EPIDURAL ANALGESIA FOR TRIAL OF LABOUR:

* Preload with Ringer's lactate, 500-1000ml.
* Place the patient in the let lateral position with les fully fleed and back aligned along the edge of the bed.
* Prepare the back with antiseptic (eg. povidone-iodine), and drape appropriately.
* Infiltrate (1% lignocaine) skin overlying a lower thoracic or upper lumbar interspace eg. T12- L1, L1-2.
* Infiltrate deeper tissues at the same leel.
* Using loss of resistance to air or saline, identify the epidural space (angulation of lower thoracic vertebral spines may require a more cephalad approach).
* Inject 5-10 mL dilute bupivacaine (eg. 0.0625%).
* Thread the epidural catheter approximately 5 cm into the epidural space, and confirm catheter placement in the epidural space. Tape the entry point of this upper catheter.
* Infiltrate the skin over the lower lumbar L4-5, or L5-S1, interspace. After deep infiltration, locate the epidural space by loss of resistance to air or saline.
* Gently rotate Tuohy needlesuch that bevel faces caudally. (Avoid inward displacement of the Tuohy needle which can 'core' the dura mater.)
* Inject 5ml 0.9% preservative-free saline, and insert the catheter approximately 5cm into the epidural space.
* Tape the entry point of this lower catheter. Remove drapes. Then, tape both catheters to the back, labelling each appropriately.
* Commence continuous infusion of dilute local anaesthetic plus opioid (eg. bupivacaine 0.0625% + fentanyl 0.0004%) through the upper catheter at a rate of 6-8 ml/hr.
* If patient experiences premature urge to push, inject opioid (eg. fentanyl 100 mcg) +/-dilute local anaesthetic (eg. bupivacaine 0.03125%, 5-10 mL) via the lower catheter.