Lumbar epidural is considered the gold standard for analgesia in labor and is recommended by WHO, with estimates of use in the range of 10%-64% in high-income countries. 1 During labor, uterine contraction and cervical dilatation stimulate nociceptive afferent fibers that travel to spinal nerves T10-L1, producing poorly localized visceral pain. As the fetal head descends, stretching the perineum and vagina, pain fibers via the pudendal nerve and spinal roots S2-4 are also activated. 2 To modify these afferent pathways and achieve analgesia, local anesthetics, opioids, and other adjuvants can be administered to the epidural space by an epidural catheter. Despite widespread use, there are many uncertainties regarding the optimal epidural regime. Different combinations and concentrations of drugs administered epidurally have been shown to have varying effects in both the partum and postpartum periods. With so many variables surrounding childbirth, it can be difficult to separate association and causation. Epidurals are associated with, but probably do not cause, prolonged labor and increased risk of operative delivery. 3 These factors directly affect obstetric decision making. For certain maternal conditions that may be decompensated by labor and delivery, such as pre-eclampsia or cardiac disease, labor epidural is indicated. In cases where epidural is contraindicated (such as severe thrombocytopenia, coagulopathy, or sepsis) other analgesic regimes (e.g. patient-controlled remifentanil) may be available.Improving communication and understanding between anesthetists and obstetricians is mutually beneficial. The aim of the present narrative review was to provide an overview of epidural literature for the obstetric audience, incorporating techniques of insertion, medications used, and associations with maternal and neonatal outcomes.Spinal anesthesia, and the use of epidural anesthesia for cesarean/ operative delivery are outwith the scope of the present review. | ME THODS | Search strategyA literature search without language restriction was conducted (MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, and Cochrane Central Register of Controlled Trials [CENTRAL]) from date of inception to October 5, 2020. Randomized controlled trials (RCTs), reviews, and relevant references were included. Search terms were "neuraxial analgesia," "epidural," "peridural," "combined spinal-epidural," "CSE,"

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Summary Lumbar epidural is the gold standard for labour analgesia. Low concentrations of local anaesthetic are recommended. This network meta‐analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia. We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra‐low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes. Bayesian network meta‐analysis with random‐effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals. A total of 32 studies met inclusion criteria (3665 women). The total dose of local anaesthetic received increased as the concentration increased; ultra‐low compared with low (weighted mean difference −14.96 mg, 95% credible interval [−28.38 to −1.00]) and low compared with high groups (weighted mean difference −14.99 [−28.79 to −2.04]), though there was no difference in the number of rescue top‐ups administered between the groups. Compared with high concentration, ultra‐low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0.54]) and reduced duration of second stage of labour (weighted mean difference −13.02 min [−21.54 to −4.77]). Compared with low, ultra‐low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference −1.92 min [−14.35 to 10.20]); spontaneous vaginal delivery (OR 1.07 [0.75 to 1.56]; assisted vaginal delivery (OR 1.35 [0.75 to 2.26]); caesarean section (OR 0.76 [0.49 to 1.22]); pain (scale 1–100, weighted mean difference −5.44 [−16.75 to 5.93]); and maternal satisfaction. Although a lower risk of an Apgar score < 7 at 1 min (OR 0.43 [0.15 to 0.79]) was reported for ultra‐low compared with low concentration, this was not sustained at 5 min (OR 0.12 [0.00 to 2.10]). Ultra‐low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption.

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