The long-term effects of analgesia in labour

Women frequently use a mixture of analgesics to gain relief from the distress of childbirth and antenatally require information on their effectiveness and side-effects. One such example would be the reported long-term neonatal behavioural changes following systemic opioids such as pethidine. The most frequently reported maternal effects of epidural or spinal analgesia are prolonged symptoms of headache, backache and neurological sequelae. Large retrospective studies of postpartum symptomatology have focused on correlations with regional nerve blockade rather than on other more commonly used analgesics. Post-dural puncture headache is a recognized long-term complication of epidural nerve blockade. However, prospective studies have not confirmed any causal relationship between epidural analgesia and backache and neurological complications are five times more common after childbirth itself than after regional nerve blockade. Postpartum symptomatology describes significant morbidity in the community but its relationship to analgesia in labour is still to be proved.     

Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labour

OBJECTIVE: To assess maternal satisfaction with childbirth and intrapartum pain relief in nulliparous women labouring at term. METHODS: Prospective randomised clinical trial comparing epidural and non-epidural analgesic techniques on term labour outcomes in nulliparous women. Within 24 h of delivery the women were surveyed regarding their opinions about the birthing experience and the allocated analgesic regimen. A postal survey was conducted 6 months postpartum to assess opinions about intrapartum analgesia in a subsequent pregnancy. RESULTS: A total of 992 women were randomised to receive continuous midwifery support (CMS) or epidural (EPI) analgesia on presentation for delivery. There was a high crossover rate from CMS to EPI (61.2%) and a lesser non-compliance rate in the EPI group (27.8%). The early post-partum recollections revealed a high satisfaction with epidural analgesia and lower satisfaction with alternative pain relief measures. Ten percent of women in the CMS group reported negative feelings about their allocated pain relief compared with 1% in the EPI group (P < 0.001), and 10% of all women reported negative feelings about their overall childbirth experience. At the 6-month postpartum survey factors associated with the planned use of epidural analgesia in a subsequent pregnancy were induction of labour (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2, 4.7) and prior utilisation of epidural analgesia (OR 28.1, 95% CI 14.5, 54.7). CONCLUSIONS: Maternal satisfaction with intrapartum analgesia was significantly higher with epidural analgesia than non-epidural analgesic techniques. Overall satisfaction scores for labour and delivery were high regardless of analgesic approach, reflecting the multiple issues other than pain relief that are involved in the childbirth experience.     

The effects of epidural analgesia on the course and outcome of labour

The potential effects of epidural analgesia on the progress and outcome of labour have been the subject of lasting controversy. Retrospective reviews indicate that epidurals are associated with longer labours and/or an increase in the incidence of instrumental or operative delivery. Similar results were obtained in non-randomized prospective studies. None of them established a causal relationship, because without randomization the selection bias cannot be ruled out. Other factors, such as premature rupture of membranes and maternal socioeconomic status, may affect the outcome of labour. It was also reported that introduction of the on-demand epidural service did not increase the primary caesarean section rate. The few prospective randomized studies are contradictory and not very reliable owing to small patient populations and high cross-over rates. There is, however, unanimity among the authors regarding the superiority of pain relief provided by epidural blocks over systemically administered opioids.     

Fear of childbirth before, during, and after childbirth

BACKGROUND: Only scanty research exists about the relationship between women's expectations during pregnancy and their experiences as reported during the actual process of labor and afterwards. The aims of the present study were: (1) to investigate the associations between fear of childbirth during pregnancy and postpartum and fear and pain during early active labor (phase 1: cervix dilatation 3-5 cm), and (2) to explore possible differences regarding fear of childbirth during pregnancy and postpartum between women who did or did not receive epidural analgesia during labor. Methods. Fear of childbirth was measured in 47 nulliparous women during gestation weeks 37-39 by means of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ version A). During early active labor we measured women's fear (Delivery Fear Scale) and their experiences of pain (a pain intensity scale). Finally, fear after childbirth (W-DEQ version B) was measured two hours, two days, and five weeks after delivery. RESULTS: A positive correlation appeared between fear of childbirth during pregnancy, postpartum, and early active labor. There were no differences in fear of childbirth during late pregnancy between women who received epidural analgesia and those who did not. Postpartum fear was higher in the women who had received epidural analgesia. CONCLUSIONS: Pregnant women who fear childbirth are prone to report fear during the actual labor and postpartum. The administration of epidural analgesia is not a sufficient response to women's fear during the process of labor.     

Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries

A prospective randomized study was performed to evaluate the influence of epidural analgesia compared to parenteral pethidine in parturients with pain in the first stage of labour on the progress of labour and the frequency of instrumental deliveries. There was no significant difference in the two groups in the duration of either the first or second stage of labour. The overall instrumental delivery rate was 25%, with no difference between the groups. The analgesic efficacy of the epidural blockade was significantly better than that of parenteral pethidine. We conclude that epidural bupivacaine with our technique and obstetric practice did neither prolong labour nor increase the frequency of instrumental delivery.     

Epidural analgesia during labour: maternal, fetal and neonatal aspects

AIM: The most effective technique for eliminating labour and childbirth pain is continuous lumbar epidural analgesia. The preoccupation regarding the possible negative effects on the time taken for labour and on dystocias in general represents one of the greatest hindrances in the way of its wider use. The purpose of the present study is to monitor the effects of continuous lumbar epidural analgesia on delivery times, on the state of the fetus, on the incidence of dystocic deliveries and on neonatal outcome. METHODS: Comparative prospective study. The data relating to the deliveries of 148 nulliparas and 51 pluriparas at term, submitted to epidural analgesia at the Obstetric Clinic of the University of Parma in 1999-2000 were compared with data from 144 nulliparas in labour and 60 pluriparas without epidural analgesia, selected in random fashion out of 4251 women who delivered children in the same period. The anesthetic procedure employed consisted in an injection of 20 mg/10 ml ropivacaine and 50 mg fentanyl in the epidural space at intervals of 1-2 h. RESULTS: The duration of the dilatation period was not influenced by administration of epidural analgesia while the expulsion period was longer in the course of epidural analgesia. There were no significant differences between delivery modalities in the 2 groups either as regards vaginal operative delivery or the number of cesarean sections for dystocia. The cardiotocographic profile was similar in the 2 groups. The neonatal outcome (Apgar index at 1' and 5' and transfer to the intensive care department) did not show significant differences, confirming the absence of noteworthy side-effects even from the neonatal standpoint. CONCLUSIONS: The use of low concentrations of ropivacaine (0.2%) associated with fentanyl in the epidural space proved to be a safe and effective technique for controlling labour and delivery pain.     

Intra-partum epidural analgesia in grandmultiparous women

Objective. The present study aimed to characterise grandmultiparous women receiving intra-partum epidural analgesia and investigate associations between this method of pain relief and labour outcomes in grandmultiparas.

Methods. A population-based study was conducted comparing obstetric and perinatal characteristics of grandmultiparous women with and without epidural analgesia. Deliveries occurred during the years 1988–2006. Multiple logistic regression models were constructed to find independent risk factors associated with epidural analgesia, cesarean section and 1st stage labour dystocia.

Results. Out of 41,488 deliveries to grandmultiparous women included in the study, intra-partum epidural analgesia was utilised in 877 (2.1%). Multivariate analysis revealed that grandmultiparas who received epidural pain relief were significantly older and more likely to suffer from pre-mature rupture of the membranes, polyhydramnion, oligohydramnion, labour induction and a macrosomic fetus. After controlling for potential confounding, use of epidural analgesia remained an independent risk factor for 1st stage labour dystocia (odds ratio (OR) = 1.5; 95% confidence interval (CI) = 1.08–2.2) and cesarean delivery (OR = 2.9; 95% CI = 2.4–3.5) in grandmultiparas.

Conclusion. Grandmultiparous women who received intra-partum epidural analgesia have entirely different obstetric characteristics as compared with those who did not receive this method of pain relief. Although epidural use was demonstrated to be an independent risk factor for 1st stage labour dystocia and cesarean section in this population, residual confounding cannot be excluded.     

Segmental epidural analgesia in labour: related to the progress of labour, fetal malposition and instrumental delivery.

The effect of low-dose continuous segmental epidural analgesia given during the first stage of labour on the progress of labour, the frequency of fetal malpositions and the rate of vacuum extractions was studied prospectively in 100 parturients (epidural group). The results were compared with 100 parturients given none or conventional analgesia (control group). The results showed that in the primiparous epidural group the progress of labour before analgesia was induced was significantly slower than in the control group. After the block, however, the subsequent course of the labour was of equal duration in both groups. The durations of the second stages of labour did not differ significantly between the groups. The differences in fetal malpositions at delivery were statistically insignificant. Nor did the rate of vacuum extractions, 8% in the primiparous and 0% in the multiparous epidural group, differ statistically from the corresponding rate in the control groups. The results signify a normal progress and outcome of labour after low-dose segmental epidural analgesia.     

Analgesia in labour and delivery

Pain is defined as “an unpleasant sensory or emotional experience associated with actual or potential tissue injury”. Labour pain is encountered during contractions in labour, and patient satisfaction correlates closely to how well it is managed. Doctors commonly encounter acute pain in clinical practice which can be treated simply by applying some basic rules. However, pain due to labour requires specific management which falls outside the basic principles of acute pain management and it is important for practitioners who look after these patients to understand what can be offered. This review considers the basic principles of each of these techniques using some common clinical scenarios. The type of analgesia given will determine where labour takes place and this will be reflected in each case. Specifically, the World Health Organisation (WHO) analgesia ladder is not applicable in these patients because the periodic nature and the intensity of labour pain renders this model obsolete, although is applicable after delivery or after a caesarean section (CS) under general anaesthetic.     

Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women

BACKGROUND: The effect of intrapartum analgesia on post-partum maternal back and neck pain, headache and migraine, is uncertain. AIMS: To determine if nulliparous women having epidural analgesia during labour have a similar incidence of the above-mentioned post-partum symptoms compared with women managed using other forms of pain relief. METHODS: Secondary analysis of cohort data from a randomised trial in which nulliparous women intending to deliver vaginally were randomised to either epidural analgesia (EPI) or continuous midwifery support (CMS) at admission for delivery. Because of high cross-over rates, groups were initially defined by the randomised treatment allocation and the actual treatment received (CMS-CMS n = 185, EPI-CMS n = 117, EPI-EPI n = 376 and CMS-EPI n = 314). Univariate analysis showed no difference between groups, so final analysis was based on the actual treatment received. RESULTS: Six hundred and ninety women received epidural analgesia (EPIDURAL) and 302 received other methods of pain relief including CMS. Back pain was common before, during and after pregnancy, and risk factors for post-partum back pain at six months were back pain prior to pregnancy or at two months post-partum. Epidural analgesia, mode of delivery, spontaneous or induced labour, birthweight and back pain during pregnancy had no significant relationship with post-partum back pain at six months. Headache was significantly more common in the EPIDURAL group during pregnancy and at two months post-partum, but not at six months. Migraine was not associated with intrapartum analgesia. CONCLUSIONS: This analysis supports previous research suggesting that epidural analgesia is not a significant risk factor for persisting post-partum back pain, headache or migraine.     

A randomised double-blind comparison of epidural fentanyl versus fentanyl and bupivicaine for pain relief in the second stage of labour

OBJECTIVES: To compare the effectiveness of two different methods for epidural analgesia in the second stage of labour-fentanyl alone versus the usual mixture of bupivicaine and fentanyl. DESIGN: A double-blind, randomised, controlled trial. SETTING: An English maternity hospital. SAMPLE: Eighty nulliparous women in the second stage of labour. METHODS: After successful institution of epidural analgesia with a continuous infusion of bupivicaine/fentanyl mixture in the first stage of labour, the patients were randomised at full dilatation to receive either continuation of the same solution or a change to a fentanyl-only solution given at the same rate. MAIN OUTCOME MEASURES: Mode of delivery, duration of the second stage and quality of analgesia. RESULTS: There was no difference in the number of instrumental deliveries (30%vs 27.5%) or the duration of the second stage (141 vs 147 minutes) between the bupivicaine/fentanyl and fentanyl groups, respectively. The bupivicaine/fentanyl group demonstrated a lower need for rescue epidural analgesia (1 vs 6, RR 0.2, 95% CI 0.02-1.3) and significantly fewer high pain scores (11 vs 20, RR 0.6, 95% CI 0.3-1.0). CONCLUSION: Second stage epidural analgesia with fentanyl did not alter delivery outcomes or labour duration but resulted in poorer analgesia.     

Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups

Summary. The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour.     

Maternal and fetal effects of epidural analgesia during labour

We can state that an effective pain relief during labour, like epidural analgesia, is indicated and it prevents or modifies the pain-induced harmful effects on mother and the fetus. Maternal and fetal ACTH or BE response in labour are not altered, but the increase of maternal cortisol secretion is reduced, thus probably suggesting a lesser maternal stress, to which also point the changes of PRL. Epidural analgesia prevents harmful maternal metabolic changes like hyperventilation, hypocapnia, metabolic acidosis and lactic acid accumulation. These beneficial effects are also reflected in a better fetal and neonatal condition. Carbohydrate and fat metabolism, on the contrary, seem not to be significantly changed by epidural analgesia. Epidural analgesia is beneficial also by reducing the pain induced catecholamine release, and by improving the intervillous blood flow, especially in pre-eclamptic parturients.     

Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups

The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour.     

Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups

Summary. The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour.     

Update on best available options in obstetrics anaesthesia: perinatal outcomes,side effects and maternal satisfaction. Fifteen years systematic literature review

Purpose

In modern obstetrics, different pharmacological and non-pharmacological options allow to obtain pain relief during labour, one of the most important goals in women satisfaction about medical care. The aim of this review is to compare all the analgesia administration schemes in terms of effectiveness in pain relief, length of labour, mode of delivery, side effects and neonatal outcomes.

Methods

A systematic literature search was conducted in electronic databases in the interval time between January 1999 and March 2013. Key search terms included: “labour analgesia”, “epidural anaesthesia during labour” (excluding anaesthesia for Caesarean section), “epidural analgesia and labour outcome” and “intra-thecal analgesia”.

Results

10,331 patients were analysed: 5,578 patients underwent Epidural-Analgesia, 259 patients spinal analgesia, 2,724 combined spinal epidural analgesia, 322 continuous epidural infusion (CEI), 168 intermittent epidural bolus, 684 patient-controlled infusion epidural analgesia and 152 intra-venous patient-controlled epidural analgesia. We also considered 341 women who underwent patient-controlled infusion epidural analgesia in association with CEI and 103 patients who underwent patient-controlled infusion epidural analgesia in association with automatic mandatory bolus.

Conclusion

No significant differences occurred among all the available administration schemes of neuraxial analgesia. In absence of obstetrical contraindication, neuraxial analgesia has to be considered as the gold standard in obtaining maternal pain relief during labour. The options available in the administration of analgesia should be known and evaluated together by both gynaecologists and anaesthesiologists to choose the best personalized scheme and obtain the best women satisfaction. Since it is difficult to identify comparable circumstances during labour, it is complicate to standardize drugs schemes and their combinations.     

Pain relief in labour by transcutaneous electrical nerve stimulation (TENS)

For several years Transcutaneous Electrical Nerve Stimulation (TENS) has been used in the management of chronic and acute pain. The aim of this trial was to determine its effectiveness in providing pain relief during labour as well as its influence on the incidence of requests for epidural analgesia. The experimental group (receiving TENS by a burst – conventional obstetric TENS-apparatus) and the control population (not receiving TENS) consisted of 24 and 35 women respectively. In the experimental group the TENS application was switched off for a period of 15 min. The 24 women were asked to point out the intensity of their pain on a visual analogue scale before, during and after this temporary interruption. Two days postpartum the parturient’s satisfaction was evaluated by two questions, a procedure which revealed that 96% degree of satisfaction. The incidence of epidural analgesia in the experimental group was compared to the control-group. During TENS application the pain scores were significantly lower (p<0.0001), but no statistically significant difference in incidence of epidural analgesia was found between the experimental group and the control group. Received: 15 January 2000 / Accepted: 20 May 2000     

A comparison between the effectiveness of epidural analgesia and parenteral pethidine during labor

The study was aimed to define parturients' opinion on either epidural analgesia or intravenous pethidine, and to determine the effect of both analgesics after delivery. We interviewed and examined 401 consecutive parturients who requested analgesia during the beginning of their active stage of labor. Of those, 131 women requested and underwent epidural analgesia, and 270 received parenteral pethidine. The pain experienced before admission of any analgesia, was significantly higher in the epidural group than in the parental group (mean visual analog scale (VAS) score 8.9 and 8.4, respectively; P=0.004). However, after analgesics, women from the epidural analgesia experienced significantly less pain during labor as compared to those receiving pethidine (mean VAS scores 5.05 vs. 9.14, respectively; p<0.001). The pain scores 24 h after labor were significantly lower in patients who underwent epidural analgesia (1.69 vs. 2.13, respectively; p<0.001). We conclude that epidural analgesia is more effective than parenteral analgesia in pain and discomfort relief. This method is helpful also the day after delivery. Thus, epidural analgesia should be strongly recommended to all patients who do not have any medical contraindications to this method of treatment.     

Poor outcome following epidural abscess complicating epidural analgesia for labour

Abscess is a rare complication of epidural analgesia that may occur post-partum. A case is described where a lumbar epidural abscess initially presented with back and leg pain 7 days after seemingly uneventful block for labour and forceps delivery of twins. Definitive diagnosis of abscess was delayed until 5 days later when neurological sequelae became apparent. Despite surgical evacuation, recovery was delayed and incomplete. The importance of prompt diagnosis and the involvement of anaesthetic personnel are emphasised.     

Pain relief in maternity care and the role of the obstetric anaesthetist

Pain is a common and treatable symptom in all stages of pregnancy. All agents must be prescribed considering the perceived benefits whilst acknowledging the potential fetal adverse effects. Oral agents can be used safely and effectively during the antenatal period, and management must be tailored for each individual. Intrapartum analgesia should be multi-modal with consideration for complimentary therapies including continuous labour support and water immersion. Epidural anaesthesia is the gold standard for pain management in labour, with inhalation anaesthetic offering excellent adjunct analgesia. A combined spinal/epidural anaesthesia acts rapidly compared to traditional epidural. Pudendal nerve blocks are effective methods of analgesia with decreasing popularity. Transversus abdominis plane blocks and wound infiltration of local anaesthetic reduces post-operative requirement for opioids. The obstetric anaesthetist plays a significant role in the multidisciplinary team in identifying and planning care for high-risk individuals. Furthermore, anaesthetic intervention at the time of delivery is not infrequent and can be optimized.