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Should the Labor Progress Fail the Epidural or the Epidural Fail the Prolonged Labor? A Retrospective Analysis of Failed Labor Epidurals
Abstract Number: T4B-4
Abstract Type: Original Research
Failures of neuraxial analgesia and anesthesia may occur any time along the course of labor or during the process of conversion to Cesarean delivery (CD). Failed epidural often leads to pain and/or discomfort of the parturients and carries emotional/medicolegal consequences. We conducted a retrospective analysis to better understand the epidural catheter failure and replacement in parturients.
Among all parturients who had failed epidural analgesia and/or anesthesia who received epidural catheter replacement in 2017 were identified and grouped based on delivery method: vaginal delivery (VD) vs CD. Parturients who had epidural replacement due to obvious technical failures such as catheter disconnection, down-going catheter or intrathecal placement were excluded due to small sample size. Demographic information and characteristic data of placements were collected. (Table 1) Wilcoxon rank-sum test was used for analysis.
Seventy-three VDs and thirty-two CDs had been identified. Their catheters were replaced due to either uncontrolled pain or non-functioning catheter. We found that parturients who had VDs had significantly shorter time period between 1st and 2nd placements and fewer top-ups compared to parturients who had CD (P<0.0001, P<0.0001).
The time period elapsed between the two epidural placements were much shorter in parturients who had successful VD compared to those who converted to CD. Failed epidurals due to labor pain often indicate fast progressing labor. In other words, the characteristics of the epidural and the comfort level of parturient may indicate the progress of labor. We advocate for using point-of-care ultrasound to identify the catheter before universally replace an under-bolused working epidural catheter. However, one may also argue that a replacement of combined spinal epidural or dural puncture epidural could provide better pain coverage. Early recognition of inadequate anesthesia provided by existing catheter is the key to successful management of block failures at critical moments. A quiet prolonged labor does not always serve the good outcomes, during which the unscheduled urgent and/or emergent CD could land in inconvenient times. We advocate for a multidisciplinary approach the better assess such situations.
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3. Mankowitz SK. 2016;123(5):1174-80.