European Journal of Cardiovascular Medicine

Child birth is a painful process and pain relief during labour has always been associated with myths and controversies. Labour pains are one of the most distressing pains known. It cannot be considered acceptable for a person to experience such severe pain, amenable to safe intervention, while under a physician's care.¹

Unlike post-operative pain which tends to diminish with the passage of time, labour pains increase as the labour progresses and are often most severe at the end of the first stage of labour. Many pharmacological and non-pharmacological methods of labor analgesia have been adopted over the years. The contemporary goal of providing maternal labour analgesia is the relief of the suffering and the pain of labour and delivery, while minimizing effects on maternal safety, awareness, motor functions, progress of labour and foetal wellbeing. ²

Different regional 'anesthesia techniques include epidural analgesia, spinal analgesia, or a combination of epidural and spinal analgesia. Not only newer techniques such as combined spinal-epidural, continuous epidural infusions, walking epidurals and patient controlled epidural analgesia (PCEA) are now available, but also better drugs that provide selective sensory block like Ropivacaine is available.³ This study is being undertaken to know the outcome of this epidural labour analgesia programme in a tertiary care hospital.

Present study was prospective epidemiological observational study, conducted in department of anaesthesiology, The study was done at the Armed Forces tertiary care center with a diverse population base to access. Study duration was of 2 years (July 2018 to June 2019). Study was approved by institutional ethical committee.

Inclusion criteria

• Pregnant female, gestational age of 37- 42 weeks, Singleton foetus with engaged head & adequate pelvis, cervical dilatation ≥ 4cm, Bishop’s score >6, American Society of Anaesthesiologists (ASA) Grade I or ASA Grade II, willing to participate in present study.

Exclusion criteria

• Any allergy to drugs-bupivacaine, fentanyl
• Associated medical disease. - Hypertension, Diabetes, RHD, Renal diseases
• Obstetric complications – pre-eclampsia, Gestational Diabetes, Placenta Previa and premature rupture of amniotic membranes
• Local sepsis, skin lesions
• Hemorrhagic disorders
• Previous neurological diseases.
• Spinal deformity
• Cephalo-pelvic disproportion.
• Administration of IV analgesics within 1 hour of epidural request.
• Patients not experiencing analgesia within 15 min of drug administration

Study was explained to participants in local language & written informed consent was taken. A general, systemic and obstetric assessment was done. Automated maternal non-invasive blood pressure and heart rate was monitored. Cardiotocography and fetal heart rate monitoring was carried out. A multi-orifice epidural catheter was inserted 4 cm into the epidural space at the L2-3 or L3-4 inter-vertebral space. Parturients were given epidural analgesia as per the Programmed Labour Protocol.

Table 1: Dosage and Timing of Regional Blocks for Labour Analgesia

Patients who experienced inadequate analgesia during labor, defined as a patient requesting additional analgesia was given an additional 10-mL bolus of study solution. Fetal heart sound, maternal blood pressure and heart rate before & after injection of drugs for 30 minutes after initial dose / every top-up of the epidural block was recorded. Where an epidural infusion was used in labour OR the block was stable, observations were performed half-hourly with continuous CTG monitoring.

Patients were asked to rate pain intensity during uterine contractions. Pain intensity was monitored using a numeric Visual Analogue Score (VAS) where 0 = no pain, 10 = worst pain imaginable. Sensory levels to cold were assessed in the midline every ten minutes. Motor block was assessed every ten minutes using the modified Bromage scale (0=no block; 1=unable to flex either hip joint but able to move knee and ankle joints; 2=unable to move hip and knee of either limb but able to move either ankle; 4=unable to move hip, knee or ankle joint of either lower limb). Pain relief and motor blockade was assessed at 15 minutes after epidural and every 30 minutes thereafter till vaginal delivery

Cumulative study solution volumes and delivered demand doses were recorded at complete cervical dilation and at delivery. Patients requiring supplemental perineal analgesia for vaginal delivery were given local anaesthetic. Patient satisfaction was assessed immediately after delivery as excellent, good, fair, or poor. Following delivery, the Apgar score of the neonate was recorded at 1 and 5 min. Any neonatal or maternal side effects of drugs were recorded.

Those patients who developed an indication of LSCS were excluded from the study group if they had inadequate pain relief. In those who had adequate pain relief but had an developed an indication of LSCS, received either conversion to GA or Epidural anaesthesia (10-12 mL of 0.5% bupivacaine was injected through the epidural catheter, an initial dose of 5 mL was followed after 5 min by the complete dose). \

The data was tabulated in Microsoft Excel data sheet with relevant numerical grading and analysed by using SPSS software. Data will be presented as mean ±SD.Statistical analyses included analysis of variance, x2, valid percent and cumulative percentage was calculated for observational parameters. P < 0.05 will be considered significant.

Among 847 parturients, 257 (30.34%) were through normal conception and 590 (69.66%) were through Artificial Reproductive Techniques (ART). Among these, 261 parturients received labour analgesia. Out of these, six parturients were excluded from study as per protocol because two had no relief in labour pains within 15 min of administering labour analgesia and four patients delivered within 1hour of administering labour analgesia.

Table 1: General characteristics

Parturients in the study were in the age group of 23-35 yr with mean of 27.99 + 1.94 years. Maternal weight was in range of 58 – 88 kg with mean weight of 66.76 + 4.65 kg. Maternal height was in range of 152-172cm with mean of 162.39 ± 4.59 cm. In the current study, the duration of the first stage of labour after institution of labour analgesia was 100.32 + 20.619 minutes & duration of 2^nd stage was 88.53 + 15.67 minutes.  In our study mean Apgar at 1 min 6.26 ± 0.8 and at 5 min 9.8 ± 0.7.

Table 2- Demographic data

In the study group there were 228 (89.4%) primiparous parturients ,20 (7.8%) parturients were of second parity and 7 (2.7%) parturients were of third parity. Out of 255 parturients, 165 patients (64.7%) had 3-4 cm cervical dilatation at the time of first administration of the labour analgesia ,87 parturients (34.11%) had 5-6 cm dilatation and 3 parturients (1.1%) had 7cm dilatation. Out of the 255 parturients included in this study, 205 parturients underwent normal delivery, 29 (11%) parturients required instrumental assistance and 21 parturients i.e., 8.6% underwent caesarean section.

Table 3: Delivery characteristics

In the study group most parturients (76.1%) required TWO TOP-UP doses of 8ml for analgesia,22.4% parturients required one dose of 8ml of top-ups and 1.6% required 5ml of top-ups. 252 parturients received fentanyl. Out of these, 199 parturients had a sedation score of 2 after 1 h. Two parturients out of these had a sedation score of 2 after 4 h. Rest were comfortable with no sedation.

Table 4: Epidural Top Up in % mL Aliquots

199 parturients had sedation and 56 parturients had no sedation. In the study group 5 parturients (i.e. 2%) had hypotension following administration of labour analgesia. None of the parturients required vasopressor support. In the study group 7 parturients (i.e. 2.7%) had PDPH, Grade I. None had visual disturbances, vomiting, severe prostration.

Two parturients were discharged on their request within 24 h following delivery. Among the 253 parturients, 35 parturients (i.e. 13.7%) had backache. 6 parturients (2.4%) had urinary retention in study group after labour analgesia. No parturient needed catheterization.15 parturients had fetal bradycardia following administration of labour analgesia. 52 parturients (i.e. 20.4%) had maternal hyperpyrexia >98 F following labour analgesia. None required antipyretics. In our study 51(20%) parturients experienced nausea/vomiting.

Table 5: Side effects

The pain intensity of the parturients during uterine contraction immediately prior to administering labour analgesia was rated using Visual Analogue Scale with an empirical numerical value of 0-3 being classified as mild pain, an empirical numerical value of 4-6 as moderate pain and an empirical numerical value of 7-10 being classified as severe pain.

Labour analgesia was initiated in a majority of parturients when they had moderate pain with a VAS score of 6-7(77.3%) Most of the parturients were relieved of labour pain at 15 min i.e. VAS 3 (96.5%). At 30 min, most of parturients pain relief was sustained i.e. VAS 3,4(47.1%,52.5%). At 1 hour, most of the parturients had adequate pain relief i.e. VAS rating of 3,4(37.6%,61.6%)

Table 6: Visual Analogue Scale

In our study 84.7% parturients graded labour analgesia was excellent 5.5% fair,8.2% good,1.6% poor.

Table 7: Maternal satisfaction

The aim of an epidural bock is to provide maximum analgesia with minimum motor block since ambulation of parturient is associated with better establishment and progression of active labour. Advantages include analgesia with reduction of maternal fatigue without blurring of consciousness. The mother gains satisfaction from being able to participate in her labour and to maintain bonding with her child. However, the procedure, local anaesthetic agents and opioids all are not without side-effects. Motor and sympathetic blockade, toxic reactions and non-specific sensory blockade with local anaesthetics as well as sedation, pruritis, lower Apgar scores and shivering with opiates can occur. Additionally, labour epidurals have a reported increase in duration of labour and increase in instrumental deliveries or caesarian sections.

Out of the 255 parturients included in this study, 205 parturients underwent normal delivery, 29 (11%) parturients required instrumental assistance and 21 parturients i.e., 8.6% underwent caesarean section. Papalkar J et al.,⁴ reported a 10% incidence of LSCS which is in concordance with this study.  Raja KS et al.,⁵ reported an incidence of 23% patients who had caesarian section and received epidural analgesia as compared to 35.9% patients who did not receive labour analgesia.

In our study 25(10%) parturients underwent instrumental delivery. In a large randomized trial involving 1,054 patients (COMET study), the introduction of a low dose of epidural infusion was associated with a 25% decrease in the instrumental vaginal delivery.⁶

In the current study, the duration of the first stage of labour after institution of labour analgesia was 100.32 + 20.619 minutes. Papalkar J et al.,⁴ noted no effect of epidural analgesia was noted on progress of first stage of labour. The authors attributed this to careful attention being paid to correct inefficient uterine action early in labour with oxytocin infusion as part of their hospital protocol. Following this policy, after augmentation further 53.33% had duration of labour less than 8 hours which was again comparable to control group (56.67%) In the current study also, oxytocin is given in the first stage of labour at the rate of 5 IU/h as part of the hospital protocol.

In the study by S Geril et al.,⁷ duration of the first stage, second stage, and total duration of labor was reported to be longer in epidural group, however epidural analgesia was not demonstrated as an independent risk factor for a prolonged labor. The variable most influencing the total duration of labor and the duration of the first stage was nulliparity; the variables most influencing the duration of the second stage were the older age, a reduced body mass index, a high newborn weight and nulliparity.

In the current study duration of 2^nd stage was 88.53+15.67 (mean +SD) min which is in concurrence with studies done by Shahram N,⁸ According to Halpern et al.,¹⁰ the second stage is more constantly prolonged as compared to first stage. This claimed association has long been attributed to motor blockade with concomitant weakness of pelvic floor muscles that reduces the effective maternal pushing and the involuntary bearing down reflexes correspondingly high in various studies.

In our study mean Apgar at 1 min 6.26 with sd 0.8 and at 5 min 9.8 with SD of 0.7. APGAR score at 5 min was > 7 in 97% neonate. Following epidural WF Mousa et al.,¹¹ proved normal 5 min APGAR score, absence of need for naloxone, or mechanical ventilation for the neonates. Also. Somuah A et al.,¹² in large Cochrane database including 21 studies proved no evidence of low neonatal APGAR scores at 5mins.

In our study 52 mother (20.4%) out of 255 had pyrexia following labour analgesia. In obstetric patients demonstrate that epidural analgesia during labour is associated with maternal pyrexia and increased neonatal sepsis workup. The exact cause of maternal pyrexia is not known. The temperature rise generally is never above 1C with epidural, sometimes observed in women with long labours. Fever, in association with epidurals is seen more often in nulliparous women (19% of nulliparous women, 1% of multiparous women).¹³

In our study 84.7% parturients graded labour analgesia was excellent 5.5% fair,8.2% good,1.6% poor which is concurrence with Papalkar et al.,⁴ Study done by Sharma et al.,¹⁴ 55 involving 2703 nulliparous women,95% of women in epidural group reported their satisfaction as excellent. 15 (5.9%) neonates had bradycardia. Fetal bradycardia occurs in 8% of cases. Fetal bradycardia after induction of regional analgesia may result from decreased cardiac output, decreased uterine perfusion, or uterine tetany caused by maternal hypotension.¹⁵

5 parturients (2%) had hypotension in our study.3.33% patients had hypotension following epidural analgesia.⁴ Hypotension, a common complication, develops soon after injection of local anesthetics. Because of the speed of the onset of regional block, it is seen more often with spinal block (25-67%) than with epidural block (8.5-9% in women with prior hydration or fluid bolus; 28-31% in women without rehydration).¹⁶ In patients with diminished intravascular volume (e.g., preeclampsia, antepartum bleeding, dehydration) regional block is more highly associated with hypotension.

10(4%) parturients had pruritis in our study.1.67% parturients had pruritis following epidural analgesia J. Papalkar et al.,⁴ The rapid onset of analgesia and the high frequency of itching readily identify patients who have received CSE analgesia Norris et al.,¹⁷ In our study 51 parturient (20%) had nausea.1.67 % parturients had nausea and vomiting after epidural analgesia in study done by J. Papalkar et al.,⁴

In the current study 84.7% parturients graded labour analgesia as excellent, 5.5% fair, 8.2% good and 1.6% poor. These subjective findings are in concurrence with Papalkar et al.,⁴ A number of studies have proved that epidural analgesia offers superior pain relief as compared to other forms of pharmacological or non-pharmacological methods.^18,19,20 Morgan B M et al.,¹⁸ studied the amount of pain that had been experienced by 1000 women during vaginal delivery of a live child by interview within 48 hours of delivery. Patients had been offered a choice of analgesia, and 536 had received epidural analgesia: pain relief was greatest in this group, just over half having had a painless labour.

Programmed epidural labour analgesia protocol alleviated labor pain, without an increase in cesarean section and instrumental vaginal birth. Improved parturients' satisfaction with associated neonatal safety provides a positive birth experience. No major complications were noted in mother.

Programmed epidural labour analgesia protocol can be implemented as a safe and effective method of pain relief during labour in facilities where expertise for epidural analgesia is available. 

Conflict of Interest: None to declare

Source of funding: Nil

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