Labor Epidural Complications
Labor epidurals are among the most common anesthetic procedures performed. Spinal and combined spinal-epidural techniques are also widely used, and neuraxial anesthesia is the usual choice for cesarean delivery. Most of these procedures go smoothly. When one does not, the setting adds complexity. There are two patients, the mother and the baby. Labor moves quickly. Several teams share responsibility, and the obstetric plan can change from a vaginal delivery to an urgent cesarean in minutes.
Labor epidural complications raise the same core safety questions as other neuraxial procedures: placement, monitoring, recognition, and response. They also raise obstetric-specific issues. This article outlines how a physician expert approaches them.
How often do serious complications occur?
The Society for Obstetric Anesthesia and Perinatology (SOAP) created the Serious Complication Repository Project to measure this. D'Angelo and colleagues (Anesthesiology, 2014) reported data from 30 institutions over about five years, covering more than 257,000 anesthetics. They recorded 157 serious complications, 85 of which were anesthesia related. The most frequent were high neuraxial block, respiratory arrest in labor and delivery, and unrecognized spinal catheter. Overall, a serious complication occurred in about 1 in 3,000 obstetric anesthetics. Because each type was rare, the authors could not identify risk factors for each one. They recommended that anesthesia providers stay vigilant and be prepared to diagnose and treat complications rapidly.
Standard-of-care questions at placement
- Pre-procedure evaluation. Was a focused history obtained, including bleeding history, medications, airway assessment, and relevant conditions?
- Anticoagulation and platelets. Was the timing of any blood thinner documented, and were relevant laboratory values reviewed when indicated?
- Consent. Was the discussion documented, recognizing that it often takes place during painful labor?
- Technique. Is the level, the approach, any difficulty, any dural puncture, and the catheter depth documented?
- Test dosing and catheter checks. Was the catheter tested in a way meant to detect placement in a vein or the spinal fluid space before larger doses were given?
Monitoring, recognition, and response during labor
The complications D'Angelo and colleagues found most often, high block, respiratory arrest, and unrecognized spinal catheter, are ones in which monitoring and early recognition matter most.
- Block height and level of consciousness. Were sensory level, motor block, and the patient's alertness and breathing checked at reasonable intervals, especially after top-ups?
- Blood pressure and fetal heart rate. Were drops in maternal blood pressure treated promptly, and was the obstetric team informed of changes?
- Catheter migration and handoffs. Was the catheter re-evaluated when the block became too dense, one-sided, or ineffective? Were bolus doses and handoffs between clinicians documented?
- Conversion to cesarean delivery. If an existing epidural was used for an urgent cesarean, was it adequate, and was the decision to use or replace it reasonable given the urgency?
- Resuscitation readiness. Were airway equipment, medications, and staff available on the labor unit?
Anticoagulation in obstetric patients
SOAP published a consensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher-dose anticoagulants (Leffert and colleagues, Anesthesia & Analgesia, 2018). The statement weighs the risks of a neuraxial procedure in the presence of anticoagulation against the competing risks of general anesthesia with a potentially difficult airway, and against harm to the mother or baby from avoiding or delaying neuraxial anesthesia. It also provides decision aids and approaches to multidisciplinary communication. Hematoma questions are covered in more detail in Week 2 of this series.
After delivery
Many problems involve events after the baby is born.
- Headache. Accidental dural puncture and post-dural puncture headache are discussed in our post on dural puncture and post-dural puncture headache. Headache after delivery has several possible causes, so the evaluation documented in the chart matters.
- Prolonged numbness or weakness. Was a block that lasted longer than expected examined and followed? Childbirth itself can injure nerves through pressure or positioning, so the timing and pattern of the deficit are central to causation.
- Back pain and catheter-site problems. Was the site examined if there was fever, redness, severe pain, or a new neurologic change?
Causation in obstetric neuraxial cases
Causation can be complicated in this setting. Nerve injuries can come from labor and delivery, from prolonged pushing or positioning, or from the neuraxial procedure. Low blood pressure, bleeding, pre-eclampsia, and medications can all affect both the mother and the baby. An expert sorts these possibilities using the timeline, the anatomic pattern of any deficit, monitoring data, and the obstetric record, and stays within the anesthesiology issues rather than offering opinions reserved for other specialties.
Records that usually matter
- The anesthesia record and neuraxial procedure note, including catheter depth and any dural puncture
- Epidural pump records and bolus or top-up documentation
- Labor and delivery nursing flowsheets, with maternal vital signs and block assessments
- Fetal heart rate tracings and the obstetric record
- Medication administration records, including anticoagulant timing
- Postpartum notes, neurology consults, and imaging
- The unit's labor analgesia and anticoagulation policies on the date of care
The published background behind this review
Dr. Urits co-authored a report on greater occipital nerve blocks for treating post-dural puncture headache after labor epidural (Hasoon and colleagues, Saudi Journal of Anaesthesia, 2020). He co-authored Racial disparities in obstetric outcomes and anesthetic techniques for deliveries (Herman and colleagues, Journal of Clinical Anesthesia, 2022). He also co-authored a report on cerebrospinal fluid removal during spinal anesthesia for cesarean delivery in a patient with idiopathic intracranial hypertension (Hasoon and colleagues, Anaesthesiology Intensive Therapy, 2020). His opinions rest on the complete record, the peer-reviewed literature, and generally accepted methodology.
Key takeaways
- Serious obstetric anesthesia complications are rare, about 1 in 3,000 in the SOAP repository. The most frequent were high block, respiratory arrest, and unrecognized spinal catheter.
- Monitoring of block height, breathing, and blood pressure, and the response to changes, are often central.
- The SOAP anticoagulation consensus statement frames risk-benefit decisions in pregnant and postpartum patients.
- Causation requires separating anesthesia-related effects from the effects of labor, delivery, and obstetric conditions.
References
- D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2014;120(6):1505-1512. Abstract: https://pubmed.ncbi.nlm.nih.gov/24845921/
- Leffert L, Butwick A, Carvalho B, et al. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg. 2018;126(3):928-944. Abstract: https://pubmed.ncbi.nlm.nih.gov/29099429/
- Hasoon J, Berger A, Urits I, Orhurhu V. Greater occipital nerve blocks for the treatment of postdural puncture headache after labor epidural. Saudi J Anaesth. 2020;14(2):262-263. Abstract: https://pubmed.ncbi.nlm.nih.gov/32317891/
- Herman JA, Urits I, Kaye AD, Urman RD, Viswanath O. Racial disparities in obstetric outcomes and anesthetic techniques for deliveries. J Clin Anesth. 2022;79:109989. Abstract: https://pubmed.ncbi.nlm.nih.gov/32718775/
- Hasoon J, Urits I, Viswanath O, Orhurhu V, Munnur U. Cerebrospinal fluid removal during spinal anaesthesia for caesarean delivery in a patient with idiopathic intracranial hypertension. Anaesthesiol Intensive Ther. 2020;52(3):259-260. Abstract: https://pubmed.ncbi.nlm.nih.gov/32876416/
Related: Obstetric Anesthesia Cases
Educational information only. Not legal or medical advice.
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