First-stage pain is visceral — cervical stretching and uterine ischaemia referred through T10 to L1, poorly localised. Second-stage pain is somatic — the pudendal nerve carrying vaginal and perineal distension through S2 to S4, sharp and exact. That single piece of anatomy explains why a block adequate for one stage may be useless for the other. Light up the pathway, test each measure against it, clear the patient for the needle, and then handle what follows it.
Choose a bench
Which pain are you treating?
What are you offering?
3 h
Steps of 30 minutes; the two lowest positions are 30 and 45 minutes.
Non-pharmacological measures are not a consolation prize. Continuous one-to-one labour support reduces caesarean birth, shortens labour and improves satisfaction more reliably than most drugs — and it has no fetal effect at all. Offer these first, and keep offering them after an epidural is placed.
Patient factors
Preparation completed
Case 1 of 6
Step one — what is happening?
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First-stage painVisceral, T10 to L1
First-stage pain
Clearance for neuraxial analgesiaSet the patient on the left
Waiting
What each option actually is. An epidural places a catheter in the epidural space for continuous local anaesthetic with an opioid. A spinal injects a single dose into the cerebrospinal fluid and is the workhorse for caesarean birth. A combined spinal-epidural gives the rapid onset of the spinal plus a catheter for topping up.
Blood pressure is checked every 5 minutes for the first 15 to 20 minutes after dosing, and again after every top-up. Maternal hypotension is the commonest complication and it reduces placental perfusion within seconds — which is why late decelerations often appear before the patient feels faint.
Six things that follow the needleIdentify it, then act
Read the case on the left
Each case gives you a cluster of findings. Name what is happening, then choose the first action — the order is the treatment.
Lipid emulsion calculator
Local anaesthetic systemic toxicity is treated with 20 per cent lipid emulsion, 1.5 mL/kg as a bolus, followed by an infusion.
Recognise it before the seizure. Local anaesthetic systemic toxicity begins with circumoral numbness, a metallic taste, tinnitus and agitation, and progresses to seizures and cardiac arrest. Stop the injection, secure the airway, give the lipid emulsion.