin, perineal trauma or maternal infection.

2015 Royal College of Obstetricians and Gynaecologists

Table 1. Commonly used hypnobirthing terminologies and words to

avoid
Hypnobirthing terminology

Words/phrases to avoid

Uterine surge
Birthing companion
Birthing/birthed
Receive the baby
Birthing date/month
Pressure/sensation/tightening
Membrane release
Breathing down
Special circumstances

Contraction
Coach
Delivery/delivered
Catch the baby
Due date
Pain
Water breaking
Pushing
Complications

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Breathing/relaxation techniques and massage

Respiratory autogenic training involving progressive muscle
relaxation and focused slow breathing and traditional
psycho-prophylactic course, an alternative form of
relaxation training, are two relaxation techniques used in
labour. Limited evidence from a small number of trials
suggests that breathing, relaxation techniques and/or massage
reduces labour pain with no adverse affects on maternal or
neonatal outcomes.4

Pharmacological methods
The Nursing and Midwifery Council (2008) recommends
that all women should be provided with adequate
information regarding medications offered during labour.27
Pharmacological options in labour are limited, however,
because they have dose-dependent maternal and fetal adverse
effects and if used in labour many medications for analgesia
would likely require large cumulative doses. Pharmacological
options can be classified by their route of administration and
can be further subdivided into opioid and nonopioid options.

Nitrous oxide (gas and air)

Gas and air (Entonox) is a mixture of inhaled nitrous oxide

plus oxygen in a fixed 1:1 ratio. It has been available since
1962 and approved for administration by midwives since
1970. It is the most popular form of analgesia for mild labour
pain and should be available to all labouring women in the
UK.4 It acts as a very weak anaesthetic at high concentrations
and as an analgesic and anxiolytic at lower concentrations.5 It
suppresses activity within the reticulo-endothelial system and
increases the release of endogenous endorphins,
corticotrophins and dopamine, which activate descending
pain pathways.28 Nitrous oxide has a short half-life of 23
minutes and is cleared rapidly via the lungs.
Nitrous oxide probably does not interfere with
endogenous oxytocin and is unlikely to affect the labour
process or spontaneous vaginal birth rate. While it crosses the
placenta readily, nitrous oxide does not affect the fetal heart
rate or respiratory rate in the newborn.29 Common adverse
effects include lightheadedness, nausea, vomiting and, less
commonly, hallucinations, hyperventilation and tetany.
Prolonged nitrous oxide exposure for more than 5 hours
per week in some healthcare workers has been linked to
decreased fertility, preterm birth and vitamin B12 deficiency,
although such side effects have not been reported with its use
in labour.5,30
In trials comparing nitrous oxide with a placebo, pain
scores are lower in women in the nitrous oxide group.
However, the incidence of nausea, vomiting, dizziness and
drowsiness is higher than in women in the placebo group.2
Despite nitrous oxide being one of the popular analgesic

150

options in the UK, a large systematic review of 58 studies,

carried out in 2014, found few good-quality studies
supporting the use of nitrous oxide for labour pain.31

Non-opioid analgesics
Non-opioids include paracetamol, non-steroidal antiinflammatory drugs, sedatives and antispasmodics. Other
than paracetamol, these drugs are seldom used in the UK and
will not be discussed further here.
Paracetamol is a cyclo-oxygenase 2 inhibitor that reduces
the inflammatory response and subsequent pain by blocking
the production of prostaglandins via the arachidonic acid
pathway. Adverse effects are rare and it appears that when
used in therapeutic doses, paracetamol is not toxic to the
fetus. Paracetamol hepatotoxicity is, however, one of the top
causes of acute fulminant liver failure in young individuals
worldwide and is a potential maternal concern. Paracetamol
offers better pain relief and satisfaction with the childbirth
experience than placebo.32

Opioids
Commonly used opioids include dihydrocodeine, pethidine,
diamorphine, fentanyl and remifentanil. Intramuscular
pethidine is the most commonly used opioid worldwide for
labour analgesia and is one of the most frequently used in the
UK because midwives are licensed to prescribe and
administer it.33 Tramadol, meptazinol and pentazocine are
not used routinely in the UK although evidence suggests no
advantage over pethidine.4
Opioid receptors are mainly located in the periaqueductal
grey area of the brain and spinal cord, with sparse locations
elsewhere. Their activation leads to a reduction in neuronal
cell excitability and transmission of nociceptive impulses.34
Adverse effects of all opioids include drowsiness,
hypoventilation, urine retention, nausea/vomiting and an
increase in gastrointestinal transit time (with a risk of
aspiration). Opioids cross the placenta by passive diffusion
and some are trapped by ionisation.35 Opioids will often
produce a prolonged sleep phase pattern on
cardiotocography, with a reduction in fetal heart rate
variability, accelerations and decelerations. A neonate may
take up to 6 days to eliminate pethidine from its system, with
respiratory depression, hypothermia, poor feeding, altered
crying and decreased alertness as recognised adverse effects.35
A large systematic review of 57 studies (n=7000) assessing
the use of opioids in labour found that parenteral opioids
provide some effectiveness in relief from pain in labour but
are associated with a number of adverse maternal and fetal
effects.36 Maternal satisfaction with any specific opioid
analgesia was largely unreported but appeared moderate at
best. There is also evidence that other pharmacological
interventions such as nitrous oxide appear to have a better
analgesic effect than opioids for labour pain.37

2015 Royal College of Obstetricians and Gynaecologists

Alleemudder et al.

Table 2. Indications, benets, adverse effects and risks of epidural and remifentanil patient-controlled analgesia
Information

Epidural

Remifentanil patient-controlled analgesia (PCA)

What is it?

An infusion of anaesthetic and analgesia

An ultra fast acting opioid-type drug

How is it used?

A ne plastic tube is inserted into the epidural

space L4L5 or L5S1
Takes 20 minutes to set up and 20 minutes to work

IV access attached to a PCA pump

Provides pain relief on demand
Takes 5 minutes to work
1 in 8 will require gas and air in addition

Who is it for?

Those in established labour on a labour ward.

Caution if previous spinal surgery or clotting disorders.

Those in established labour.

Contraindicated if morphine or pethidine given in previous 4 hours
Caution if heart problems or allergy to pethidine or morphine

What monitoring
is needed?

Continuous fetal monitoring

Intravenous access
Regular blood pressure measuring

Continuous monitoring not required

Oxygen saturation monitoring

Benets

Provides the most complete pain relief of all

pain relief in labour
Non-drowsy
No neonatal drowsiness
Top ups for extra procedures in theatre such as a
caesarean with no extra injections

Promotes a feeling of maternal relaxation and sleepiness

Considered safe for the fetus

Adverse effects

Failure to work (1 in 10)

Pruritus and shivering
Signicant hypotension (1 in 50)
Severe headache (1 in 100)
Temporary nerve damage (1 in 1000)
Permanent nerve damage (1 in 13 000)
Infection, meningitis, epidural blood clot (<1 in 50 000)

Failure to work (1 in 10)

Pruritus, nausea and vomiting
Drowsiness and dizziness
Causes neonatal drowsiness
Can cause a reduced respiratory rate with a requirement for
supplemental oxygen
Stopping the use of the PCA because of hypoxia and reduced
Glasgow Coma Scale (1 in 28 women)
Cardio-respiratory arrest (<1 in 2200)

Adapted from guidance from the University of Southampton Teaching Hospitals*

*http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Pregnancyandbirth/Pain-relief-in-labour-epidurals-and-remifentanilpatient-information.pdf

Intramuscular pethidine versus diamorphine

In 2014 a two-centre double-blind RCT of 406 women (the
IDvIP trial)38 compared the analgesic efficacy and adverse
effect profile of two of the most commonly used opioid
analgesics in the UK: intramuscular pethidine and
intramuscular diamorphine. Results of the study showed
that intramuscular 7.5 mg diamorphine gave significantly
better analgesia than 150 mg pethidine but prolonged
delivery by approximately 82 minutes. Women given
diamorphine were also more likely to be satisfied with their
analgesia. There were no significant differences in neonatal
adverse outcomes between the two medications. It is worth
noting, however, that the authors of the study do not
recommend the use of intramuscular diamorphine in labour
because of the prolonged delivery time and the cost.

Patient-controlled analgesia
Patient-controlled analgesia (PCA) is the delivery of drugs
through a preprogrammed pump. The programming usually
involves clinician input plus self-administered boluses by the

2015 Royal College of Obstetricians and Gynaecologists

patient. It offers an alternative to regional analgesia

where regional anaesthesia is unavailable, unsuccessful,
contraindicated or refused. Although a number of opioids
have been reported for their use in PCA, the only one widely
used in the UK for labour pain is remifentanil.

Remifentanil PCA
Remifentanil is a rapidly acting synthetic opioid, which is
rapidly metabolised by tissue esterases and has a half-life of 3
minutes.39 One-third of labour units in the UK now offer
remifentanil PCA as a form of analgesia.40 Table 2 gives a
summary of the indications, benefits and adverse effects of
epidurals versus remifentanil PCA.
Widespread national and international implementation
has been hampered by concerns over its safety. Respiratory
depression is reported in up to 32% of patients and 5%
encounter oxygen saturations below 90%.41 Eleven percent of
respondents in a UK survey reported critical incidences
relating to the use of remifentanil and respiratory
depression.40 Alarmingly, there have been a number of

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Analgesia for labour

reported cases of respiratory and cardiac arrest associated

with the use of remifentanil PCA.42,43 Continuous oxygen
saturation monitoring is therefore mandatory during its use.
Other common adverse effects of remifentanil include
maternal pruritus, nausea and vomiting.
Another issue with remifentanil PCA is the potential
tolerance that may occur after just 60 minutes of use,
resulting in a reduction in efficacy.44 There are also
concerns regarding the pharmacokinetic profile of
remifentanil. A bolus dose of the drug has a peak effect
13 minutes after administration, which often results in
suboptimal analgesia for contraction pain because it is used
either too early or late. Likewise, its effect on respiration is
also delayed by some 24 minutes from administration
meaning respiratory depression is sometimes missed.45
A variety of dosing regimens exist but generally tend to
involve a bolus dose of remifentanil of 0.151 micrograms/kg
with a 2-minute lock out and a background infusion of
0.0250.05 micrograms/kg/minute. There are however wide
variations according to local policies.46 A 2013 observational
study suggests a stepwise approach to the use of remifentanil
to avoid initial overdosing.47 The study recommended a
bolus dose range of 0.151.05 micrograms/kg which was
found to provide analgesia with high maternal satisfaction
and low maternal and fetal adverse effects. The authors
advocated increasing the bolus dose by steps of
0.15 micrograms/kg, a dose calculation (based on lean
body mass) with a lock out time of 2 minutes. A
maximum bolus dose of no greater then 0.7 micrograms/kg
remifentanil is also recommended.
A comprehensive list of relative contraindications to
remifentanil PCA is yet to be established but could include
morbid obesity, clinical features of a chest infection and
primigravida women who are at risk of prolonged labour.48
Remifentanil has been compared with other analgesics in
labour, with the main question being whether it provides
equivocal analgesia to epidural analgesia. A meta-analysis of
five studies comparing epidural analgesia with remifentanil
PCA found it was not superior to epidural analgesia in
analgesic efficacy during labour.49 The study found wide
confidence intervals in the pooled results for secondary
maternal and neonatal outcomes meaning definite
conclusions could not be drawn for those outcomes.49
There are also still many unanswered questions and a lack
of national guidance regarding the use of remifentanil,
including the optimal regimen, the importance of trained
midwifery staff and whether there is the need for apnoea
monitoring and or capnography during its use.48

Regional analgesia
Regional analgesia remains the gold standard for pain relief
in labour, with more than 150 000 women opting for

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Table 3. Indications and contraindications for regional anaesthesia

based on guidance from the Obstetric Anaesthetists Association*
Contraindications (absolute
and relative)

Indications
Maternal request
Expectation of operative delivery
Maternal cardiac, respiratory
disease
Pre-eclampsia
Trial of labour after previous
lower segment caesearan section
Neurological disease eg
intracranial arteriovenous
malformations
Obstetric disease e.g. preeclampsia
Breech delivery or multiple
pregnancy
General anaesthetic
contraindicated e.g. morbid
obesity
Intrauterine death

Maternal refusal
Local and untreated systemic
infection
Coagulopathy (platelets
<80, INR>1.4)
Uncontrolled hypovolaemia or
haemorrhage
Expectation of signicant
haemorrhage
Certain spinal surgery and spinal
abnormality
Lack of trained staff to provide
safe care

INR = international normalisation ratio.

*http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/
Guidelines/epidural%20for%20labour/Painrelief_for_labour_
Swales_Southampton.pdf

epidural analgesia for pain relief in labour annually in the

UK.37 Regional analgesia was first introduced in the 1960s
and includes epidural, combined spinalepidural and spinal
analgesia. No woman should be refused regional analgesia on
the basis of her original birth plan, stage of labour (unless
delivery is imminent) and/or relative/spouse request.4 The
indications and contraindications for regional analgesia are
outlined in Table 3.

Epidural anaesthesia
Epidural anaesthesia involves the use of local anaesthetics
with or without an opioid injected into the epidural space to
produce a reversible loss of sensation and motor function.
Local anaesthetics inhibit nerve conduction by blocking
sodium channels in nerve cell membranes, thereby
preventing the propagation of nerve impulses. Since the
1980s, the advent of lower concentration of local anaesthetic
solutions in combination with a variety of opiates (such as
0.06250.1% bupivacaine and 2 micrograms/ml fentanyl) has
vastly reduced the adverse effects of epidural anaesthesia
in labour and has improved maternal satisfaction.
Improvements include the retention of more motor
function and even the ability to walk during labour (known
as a mobile epidural), better ability to bear down and also a
reduction in hypotension and its accompanied
adverse effects.4

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Alleemudder et al.

Maintenance regimens for epidural anaesthesia, containing

a low concentration of local anaesthetic with opioid
solutions, are administered by one of three methods:
 Intermittent midwifery top-ups
 Patient-controlled epidural pump (PCEA)
 Continuous infusion with or without PCEA
The use of the PCEA allows the woman to be in control
of her pain by self-administered top-ups. PCEA pumps are
preprogrammed with a set dose and lock out time (usually
30 minutes) to avoid high blocks and toxicity. In contrast
to other maintenance regimens, the use of PCEA is
associated with lower pain scores, less motor block and
better maternal satisfaction.4 The exact regimen used is
dependent on local policy. The care and observations for
insertion and maintenance of regional analgesia are shown
in Box 1.
Women should be provided with information regarding
the benefits and drawbacks of regional analgesia prior to
labour; the Obstetric Anaesthetists Association provides a
summary of these.50 The National Audit Project 3, one of the
largest studies conducted on regional analgesia, highlighted
the safety of epidural analgesia in labour, finding an
incidence of 1:54 000 of permanent injury and a 1:140 000
risk of paraplegia or death.51 There is high-level evidence that
epidural analgesia is associated with a prolonged second stage
of labour and increased instrumental delivery rates.2,52 There
is, however, no association with a prolonged first stage of
labour, increased risk of caesarean section or long-term back
problems, which epidurals have been commonly associated
with.2,4 Epidural analgesia during labour is associated with an
improved neonatal acidbase status, suggesting that placental
exchange is well maintained during epidural analgesia.4 See
Table 2 for a summary of the indications, benefits and
adverse effects of epidurals.

Combined spinal and epidural

Epidural analgesia during labour can also be provided in
the form of a combined spinalepidural (CSE). This
involves a single injection of local anaesthetic and/or
opioid into the subarachnoid space (spinal) and the
insertion of an epidural catheter with the use of the
epidural as per usual once the effects of the spinal analgesia
Box 1. Care and observations recommended for regional analgesia4
 Intravenous access prior to commencing regional analgesia
 Do not administer routine preloading and maintenance uid
 Check blood pressure every 5 minutes for 15 minutes during
establishment or after further boluses
 Anaesthetic review after 30 minutes if woman not pain-free
 Check sensory block hourly
 Continuous electronic fetal monitoring for 30 minutes during
establishment or after boluses of 10 ml or more

2015 Royal College of Obstetricians and Gynaecologists

wear off. The main advantage of the CSE is the rapid onset
of pain relief it provides compared with conventional
epidural and it can be useful in women with very severe
labour pain. It has been postulated that the hole in the
dura from a CSE results in spread of epidural local
anaesthetic into the subarachnoid space as well as the
epidural space, increasing the effectiveness of analgesia.
This, however, is unclear with evidence suggesting that
epidural anaesthesia and CSE have the same analgesic effect
over the duration of the labour.4 A meta-analysis
comparing both showed maternal satisfaction, caesarean
delivery rates and mobility as being similar but with
adverse effects such as pruritus more common with CSEs.
There were also no differences in umbilical pH, Apgar
score or neonatal outcomes.53,54 A disadvantage of CSE is
the uncertainty over whether the epidural is working
immediately because of the initial effects of the spinal
injection. In a number of institutions, CSE has replaced
epidural anaesthesia as the primary form of regional
analgesia offered to labouring women.

Practical issues with regional analgesia

Time from epidural request to the anaesthetist attending
Until the advent of a 24-hour consultant-delivered
anaesthesia service, labour ward units in the UK continue
to face an ever-increasing obstetric population often manned
only by a single anaesthetist during unsociable hours. The
Royal College of Anaesthetists recommends that time from
epidural request to the anaesthetist attending should not
exceed 30 minutes, after which a second anaesthetist should
be available.55

Obese patients
Obesity is associated with increased maternal and fetal
morbidity and mortality, including increased rates of labour
dystocia, fetal distress, operative delivery, postpartum
haemorrhage and anaesthesia-related complications.55,56
Many authorities, such as the American Congress of
Obstetricians and Gynecologists, recommend the insertion
of an early epidural anaesthesia in obese mothers to alleviate or
prevent these issues.56 Despite this recommendation, the
technicalities of epidural insertion in the obese woman include
multiple attempts at insertion, longer epidural needles and
higher rates of dural puncture and epidural migration into the
fatty subcutaneous tissue.57 Ultrasound guidance to facilitate
catheterisation of the epidural space may help overcome such
difficulties. Both real-time ultrasound and pre-puncture
ultrasound improve the success rate of catheter insertion. In
an RCT comparing real-time ultrasound, prepuncture
ultrasound and no ultrasound in pregnant women (n=30),
only one puncture attempt was required in 100% (10/10), 70%
(7/10) and 40% (4/10), respectively.58

153

Analgesia for labour

Table 4. Summary of analgesics in labour2

Evidence available

Analgesia

Shown to be effective

Epidural
Combined spinalepidural
Continuous one-to-one support

May be effective

Music/music-assisted relaxation techniques

Birthing ball/upright posture
Water immersion
Nitrous oxide
Relaxation techniques/massage
Acupuncture/acupressure
Non-opioids
Sterile water injections
Remifentanil patient-controlled analgesia

Insufcient evidence

Transcutaneous electrical nerve stimulation

Biofeedback
Hypnosis
Aromatherapy
Oral/parenteral opioids

Disclosure of interests
The authors declare no conflicts of interest.

Contribution to authorship

Maternal request for epidural near or at full dilatation

The American Congress of Obstetricians and Gynecologists
recommends that maternal request is a sufficient indication
for analgesia during labour.59 However, where vaginal
delivery is imminent, the decision to offer regional
anaesthesia should be individualised to avoid the potential
risks of regional anaesthesia. This decision will depend on
various factors including a womans parity, the fetal
condition on cardiotocograph and whether a prolonged or
difficult second stage is anticipated, such as malposition of
the fetus and macrosomia.

Conclusion
Analgesia in labour plays a crucial part in affecting maternal
satisfaction during one of the most painful periods of a
womans life. This article has discussed the main analgesic
options that exist for labouring women in the UK Table 4
provides an overview of the evidence for the analgesic options
discussed. Also key to providing the best possible analgesia for
the labouring woman is the provision of appropriate and
relevant information on labour analgesics and continuous oneto-one support from a trained individual provider during
labour. While a number of pharmacological and nonpharmacological options exist for labour pain, epidural
anaesthesia remains the gold standard for severe pain. Over
the last decade, the biggest changes in labour analgesia in the
UK have been the spectrum of non-pharmacological
treatments available and the advent of remifentanil PCA.
Continuing safety concerns and issues with clinical
effectiveness with prolonged use have, however, limited the
widespread adoption of remifentanil PCA.

154

DIA: conception and design, acquisition of data and analysis/

interpretation of data, drafting the article, final approval of
the version to be published. YK: acquisition of data, drafting
the article, final approval of the version to be published. CK:
acquisition of data, drafting the article, final approval of the
version to be published. AM: revising the article critically for
important intellectual content, final approval of the version
to be published. SF: revising the article critically for
important intellectual content, final approval of the version
to be published. RK: drafting the article, revising the article
critically for important intellectual content, final approval of
the version to be published.

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