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‘Walking’ epidurals in labour

Epidural blockade, when used for pain relief in labour, should produce a barely perceptible sensory block from T,&, with retention of sensation without pain and maintenance of motor power. On the other hand, regional blockade when used for abdominal surgery such as Caesarean section should achieve a dense motor and sensory block from at least T4-Ss. To confuse these aims results in patient dissatisfaction with both analgesic and anaesthetic techniques-‘Epidural anesthesia during labor is not a generic procedure’ [l]. Maintaining motor power during labour analgesia has been shown to increase maternal satisfaction [2], reduce long-term maternal backache [3] and possibly reduce the requirement for forceps delivery [4]. No studies have shown any advantage to the unpleasant side effect of loss of motor power during labour. The way of achieving epidural analgesia without anaesthesia and loss of motor power is to reduce the rate of usage of milligrams of bupivacaine per hour. How this can best be done, while achieving analgesia, forms the basis of many present obstetric anaesthetic clinical studies. Three methods of reducing the amount of bupivacaine used, have been reported. Firstly, injecting the initial analgesic dose into the subarachnoid space using a combined spinal epidural technique, has been shown to reduce the bupivacaine requirement throughout labour to less than half that needed when using the epidural space only [5]. The main objection to penetrating the dura in the obstetric patient has disappeared with the introduction of fine, atraumatic spinal needles, which have reduced the rate of postdural puncture headache [6]. However, the subarachnoid space remains a delicate space that requires greater safeguards than the epidural space [7]. A spinal injection of an initial analgesic dose of opioid alone or opioid and bupivacaine mixture gives between 30 and 90 min of analgesia for little or no bupivacaine [8]. The second way of reducing the dose of bupivacaine is using the well described synergistic effects of opioids and local anaesthetics in both the subarachnoid and epidural spaces [9]. In clinical practice, the use of bupivacaine can be reduced by almost half by the addition of opioids [4]. Thirdly, maintenance of epidural analgesia using intermittent top-up doses given by a midwife or patient-controlled epidural analgesia has a 35% dose sparing effect, as compared to using epidural infusions