Patient-controlled epidural analgesia for labor and delivery: a novelty or a practical method?

Patient-controlled analgesia, familiar worldwide as “PCA” and derived from a conceptual framework designed to improve standards of pain relief, developed rapidly from an experimental paradigm to the gold standard of modern acute pain management. While PCA has been universally adopted for postoperative parenteral drug administration, as an approach to epidural drug delivery during childbirth, its acceptance has been slow and characterized by isolated flourishes of energy and pockets of clinical activity. Once largely confined to academic or tertiary maternity units, patient-controlled epidural analgesia (PCEA) now seems to be more widely used, although new survey data are awaited before this impression can be affirmed or refuted. World wide, the clinical use of PCEA during labor and delivery varies widely. In parts of North America and Western Europe, PCEA has firmly established a place in the provision of epidural analgesia for parturition, partly accounted for by regional practice patterns, by requirements with respect to epidural management by medical and nursing staff, and by remuneration issues. In other countries and institutions, a variety of factors, not least of which is cost-containment, finds PCEA rarely considered as an alternative to continuous infusion epidural analgesia (CIEA) or intermittent bolus epidural analgesia (IBEA). Consumer-focused epidural services placing emphasis on choice or satisfaction frequently offer PCEA as an option or have adopted PCEA as the routine approach. Nevertheless, while there is strengthening evidence for several advantages of PCEA compared with the alternatives methods of drug delivery, assessing and documenting maternal satisfaction is difficult and any general benefit of PCEA in this respect is largely theoretical. This chapter reviews the literature pertaining to the efficacy and safety of PCEA during labor and delivery, especially in comparison with CIEA and IBEA.