Failed epidural for labor: what now?

Labor epidural failure is a challenging situation for the obstetric anesthetist, especially when associated to high risk of caesarean delivery, obesity, and difficult airway predictors. Labor epidural failure is still not standardly defined, consequently its incidence is uncertain: improving the knowledge of risk factors related to failure will increase epidural block success rate. Prolonged labors, previous history of epidural failure, and repeated top-ups needed during labor are recognized risk factors for failure. Clinical experience and the use of modern equipment (ultrasound guided blocks), as well as the choice of neuraxial technique (epidural versus combined spinal-epidural) may affect failure rate. Software-controlled infusion pumps seem to increase epidural analgesia success rate. Among non-technical skills, good communication among medical team members and parturient women is another pivotal point to achieve a satisfactory analgesia for labor. Clear algorithms should be promoted where epidural failure during labor or caesarean delivery may occur.