Use of intrathecal analgesia in a rural hospital Case studies

A woman's experience of unrelenting back pain with a fetus in an occipitoposterior position and the escalating interventions culminating in a cesarean birth is every midwife's nightmare. Intrathecal analgesia is a relatively simple and rapid method to provide maternal relaxation and relief from severe back labor. This article describes the use of intrathecal opioid analgesia in labor complicated by failure to progress in first-stage labor due to persistent occipitoposterior position of the fetus. Intrathecal analgesia has the advantage of being inexpensive and providing rapid onset of adequate pain relief for the first stage of labor. It does not cause motor blockade, so it allows the mother to be mobile and feel the urge to push. Consequently, there is no associated risk of an increased need for forceps or vacuum-assisted delivery. The authors note a decreased incidence of operative delivery for fetal occipitoposterior position with the use of intrathecal narcotics.     

Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor

ABSTRACT: Background: Hands‐and‐knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands‐and‐knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods: Thirteen labor units in university‐affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands‐and‐knees positioning for at least 30 minutes over a 1‐hour period during labor) and 77 to the control group (no hands‐and‐knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1‐hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands‐and‐knees positioning had fetal heads in occipitoanterior position following the 1‐hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1‐minute Apgar scores, and time to delivery. Conclusions: Maternal hands‐and‐knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands‐and‐knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands‐and‐knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)     

Anesthesia and analgesia for labor.

Epidural analgesia remains the mainstay for providing pain relief during labor. The search continues to find the ideal combination of analgesic agents and administration techniques that will provide excellent pain relief for the mother yet minimize side effects to the mother and fetus. This article reviews recent studies of epidural analgesia, including the increased use of epidural opioids, patient-controlled epidural analgesia, and the complications of epidural analgesia (including effects on gastric emptying, maternal temperature control, and hemodynamic changes to the mother and fetus). Intrathecal (spinal) analgesia, especially using opioids, is also discussed.     

Uterine contractility in women whose fetus is delivered in the occipitoposterior position

OBJECTIVE: Most fetuses in the occipitoposterior position rotate spontaneously after striking the pelvic floor. The increased prevalence of prolonged labor, operative delivery, and oxytocin augmentation in women with an occipitoposterior fetal position seems consistent with decreased uterine contractility. We sought to test the hypothesis that women with a persistent occipitoposterior fetal position have inadequate intrauterine pressure. STUDY DESIGN: Intrauterine pressure was measured prospectively electronically in 94 women whose labor pain was controlled by patient-requested epidural analgesia. Eleven women (12%) were delivered as a persistent occipitoposterior fetal position. In a nested case-control study, these women were compared with 22 women who were delivered as an occipitoanterior fetal position who were matched for age, parity, gestational age, cervical examination at study enrollment, and body mass index. The intrauterine pressure measurements were initiated during the first stage of labor and continued throughout the entire labor process. Women were encouraged in the second stage of labor, after a period of recording baseline contractility, to push using a standardized Valsalva maneuver once the vertex reached the +2 station. The area under the intrauterine pressure curve (integral) was used to estimate uterine contractility and expulsive performances. RESULTS: Five women (45%) in the occipitoposterior group required operative delivery. The average duration of the second stage of labor in the occipitoposterior group was 91.4 +/- 23.2 minutes compared with 51.7 +/- 6.6 minutes in the occipitoanterior fetal position (P =.04). Ninety percent of women in the occipitoposterior group required oxytocin, compared with 59% of the women in the occipitoanterior group (P =.11). There were no differences in uterine contractility between occipitoposterior and occipitoanterior groups during either the first stage of labor (integral mean +/- SEM: occipitoposterior [1685.3 +/- 194.6 mm Hg. s] vs occipitoanterior fetal position [1700.8 +/- 128.9 mm Hg. s, P =.98]) or second stages of labor (occipitoposterior [1952.6 +/- 186.5 mm Hg. s] vs occipitoanterior fetal position [1740.8 +/- 104.3 mm Hg. s, P =.46]). Further, there were no significant differences in pushing performances between the occipitoposterior and occipitoanterior groups (Valsalva maneuver: occipitoposterior 2864.9 +/- 328.8 mm Hg. s] vs occipitoanterior [2898.6 +/- 222.2 mm Hg. s, P =.90]). CONCLUSION: Women who were delivered as a persistent occipitoposterior fetal position do not have lower intrauterine pressure levels immediately before or during the second stage of labor.     

NO FREE LUNCH ON LABOR DAY: The Risks and Benefits of Epidural Analgesia During Labor*

Epidural analgesia provides effective pain relief for women during labor. However, like all medical interventions, it also has potential side effects such as longer labor and a higher rate of intrapartum fever and operative vaginal delivery. A recent meta-analysis of randomized studies by Halpern et al concluded there was no association between epidural use and cesarean delivery. A critique of that meta-analysis, included in this paper, concludes that there are currently insufficient data to determine whether epidural analgesia leads to increased rates of cesarean delivery. This paper also presents results from several recent studies related to epidural analgesia conducted at Brigham and Women's Hospital in Boston. One study demonstrates a significant influence of prenatal planning on use of epidural during labor. Additional studies examine the strong association of epidural analgesia with intrapartum fever and the consequences of that fever for mother and infant. Epidural analgesia should remain an option available to women during labor. A more complete understanding of the risks and benefits that accompany its use is essential so that women and their care providers can make informed choices about pain relief during labor. J Nurse Midwifery 1999;44:394–8 © 1999 by the American College of Nurse-Midwives.     

Management of occiput posterior position

A 27‐year‐old, para 1 at 40 1/7 weeks' gestation presented to the labor and delivery unit in labor. Her prenatal course was uncomplicated, and her previous obstetric history included a vaginal delivery of a full‐term 7‐pound, 9‐ounce male infant. She described her first birth as being “straightforward.” It was 10 hours in length, and she received an epidural for analgesia. Upon this admission, she stated that she had been having regular, painful contractions for the past 10 hours. Her cervix was 1 cm dilated, 50% effaced, and the fetus was at ?3 station. The membranes were intact. She was experiencing intensely painful contractions every 2 to 3 minutes, and reported severe back pain and exhaustion. Leopold's maneuvers revealed small parts on the left anterior side, and the fetal back was difficult to palpate, consistent with an occiput posterior (OP) position. Per hospital protocol, she was confined to bed rest and placed on continuous fetal and uterine monitoring. Five hours after admission, her membranes ruptured spontaneously with clear fluid. The fetus was then at ?2 station, and her cervix had dilated to 4 cm and was 80% effaced. She reported increased pain and requested an epidural, hoping to get some rest. After the epidural was placed, her contractions became irregular (every 3–10 min), and as a result, oxytocin augmentation was started. Approximately 1 hour later, the external uterine monitor began failing to record contractions, and an intrauterine pressure catheter was placed. Ten hours after admission, and 4 hours after oxytocin was started, her cervix had dilated to 7 cm. Despite several epidural boluses, she continued to experience severe back pain, and a belly binder was applied as a relief measure. Throughout her labor, she stayed in bed with position changes that were limited to left lateral and right lateral. Cervical dilatation did not progress beyond 7 cm, and no fetal descent occurred over the next 4 hours, despite progressive oxytocin augmentation and an adequate contraction pattern based on Montevideo units. The midwife collaborated with the attending obstetrician and a cesarean section was recommended for failure to progress. A healthy baby boy who was noted to be in direct OP position was born via cesarean section with Apgar scores of 9/9. He weighed 8 pounds, 10 ounces.     

Epidural analgesia: effects on labor progress and maternal and neonatal outcome

The intended and unintended effects of epidural labor analgesia are reviewed. Mothers randomized to epidural rather than parenteral opioid analgesia have better pain relief. Fetal oxygenation is not affected by analgesic method; however, neonates whose mothers received intravenous or intramuscular opioids rather than epidural analgesia require more naloxone and have lower Apgar scores. Epidural analgesia does not affect the rates of cesarean delivery, obstetrically indicated instrumented vaginal delivery, neonatal sepsis, or new-onset back pain. Epidural analgesia is associated with longer second labor stages, more frequent oxytocin augmentation, and maternal fever (particularly among women who shiver and women receiving epidural analgesia for > 5 hours) but not with longer first labor stages. Epidural analgesia has no affect but intrapartum opioids decrease lactation success. Epidural use and urinary incontinence are weakly, but probably not causally, associated. Epidural labor analgesia would improve if the mechanisms of these unintended effects could be determined.     

No free lunch on labor day. The risks and benefits of epidural analgesia during labor.

Epidural analgesia provides effective pain relief for women during labor. However, like all medical interventions, it also has potential side effects such as longer labor and a higher rate of intrapartum fever and operative vaginal delivery. A recent meta-analysis of randomized studies by Halpern et al concluded there was no association between epidural use and cesarean delivery. A critique of that meta-analysis, included in this paper, concludes that there are currently insufficient data to determine whether epidural analgesia leads to increased rates of cesarean delivery. This paper also presents results from several recent studies related to epidural analgesia conducted at Brigham and Women's Hospital in Boston. One study demonstrates a significant influence of prenatal planning on use of epidural during labor. Additional studies examine the strong association of epidural analgesia with intrapartum fever and the consequences of that fever for mother and infant. Epidural analgesia should remain an option available to women during labor. A more complete understanding of the risks and benefits that accompany its use is essential so that women and their care providers can make informed choices about pain relief during labor.     

Intrathecal narcotics for obstetric analgesia in a community hospital

OBJECTIVE: Our objective was to establish whether intrathecal narcotics for obstetric analgesia offer an adequate and cost-effective alternative to epidural analgesia with minimal side effects in our small, semirural community hospital with limited anesthesia coverage. STUDY DESIGN: Low-risk patients at ≥35 gestational weeks in active labor were offered intrathecal narcotics. A retroactive chart review of every patient receiving an intrathecal injection was compared with a chart review of the next consecutive low-risk patient who did not receive an intrathecal narcotic. Age, parity, and status of labor at the time of application were noted, as was the subsequent rate of labor and the type of delivery. Side effects such as changes in vital signs, headache, vomiting, pruritis, urinary retention, and/or respiratory depression were noted. All study patients received fentanyl, 25 to 35 μg, plus 0.25 to 0.3 mg of preservative-free morphine combined with 6 to 8 mg of lidocaine. Within 15 minutes of delivery intravenous nalbuphine (Nubain), 5 mg, and oral naltrexone, 12.5 mg, were administered. Pain relief was recorded as excellent, satisfactory, or unsatisfactory (requiring additional medication). RESULTS: During the 30-month review period, 90 patients (3% of total deliveries) received intrathecal narcotics. There were three sets of twins, for a total of 93 live births. Ten patients (11%) required primary cesarean section, and of the 83 vaginal births 35 (38%) were spontaneous, two (2%) required forceps deliveries, and 46 (49%) were delivered by vacuum extraction, which was significantly higher than the 28 (31%) for controls. The rate of labor was not affected, with both groups requiring a similar rate of oxytocin (Pitocin) augmentation. Significantly more patients receiving intrathecal narcotics experienced pruritus and urinary retention compared with controls. There was no incidence of respiratory depression. Eighty-four (93%) of the 90 patients reported excellent pain relief, five patients had satisfactory relief lasting 2.5 to 6 hours, and one was unsatisfactory. CONCLUSIONS: In our hospital with limited anesthesia services intrathecal narcotics offer excellent labor pain relief with manageable side effects and without adverse obstetric outcome. (AM J Obstet Gynecol 1994;170:1643-8.)     

Hands and Knees Posture in Late Pregnancy or Labour for Fetal Malposition (Lateral or Posterior)

Background: Lateral and posterior position of the baby's head (the back of the baby's head facing to the side or the mother's back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby's position. Objectives: The objective of this review is to assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position, compared with no intervention. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004). Selection criteria: Randomised trials of hands and knees maternal posture compared to other postures or controls. Data collection and analysis: Both review authors assessed trial eligibility and quality. Main results: Two trials of hands and knees posture during pregnancy were included. In one trial involving 100 women, four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.25, 95% confidence interval (CI) 0.17 to 0.37). In a second trial including 2547 women, advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby's position at delivery or any of the other pregnancy outcomes measured. No trials of hands and knees posture during labour were included. Authors’ conclusions: Use of hands and knees position for 10 minutes twice daily to correct occipitoposterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of this position during labour has not been addressed in this review. In view of the promising short‐term effects of the technique and its simplicity, further trials are justified to determine whether encouraging the use of hands and knees posture during rather than before labour, has any effect on substantive outcomes.     

Labor pain and obstetric analgesia

GOAL AND METHODS: Labor pain is of major concern since most parturients experience significant pain of extremely severe intensity for many. The purpose of this review was to provide an overview of the mechanisms and pathways of labor pain (including new insights on integration of the nociceptive signal) and to emphasize the need of effective labor pain relief. RESULTS: Labor pain can have deleterious effects on the mother, on the fetus and on labor outcome itself. Among the current methods of obstetric analgesia, regional analgesia (the most widespread technique being epidural analgesia) offers the best effectiveness/safety ratio thanks to pharmacological innovations. Systemic analgesia (parenteral opioids, nonopioid painkillers and inhaled anesthetic agents) provides an alternative to regional analgesia but remains less effective and more hazardous. Non-drug approaches (namely psychoprophylaxis and physical methods) may be effective when used with epidural analgesia but are often not potent enough when used alone. CONCLUSION: Despite its complex pathophysiology, labor pain can be efficiently managed. Thanks to multidisciplinary care, obstetric analgesia (mainly epidural analgesia) prevents deleterious effects of labor pain on the mother and fetus.     

New epidural techniques for labour analgesia: patient-controlled epidural analgesia and combined spinal-epidural analgesia

Epidural analgesia in labour aims to provide high-quality pain relief of rapid onset and prolonged duration, while minimizing both maternal side-effects, particularly impairment of mobility, and impact on the fetus or on the outcome of labour. In conjunction with pharmacological research on spinal analgesics (local anaesthetics, opioids and other drug classes), refinement of new or established drug delivery techniques has allowed progress toward more reliable and improved pain relief at all stages of labour and childbirth, reduced individual drug doses with reduction of unwanted effects and greater safety and enhancement of maternal satisfaction. Patient-controlled epidural analgesia in labour has been in use for almost a decade, although is only now at a stage where its role is well defined and utility can be increased. Combined spinal-epidural analgesia is a more recent refinement which appears to be extremely promising but awaits further investigation.     

Effect of epidural analgesia on the primary cesarean section and forceps delivery rates

OBJECTIVE: To determine the impact of introducing epidural analgesia for labor pain relief on the primary cesarean and forceps delivery rates. STUDY DESIGN: The control group consisted of 1,720 women who delivered on a charity hospital service between September 1, 1992, and August 31, 1993; epidural analgesia was not available for this cohort of patients. The study group consisted of 1,442 patients who delivered on the same service between September 1, 1993, and August 31, 1994; elective epidural analgesia for labor pain relief was available for this cohort of patients. A computerized obstetric database was analyzed to compare the two groups regarding demographics, parity, pregnancy complications, labor characteristics, type of delivery, low birth weight incidence and five-minute Apgar scores. RESULTS: The two groups were similar with respect to demographics and pregnancy complications. No control group patient received epidural analgesia for labor pain relief; 734 of 1,285 (57%) laboring patients in the study group elected epidural analgesia for pain relief. The primary cesarean delivery rate for the control group was 9.6% and for the study group 11.0% (not statistically significant). The control group had 34 (2.0%) forceps deliveries and the study group, 88 (6.1%), for a statistically significant difference. There were significantly more vaginal births after cesarean in the study group (42 vs. 26). CONCLUSION: Epidural analgesia was not associated with an increase in the primary cesarean delivery rate but was associated with an increase in the operative vaginal delivery rate.     

Effect of availability of a parturient-elective regional labor pain relief service on the mode of delivery.

BACKGROUND/PURPOSE: Regional analgesia for labor pain relief is effective and widely used. This study evaluated the controversial association between mode of operative delivery and patient-elective labor regional analgesia. METHODS: We retrospectively compared the rates of instrumental vaginal and cesarean deliveries in parturients before the introduction, in the first 15 months after, and in the subsequent 36 months after the implementation of an elective labor regional analgesia service. A total of 9779 low-risk singleton cephalic pregnancies above 36 weeks of gestation were included. The maternal and fetal outcomes for parturients before the service was implemented and in those with or without pain relief service in the two postimplementation periods were analyzed. Multivariate logistic regression analyses were used to investigate the effects of maternal age, gestational weeks and newborn weight, in addition to regional analgesia, on the mode of delivery in nulliparous women. RESULTS: After adjusting for maternal age, gestational weeks, and newborn weight, no significant association was found between regional analgesia and cesarean delivery in nulliparas. Further, this lack of association was not affected by the receipt of regional analgesia in the early period of program implementation or in the period after staff had become familiar with the service. A higher rate of instrumental vaginal delivery was noted in nulliparas given regional analgesia. CONCLUSION: Regional analgesia for pain relief increased the likelihood of instrumental vaginal delivery, but did not increase the likelihood of cesarean delivery.     

椎管内阻滞分娩镇痛风险防范

分娩疼痛严重威胁母婴健康,是我国非医学指征剖宫产的重要原因。椎管内阻滞分娩镇痛是目前最常用且最有效的分娩镇痛方式,且不会增高剖宫产率,但仍有可能发生仰卧位低血压综合征、镇痛不全、发热等并发症。加强对分娩镇痛的流程管理、明确职责分工、开展教育培训、制定并发症处理预案是椎管内阻滞分娩镇痛风险防范的重要举措。     

The Fetal Occiput Posterior Position: State of the Science and a New Perspective

Abstract: Background: The fetal occiput posterior position poses challenges in every aspect of intrapartum care—prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe nine prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science. Methods: A search was conducted of the databases of PubMed and the Cochrane Library. Additional valuable information was obtained from obstetric and midwifery textbooks, books and websites for the public, conversations with maternity care professionals, and years of experience as a doula. Results: Nine prevailing concepts are as follows: (1) prenatal maneuvers rotate the occiput posterior fetus to occiput anterior; (2) it is possible to detect the occiput posterior fetus prenatally; (3) a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor; (4) back pain in labor is a reliable sign of an occiput posterior fetus; (5) the occiput posterior fetus can be identified during labor by digital vaginal examination; (6) an ultrasound scan is a reliable way to detect fetal position; (7) maternal positions facilitate rotation of the occiput posterior fetus; (8) epidural analgesia facilitates rotation; (9) manual rotation of the fetal head to occiput anterior improves the rate of occiput anterior deliveries. Concepts 1, 2, 3, 4, 5, and 8 have little scientific support whereas concepts 6, 7, and 9 are supported by promising evidence. Conclusions: Many current obstetric practices with respect to the occiput posterior position are unsatisfactory, resulting in failure to identify and correct the problem and thus contributing to high surgical delivery rates and traumatic births. The use of ultrasound examination to identify fetal position is a method that is far superior to other methods, and has the potential to improve outcomes. Research studies are needed to examine the efficacy of midwifery methods of identification, and the effect of promising methods to rotate the fetus (simple positional methods and digital or manual rotation). Based on the findings of this review, a practical approach to care is suggested. (BIRTH 37:1 March 2010)     

Labor Pain Management Other Than Neuraxial: What Do We Know and Where Do We Go Next?

Analgesia and coping with labor pain can prevent suffering during childbirth. Nonpharmacologic methods help women manage labor pain. Strong evidence is available for the efficacy of continuous one‐to‐one support from a woman trained to provide nonmedical care during labor, immersion in warm water during first‐stage labor, and sterile water injected intracutaneously or subcutaneously at locations near a woman's lumbosacral spine to reduce back‐labor pain. Sterile water injections also reduce the incidence of cesarean deliveries. Nitrous oxide labor analgesia is not potent, but helps women relax, gives them a sense of control, and reduces and distracts their perception of pain. It is inexpensive; can be administered and discontinued safely, simply, and quickly; has no adverse effects on the normal physiology and progress of labor; and does not require intensive monitoring or co‐interventions. Parenteral opioids provide mild‐to‐moderate labor pain relief, but cause side effects. Although observational studies have found associations between maternal use of opioids and neonatal complications, little higher level evidence is available except that meperidine is associated with low Apgar scores. Patient‐controlled intravenous administration of remifentanil provides better analgesia and satisfaction than other opioids, but can cause severe side effects; continuous monitoring of arterial oxygen saturation, anesthesia supervision, one‐to‐one nursing, and availability of oxygen are recommended. The demand for inexpensive, simple, safe but effective labor pain management for women will undoubtedly increase in places that lack wide access to it now. (BIRTH 39:4 December 2012)     

One-blade rotation of a persistent posterior vertex

Fifteen women in labor at term with no evidence of protraction or arrest disorder successfully underwent a single-blade rotation of the fetus from occipitoposterior to occipitoanterior position. There were no failures, no fetal injuries, and no significant maternal trauma. This method of forceps rotation appears to be a safe alternative to current methods of managing occipitoposterior positions.     

Obstetric pain relief and its association with remembrance of labor pain at two months and one year after birth

The association between obstetric pain relief and long-term memory of pain is poorly researched in spite of the fact that a woman's memory of childbirth may affect her emotional wellbeing and future reproduction. The aim of this study was to investigate the association between epidural analgesia and other forms of pain relief, and memory of pain at two months and one year after birth. A national sample of 2482 Swedish speaking women with vaginal delivery or emergency cesarean section preceded by labor were followed from early pregnancy to one year after birth. Data were collected by three postal questionnaires: in early pregnancy, and two months and one year after the birth. Recollection of intense pain at two months and one year was associated with high rates of pain relief, and this was most obvious regarding epidural analgesia in first-time mothers. When comparing women with the same pain score at two months postpartum who had and who did not have an epidural, the first group seemed to have greater difficulty forgetting pain 10 months later. Possible explanations of these findings are discussed.     

Epidural anesthesia in obstetrics: an accidentally placed intrathecal catheter--remove it or use it?

Epidural anesthesia is an established method in obstetrics. Despite constant practical experiences and established techniques, accidental penetrations of the dura and therefore malpositioning of the catheter in the intrathecal space are still present. This can result in post spinal headaches, a higher dispersion of the local anesthetic followed by life-threatening respiratory insufficiency and loss of overall conscious delivery. In consideration of these risks removal of the misplaced catheter and proper reinsertion in a higher position is standard. Thus significant emotional stress and re-exposure to the risks of the procedure for the parturient is accepted. We report of a 30-year-old primipara with secondary realized intrathecal placement. In due consideration of the current state of labor, we decided to leave the catheter in place and initiate a pain therapy applying bupivacain via this catheter immediately after the motor block had ceased. Within the first stage of labor sufficient pain relief was established. There was no change in tonicity. It resulted in a normal unproblematic vaginal birth. After an initial irritation due to the high dispersion the patient described a noticeable alleviation of pain during the adequate controlled labor.