Dr Varsha Deshmukh is working as Professor in Dept. of OBGY, GMCH and Govt cancer Hospital, Aurangabad. She is a recognised undergraduate as well as Postgraduate teacher since last 20 years. She has many publications in national as well as international journals to her credit. She is actively involved in activities of FOGSI and is President elect of Aurangabad OBGY Society.
Objective: Aim of study was to determine effect of epidural analgesia on progress of labour and mode of delivery, to find out its complications in labour and puerperium and to evaluate neonatal outcome in terms of APGAR score. Method The present study was conducted in Department of Obstetrics and Gynaecology at Government Medical College Aurangabad over period of 2 years from June 2014 to June 2016 after taking approval from institutional ethical board. Hundred low-risk primigravidas were included in the study, 50 women received epidural analgesia for relief of labour pain at 3–4 cm and 50 women served as control. The important outcome FACTORS studied were the following : (1) duration of active phase of I stage, and II stage, (2) mode of delivery, (3) APGAR scores, (4) untoward reactions and intrapartum complications, (5) overall satisfaction of the mother.
Results: The operative delivery rates were not significantly different in both the groups (8% in the control group and 6% in the study group: p value NS, i.e. [0.05). The duration of first stage (our study showed no significant difference in the duration of first stage in both the study and control groups p value[0.05) and second stage of labour (p value NS [0.05) and the need for oxytocin were comparable in the two groups. The side effects observed were minimal. It has given excellent pain relief and improved neonatal outcome (5 min). EA is associated with rates of vaginal delivery (88 v/s 84%) and LSCS rate (8 v/s 6%) which are comparable with control group.
Conclusion: Epidural analgesia is a very promising, safe and effective method of pain relief. No major complications and a good APGAR score make it a good option of care in modern obstetrics.
Keywords : Epidural analgesia, Patient satisfaction, Operative delivery, Labour duration
‘‘The delivery of an infant into the arms of a conscious and pain free mother is one of the most exciting and rewarding moments in medicine’’—Moir [1]. One of the worst known and most severe forms of pain known to mankind is that of labour. The pain gets progressively severe as labour advances and often aggravated by anxiety, fear and ignorance. The effects of labour pain are mainly hypercarbia, loss of consciousness, decreased uterine blood flow [2]. At present The American College of Obstetricians and Gynecologists and the American Society of Anaesthesiologists concur that maternal request is sufficient for pain relief during labour barring a medical contraindication [3]. Unrelieved maternal pain leads to a series of metabolic changes in the mother including surge in the catecholamine levels which may adversely affect the foetus [4].
Pain relief in labour has always been surrounded by myths and controversies. There was a religious debate about the appropriateness of anaesthesia in labour. Then came a time in 1950 when neuraxial techniques were used for pain relief in labour [5]. During the last two decades, there have been several advances that lead to comprehensive and evidence-based management of labour pain. Modern neuraxial labour analgesia reflects a shift in obstetrical anaesthesia, thinking away from a simple focus of pain relief towards a focus on overall quality of analgesia [6].
The International Association for the Study of Pain (IASP) declared 2007–2008 as the, ‘‘The Global Year Against Pain in Women-Real Women, Real Pain’’. The focus was to study both acute pain and chronic pain in women. Labour pain was found to be a good study model for treating acute pain. Increasing knowledge of the physiology and pharmacotherapy of pain and the development of obstetric anaesthesia as a subspeciality have improved the training in obstetric anaesthesia leading to an overall improvement in the quality of labour pain relief [7].
Epidural analgesia reverses the adverse ventilatory effects of pain [8] and results in an increase in oxygen tension in both mother and foetus [9], which may be beneficial, especially when additional conditions contributing to foetal or maternal hypoxia are also present. Hence, epidural analgesia should be strongly recommended to all patients who do not have any contraindications to this method of treatment [10]. Considering the monumental advantages of epidural analgesia, this study has been taken up in our tertiary care centre to provide pain-free delivery (since it is not widely available in government set-up). Also, labour pain is a good study model for the treatment of acute pain. Other benefits include study of pain relief of patients in labour and raising the quality of available care.
The present study was a prospective case–control clinical study conducted at GMC Aurangabad, Dept. of Obstetrics and Gynaecology from June 2014–June 2016. Fifty low risk primigravida patients at term and in labour([=4 cm) were subjected to thorough physical examination. Those who classified as physical status ASA 1 were given epidural analgesia and served as cases. The controls were 50 low risk primigravida at term and in labour with or more than 4 cm cervical dilatation. The following inclusion and exclusion criteria were considered (Tables 1, 2, 3, 4, 5, 6).
Exclusion criteria
Primigravida coming to labour room and antenatal clinic
fulfilling the inclusion criteria were offered the option of
epidural analgesia. Cases consisted of 50 parturients willing
for epidural analgesia, and controls consisted of 50
parturients in whom no analgesia was given. A complete
relevant history was obtained, and clinical examination was
done. An informed written consent was taken from parturient
and her relatives who were willing for epidural
analgesia. The whole procedure was explained to them
including its advantages and disadvantages. Lignocaine
sensitivity test was done. Routine investigations along with
BT/CT were done and noted. Insertion of epidural catheter
was done by anaesthetist in OT. Baseline parameters like
heart rate, blood pressure, SpO2 and FHR were recorded on
CTG. The epidural analgesia was practised in office hours
only.
Technique of epidural anaesthesia Prior to insertion of
epidural catheter, patient was given intravenous ranitidine.
Maternal pulse, BP, cervical dilatation, effacement, uterine
contractions were noted on partograph. Preloading was
done with ringer lactate solution 10 ml/kg. A16 G epidural
needle was placed in L2-L4 space. Inj lidocaine 1.5% was
injected in the space after the test dose. After the drug was
given the patient was monitored carefully for any rise in
pulse. The placement of epidural catheter in the epidural
space was confirmed by nondevelopment of tingling and
numbness. At 0 min, 10 ml solution of bupivacaine/ropivacaine
0.125% with 2 mcg/cc of fentanyl was given.
Monitoring After insertion of epidural catheter, patient
was shifted to labour room and monitored for pulse, blood
pressure every half hourly and cervical dilatation every 2 h.
Patient was accompanied by relative for support. Progress
of labour was monitored by partograph. Foetal heart rate
was monitored using CTG. Top-up doses were given every
60–90 min after confirming two segments regression of
sensory level or on patient request, until the delivery of the
baby. Level of pain was graded according to VAS scale.
Duration of first stage of labour was calculated as the time
interval between patient entering the active stage of labour
at which epidural catheter insertion was done and full
dilatation of cervix. Normal duration in primigravida was
8–12 h. Prolonged first stage was defined as duration of
labour [12 h. Duration of second stage of labour was
calculated from full dilatation of cervix to expulsion of
foetus from the birth canal. Normal duration in primigravida
without epidural analgesia was 1 h and with
epidural 2 h. Labour was managed according to principles
of active management. Oxytocin infusion was added if
uterine contractions were less than 3 in 10 min. Lower
segment caesarean section (LSCS) and instrumental
deliveries were performed for obstetric indication or if
CTG abnormalities were found. Occurrence of adverse
effects of epidural analgesia like hypertension, bradycardia,
pruritis, nausea, vomiting, urinary retention as well as
Neonatal NICU admissions was recorded. Patients complaining
of nausea and vomiting were treated with intravenous
ranitidine and ondansetron.
Indication of Oxytocin in Active Labour (> 4 cm)
Statistical analysis was done by using descriptive and inferential statistics using Chi-square test and Student’s unpaired t test; software used in the analysis were SPSS 17.0 version, EPI-INFO 6.0 version and GraphPad Prism 5.0 version, and p\0.05 was considered as level of significance.
There are many techniques which are both regional and
non-regional to provide labour analgesia. However, epidural
analgesia gives the most superior analgesia for labour.
The demographic characteristics are age, body mass
index, gestational age, registration status. The results in
both control and study group were comparable.
There was no case with failure of procedure or inadequate block in our study.
Our study showed no significant difference in the duration of first stage of labour in both the study and control groups. The results in our study were comparable to that of Labour EA Papalkar et al. [9] which showed no significant difference in the duration of first stage in both the study and control groups. The study conducted by Dipti et al. [11] showed shortened duration of first stage in epidural group. This may be due to the use of ropivacaine, resulting in decreased inhibitory effect of catecholamines on uterine contractility and hence rapid cervical dilatation. In the study of Hincz [12], the mean duration of first stage was prolonged in epidural group. This may be explained on the basis that prolonged labour seems to occur more frequently when a higher dose of local anaesthetic is used.
In our study, duration of second stage of labour in the study and control groups was comparable. There was no prolongation of second stage of labour. This was probably due to adequate hydration of mothers and use of appropriate dose of analgesic. The results of our study were comparable to that of Labour EA [9] papalkar et al. However, the study conducted by Dipti et al. [11] showed that second stage of labour is prolonged in epidural group. This has been attributed to motor blockade with concomitant weakness of pelvic floor muscles that reduces the effective maternal pushing and involuntary bearing down reflex. In the present study, there was no increase in the rates of operative deliveries and instrumental deliveries. The results of our study were comparable to that of Labour EA [9] papalkar et al., Dipti et al. [11] Hincz [12], which showed that the instrumental delivery rates were not increased with epidural anaesthesia in labour. However, Anwar et al. [13] and Hincz et al. [12] reported an increased rate of forceps delivery in patients receiving epidural analgesia (54, 16.7%, respectively.) This observation may be related to higher concentrations of local anaesthetic agents used in earlier days with intermittent boluses which resulted in significant motor blockade. This may further decrease maternal mobility and reduce maternal effort in the second stage. It may also predispose to inadequate rotation of the foetal presenting part secondary to relaxation of pelvic floor muscles resulting in higher rates of instrumental deliveries.
In our study, total seven LSCS were done(four in control group and three in study group). Three patients in control group underwent LSCS due to prolonged second stage of labour (DTA), and only one patient had DTA in study group who underwent LSCS. One patient (each in control and study group) underwent LSCS in view of prolonged first stage of labour. Foetal distress was diagnosed in one patient of study group who underwent LSCS. The majority of the LSCS in the study of Anwar et al. [13] were done for foetal distress depicted by decelerations on CTG (cardiotocography) and meconium-stained liquor. In our study, there were seven LSCS. Out of them five were done under general anaesthesia and two were done with top-up dose of epidural. No patient had abnormal CTG findings immediately after epidural anaesthesia, and hence no patient had undergone emergency LSCS immediately post-procedure.
In the present study, most common side effect was nausea and vomiting followed by rigor, pruritis and hypotension. In the study of Labour EA [9] papalkar et al. and magurie [14], most common side effect was hypotension followed by nausea vomiting, rigor, pruritis. In thestudy conducted by pandya et al. [15], only one patient had post-dural puncture headache. More side effects in our study could be due to increased doses of the drug. However, the side effects were not life threatening and could be managed with symptomatic treatment. It did not affect the process of labour.
In the present study, excellent satisfaction was seen in women in terms of pain relief according to VAS scoring system. The results of the present study were comparable to that of Desai et al. [16]. As known widely, epidural analgesia is the gold standard for pain management during labour and hence it is widely used all over the world. The WHO guidelines clearly mention that even the mere request from the delivering mother is an indication for administering EA.
In our study, level of acceptance was found to be significantly low as majority of women were belonging to rural areas and lower socio-economic status. There is lack of education, lack of awareness, fear of delivery complications in these women. They have a desire to deliver after suffering from labour pains.
In the present study there were a higher number of neonates with APGAR score[8 min in both the study and control groups. There was no increase in the rate of NICU admissions in both the study and control groups.
The results of the present study were comparable to other studies done by Paplakar et al. [9], Dipti et al. [11], Hincz et al. [12] and Anwar et al. [13] Hincz et al. [12] found in their study a significantly low APGAR score at 1 min (\7 score) of the babies delivered by mothers receiving EA; moreover, this observation was confirmed by logistic regression models run through their data. In contrast to other studies, they also observed lower cord arterial pH. They attributed this short-term effect of EA (low 1-min Apgar score) to the fact that fentanyl was used together with bupivacaine for EA administration during labour in their hospitals. In our study, no such observation was there.
Conflict of interests: The authors declare that they have no conflict of interest.
Ethical Standards: The authors state that approval for the study protocol was taken from the ethical comitee of Government Medical College, Aurangabad. No regulations or policies of the journal are violated.
