Epidural Placement in the Parturient

Last updated: February 9, 2026

  1. RN in room. One support person (mask on), parturient with hat covering. Wipe the table down thoroughly.

  2. Positioning: cooked shrimp back position, lumbar out. Avoid the bed crack, ensure midline and shoulders and buttocks level.

  3. Sterilize patient back. Utilize Chloraprep in a vertical or horizontal motion, not circular, per JACHO. Do not revisit areas already prepped, proceed from central outwards.

  4. Plastic cover up. Palpate patient landmarks. Aim for L3-4, L4-5.

  5. Apply local anesthetic.

  6. Insert Tuohy. Aim for engagement.

    1. Traversing occurs in 3 axes. Try to stay midline. If the spinous process is hit, that confirms midline and proceed above or below to continue into supraspinous and the interspinous ligament.

  7. Utilize intermittent or continuous technique, preferably with saline. Preferably continuous, since that is rapid intermittent.

  8. Once loss of resistance, in epidural space.

  9. At this point, potentially do spinal for CSE or DPE.

    1. If CSE → Lee recipe → 10 mcg fentanyl (10 mcg/1 mL) + 1 mL of 0.25% bupivacaine

    2. If CSE → Maryam recipe → 4 mL from the bag (0.625 mg/mL bupivacaine + fentanyl 2 mcg/mL) = 8 mcg of fentanyl + 2.5 mg bupivacaine

  10. Test dose

    1. Omit if doing spinal, since spinal dose will preclude signs of the test dose from appearing.

    2. Vascular

      1. Epinephrine will cause HR and BP to spike.

        1. HR > 10 bpm, SBP > 15 within one minute of injection.

      2. Lidocaine will cause metallic taste, oral numbness, dizziness.

    3. Intrathecal

      1. Lidocaine will cause abrupt neurological changes, such as loss of sensation and decrease in lower extremity motor function.

  11. Thread catheter to 20 cm, needle out, then catheter to LOR + 5 (usual Tuohy is 9 cm in length, but longer ones do exist).