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.     

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.     

Knowledge and decision-making for labour analgesia of Australian primiparous women

OBJECTIVE: to assess and investigate knowledge of labour pain management options and decision-making among primiparous women. DESIGN: a semi-structured guide was used in focus groups to gather pregnant women's knowledge concerning labour analgesia. Attitudes to labour and pain relief, knowledge of pain relief, trustworthiness of knowledge sources, and plans and expectations for labour pain relief were investigated. SETTING: a major tertiary obstetric hospital in metropolitan Sydney, Australia. PARTICIPANTS: twenty five primiparous women, who were 25 weeks or more gestation, and planning a vaginal birth. FINDINGS: although women considered themselves knowledgeable, they were unable to describe labour analgesic risks or benefits. There was a large discrepancy between perception and actual knowledge. The main source of knowledge was anecdotal information. Late in pregnancy was considered the ideal time to be given information about labour analgesia. Women described their labour pain relief plans as flexible in relation to their labour circumstances; however, most women wanted to take an active role in decision-making. KEY CONCLUSIONS: the large discrepancy between perceived knowledge and actual knowledge of the likely consequences of labour analgesia suggests that women rely too heavily on anecdotal information. IMPLICATIONS FOR PRACTICE: clinicians should be aware that some women overestimate their knowledge and understanding of analgesic options, which is often based on anecdotal information. Standardised labour analgesia information at an appropriate time in their pregnancy may benefit some women and assist health-care providers and women to practice shared decision-making.     

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.     

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.     

The effect of epidural analgesia on the occurrence of obstetric lacerations and on the neonatal outcome during spontaneous vaginal delivery

The aim of this study was to determine if epidural analgesia is associated with increased risk of obstetric lacerations during spontaneous vaginal delivery. Furthermore we assessed the effect of epidural analgesia on maternal and neonatal parameters. This multicenter study consisted of an analysis of data from the delivery databases of the University Hospital of Vienna and the Semmelweis Women's Hospital Vienna. This study was restricted to a sample that included all women with uncomplicated pregnancy, a gestational age >37(th) weeks and a pregnancy with cephalic presentation. Epidural analgesia was set during the first stage of labour. Techniques and management styles of epidural analgesia were the same in both hospitals. No statistically significant association was found between epidural analgesia and the occurrence of perineal tears (p=0.83), vaginal (p=0.37) or labial trauma (p=0.11). Furthermore the results demonstrated a statistically significant higher rate of primiparous women using epidural analgesia (p=0.001). A statistically significant prolonged second stage of labour was observed in women undergoing epidural analgesia (p=0.0001). Episiotomy was statistically significant more frequent in women requiring epidural analgesia (p=0.0001). Women who were treated with epidural analgesia were more likely to have labour augmented with oxytocin (p=0.001). No statistically significant differences in neonatal outcomes determined by APGAR score (p=0.84) and cord pH (p=0.23) were observed between the two groups. Women undergoing epidural analgesia demonstrated a prolonged second stage of labour, a higher rate of episiotomy and an increased use of oxytocin to augment labour. Some of these adverse effects might be caused by the higher rate of primiparous women using epidural analgesia. However, epidural analgesia showed no evidence of a detrimental effect on the integrity of the birth-canal in spontaneous vaginal delivery. In our opinion it is a save and effective method of pain relief during labour.     

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.     

Fetal oxygen saturation during epidural and paracervical analgesia

BACKGROUND: We wanted to assess changes in fetal oxygenation during maternal epidural or paracervical analgesia in labor. METHODS: A prospective, open and non-randomized study. Twenty healthy parturients were enrolled before they asked for pain relief. Informed consent was obtained. Fetal and maternal oxygen saturations were measured before and up to 1 h after the initiation of analgesia. Fetal oximetry was performed with the Nellcor N-400 oximeter+FS-14B fetal oxygen sensor (Nellcor Puritan Bennett, Pleasanton, California, USA). Maternal oximetry was done with Datex Satlite portable monitor (Datex, Finland). Visual analog scale was used for assessing pain relief. Two-way analysis of variance and students t-test were used for statistical analyses. RESULTS: Fetal oxygenation initially improved in both groups. The saturation then returned to baseline in both groups. In the epidural group, the values remained at baseline or slightly below, while in the paracervical group the saturation remained a little higher than baseline (p=0.009). No change was seen in maternal oxygenation or heart rate. No change in fetal heart rate was found either. Epidural block was superior to paracervical block with respect to pain relief (p=0.002). CONCLUSIONS: There was a small but significant difference in fetal oxygenation between epidural and paracervical groups during the observation period. The magnitude of the difference is hardly clinically significant. A larger, randomized study is needed to elucidate the mechanisms behind this finding.     

Lumbar epidural analgesia in labour. A clinical analysis.

Lumbar epidural block was given for pain relief to 296 women in labour. Bupivacaine was used as the analgesic agent and the technique is described in detail. Satisfactory analgesia was obtained in 92% of the cases during the first stage of labour and in 84% during the second stage of labour. The frequency of instrumental deliveries and of occipitio-posterior position increased but the clinical condition of the newborn seemed to be unaffected.     

A survey of parturients using epidural analgesia during labour. Considerations relevant to antenatal educators

The use of epidural analgesia (EA) during labour is increasing in Australasia. This highlights the need for improved educational and resource materials, current factual information about EA, and identification of consumer attitudes towards EA. In this survey, 350 parturients who had recently used EA for labour pain relief in a single maternity unit were asked to complete a questionnaire about their expectations and experience. The response rate was 90%. Prepartum information was most commonly derived from hearsay and least commonly from medical health professionals, 56% of respondents wanted pain to be made tolerable and 34% wanted complete pain relief. Almost half considered unrestricted mobility and delivery without obstetric assistance important. A minority were concerned about possible effects of EA on the baby or labour outcome. Anticipated pain during epidural placement was significantly greater than that experienced. Satisfaction with EA was high, although 36% described unpleasant or annoying effects associated with EA. Parent educators and epidural service providers should be aided by knowledge of where parturients obtain information and of consumer views about EA.     

Neurological complication after hip-flexed posture during labour with epidural analgesia

Obstetrical positioning is used more and more often because of the supposed or proven benefits although side effects are not well known. We therefore report the case of a patient who presented with a postpartum neurological deficit after a seven hour hip-flexed posture during labour under epidural analgesia. The parturient did not complain of pain or discomfort during labour. The neurological injury was suspected because of delayed recovery of epidural analgesia induced-motor block. Neurological examination disclosed sensory and motor abnormalities in the left femoral and sciatic nerve distribution areas. The early performed lumbar CT scan did not show any complication and electromyographic evaluation performed on the ninth postpartum day was normal. Three months after delivery, some degree of neuropathic pain in the sciatic nerve distribution remained. The risk of neurological injury directly related to obstetrical positioning is discussed. Prolonged positioning using a posture which can induce nerve stretching should be avoided. This is especially true when the patient is receiving epidural analgesia which can mask pain or discomfort.     

Diamorphine for pain relief in labour : a randomised controlled trial comparing intramuscular injection and patient-controlled analgesia

OBJECTIVES: To compare the efficacy of diamorphine administered by a patient-controlled pump (patient-controlled analgesia) with intramuscular administration for pain relief in labour. DESIGN: Randomised controlled trial. SETTING: The South Glasgow University Hospitals NHS Trust. SAMPLE: Primigravidae and multigravidae in labour at term (37-42 weeks). METHODS: Women were randomised in labour to the study (patient-controlled analgesia) or control group (intramuscular). Randomisation was achieved through a random permuted block design stratified by parity. Study group women were given a loading dose of 1.2 mg diamorphine intravenously and then attached to the pump. Control group women received intramuscular diamorphine as per hospital protocol. Participants were also given 3 mg of buccal Stemetil. Data were collected throughout labour and at six postnatal weeks. MAIN OUTCOME MEASURES: Analgesia requirements during labour and women's satisfaction with the method of pain relief. RESULTS: Women in the study group (patient-controlled analgesia) used significantly less diamorphine than women in the control group (intramuscular) but were significantly more likely to state that they were very dissatisfied with their use of diamorphine and were significantly more likely to opt out of the trial before the birth of the baby. The majority of women in both groups used other analgesia concurrent with diamorphine such as Entonox, aromatherapy or TENS. CONCLUSIONS: Patient-controlled analgesia administration of diamorphine for the relief of pain in labour offers no significant advantages over intramuscular administration. The results also suggest that diamorphine is a poor analgesic for labour pain irrespective of the mode of administration.     

Demand and utilisation of labour analgesia service by Nigerian women.

This study sought to determine the clinical correlates of the demand and utilisation of labour analgesia resources by Nigerian women in labour. All consenting women were interviewed on arrival at the Unit and while in labour. Biodata, options for relief of labour pain, request for analgesia, method of analgesia, VAS score and cervical score at time of request for analgesia were obtained. A total of 288 women in labour were studied. Of these, 108 (37.5%) patients were aware that the pain of labour can be relieved but only 26.0% had prenatal information on labour analgesia. However, 85.1% of the patients would want their pain of labour relieved. A total of 112 (38.9%) did receive analgesia during labour. Cervical dilatation of <4 cm at presentation to the Unit and nulliparity were likely factors for pain treatment during labour (p = 0.001, chi2 test). There is poor utilisation of labour analgesia services. Improved antenatal information on labour analgesia may boost the utilisation of these resources by Nigerian women in labour.     

A randomised controlled trial of epidural compared with non-epidural analgesia in labour

Objectives To investigate possible short and long term side effects of epidural analgesia, compared with non-epidural analgesia for pain relief in labour.
Design Randomised controlled study, with long term follow up by questionnaire. Analysis by intention-to-treat.
Setting Busy maternity unit within a district general hospital in England.
Participants Three hundred and sixty nine primigravid women in labour were included (randomised allocation: epidural   n = 184  , non-epidural   n = 185  ).
Main outcome measures Backache at three and twelve months after delivery, instrumental delivery rates and maternal opinion of pain relief in labour.
Results No significant differences were found in the reported incidence of backache between the groups at three months: middle backache [  22% vs 20%, χ ²= 0.057, P = 0.81; odds ratio (95% CI) 1.4(0.9-2.3)  ]; low backache [  35% vs 34%, χ ²= 0.009, P = 0.92  ; odds ratio  (95% CI) 1.0(0.6-1.6)  ]. Nor were there significant differences at 12 months: [middle backache 16% vs 16%,   χ ²= 0.013, P = 0.91; odds ratio (95% CI) 1.0(0.5-1.8)  ]; or low backache [  35% vs 27%, χ ²= 1.91, P = 0.17; odds ratio (95% CI) 1.4(0.9-2.3)  ]. The incidence of instrumental delivery was somewhat higher in the epidural group [30% vs 19%, odds ratio (95% CI) 1.77 (1.09-2.86)]. Maternal satisfaction was not significantly different between the groups.
Conclusions This study provided no evidence to support the suggestion of a direct association between the use of epidural anaesthesia in labour and the incidence of long term backache. Despite a significant proportion of women in each group not receiving their allocated analgesia, a significant difference in terms of instrumental delivery rates remained. Satisfaction in both groups of women was high.     

Patient-controlled analgesia in obstetrics and gynecology

Patient-controlled analgesia, which provides pain relief through self-administration of intravenous doses of opioids, is widely available and advocated as an effective analgesic modality. This report reviews published experiences with patient-controlled analgesia during labor and after cesarean delivery or major gynecologic surgery. Currently employed devices allow accurate record-keeping of drug use and permit patient mobility. No one device has been shown to be preferable. The form of administration most commonly described is infusion of morphine or meperidine on demand without combined continuous basal infusion. During labor, brief but progressively intensifying episodes of pain undermine the effectiveness of these devices when used intravenously. Compared with intramuscular administration of narcotics, patient-controlled analgesia after cesarean or major gynecologic surgery has been judged by patients to be more acceptable in achieving a balance between tolerable pain and sedation. Respiratory depression has been rare and is often attributable to misprogramming. Costs of these devices can be justified with frequent usage and are at least partially offset by more efficient use of nursing personnel for pain management.     

The effects of pain and its management on mother and fetus

Childbirth is frequently accompanied by pain. For religious, cultural and philosophical reasons many groups have sought to prevent treatment of pain. Pain may have adverse effects on the mother and fetus. The psychological effects of severe pain should not be overlooked particularly where it is associated with an adverse fetal or maternal outcome. There are a number of different forms of pain relief in labour with differing side-effects and efficacies. The controversy concerning medical management of women in labour has been used to dissuade women from requesting pain relief. This debate has encouraged the use of a patient-centred philosophy of care that encourages the patient to retain control. However, good pain relief may allow the women to retain control if administered in a sensitive manner. The ideal analgesic in labour is discussed. Recent and future developments of analgesia in childbirth are discussed with respect to this.     

Epidural analgesia in primigravidae in spontaneous labour at term: a prospective study

OBJECTIVES: To prospectively study the intervention rate, duration of labour, malpositions, fetal outcome, maternal satisfaction, voiding complications and adverse events in healthy primigravidae in spontaneous labour at term following epidural analgesia. METHODS: A prospective randomized study involving 55 patients in the epidural group and 68 in the control pethidine--inhalational entonox group. RESULTS: There were significantly more obstetric interventions (instrumental deliveries) in the epidural group (p < 0.01). The total duration of labour and the duration of the second stage was prolonged in the epidural group (p < 0.01). There were more malpositions at the second stage of labour in the epidural group (p < 0.02). There were no differences in fetal outcome (Apgar scores and Special Care Nursery admissions). Patients in the epidural group were consistently happier with their method of pain relief (p < 0.01). Two patients required blood patches while another 2 patients had persistent backache post epidural analgesia. CONCLUSION: Epidural analgesia in primigravidae in spontaneous labour at term led to an increased instrumental delivery rate, prolonged duration of labour, greater rate of malpositions in the second stage, increased oxytocin requirements but with no difference in fetal outcomes but with happier mothers as compared to the control group.     

Intramuscular opioids for maternal pain relief in labour: a randomised controlled trial comparing pethidine with diamorphine

Objective To compare the pain relief and side effects of intramuscular pethidine with intramuscular diamorphine in labour.
Design Double-blind randomised controlled trial.
Setting The labour ward in a UK teaching hospital.
Participants Sixty-nine nulliparous women and 64 multiparous women in labour who requested narcotic analgesia and remained undelivered one hour after trial entry.
Methods Nulliparous women were randomised to receive either 150 mg intramuscular pethidine or 7–5 mg intramuscular diamorphine. Multiparous women were randomised to receive either 100 mg intramuscular pethidine or 5 mg intramuscular diamorphine. All participants received the anti-emetic prochloroperazine at the same time as the trial drugs.
Main outcome measures Maternal analgesia assessed by a visual analogue score and verbal scales of pain intensity and pain relief, maternal sedation and vomiting, neonatal outcome assessed by Apgar scores and the need for resuscitation.
Results More women allocated to receiving pethidine than to diamorphine reported slight or no pain relief at 60 minutes after administration of these drugs (   P = 0.03  ). This trend was repeated in most of the other measures for maternal analgesia. There was no difference in maternal sedation, but the incidence of vomiting within 60 minutes was lower for women who received diamorphine (   P = 0.02  ). Pethidine was associated with lower Apgar scores at 1 minute (   P < 0.05  ).
Conclusion Intramuscular diamorphine in labour appears to have some benefits, compared with intramuscular pethidine, but the trial was small and further research, particularly into alternative opioids and long term effects on the infants is still needed.     

Intramuscular opioids for maternal pain relief in labour: a randomised controlled trial comparing pethidine with diamorphine.

OBJECTIVE: To compare the pain relief and side effects of intramuscular pethidine with intramuscular diamorphine in labour. DESIGN: Double-blind randomised controlled trial. SETTING: The labour ward in a UK teaching hospital. PARTICIPANTS: Sixty-nine nulliparous women and 64 multiparous women in labour who requested narcotic analgesia and remained undelivered one hour after trial entry. METHODS: Nulliparous women were randomised to receive either 150 mg intramuscular pethidine or 7.5 mg intramuscular diamorphine. Multiparous women were randomised to receive either 100 mg intramuscular pethidine or 5 mg intramuscular diamorphine. All participants received the anti-emetic prochloroperazine at the same time as the trial drugs. MAIN OUTCOME MEASURES: Maternal analgesia assessed by a visual analogue score and verbal scales of pain intensity and pain relief, maternal sedation and vomiting, neonatal outcome assessed by Apgar scores and the need for resuscitation. RESULTS: More women allocated to receiving pethidine than to diamorphine reported slight or no pain relief at 60 minutes after administration of these drugs (P = 0.03). This trend was repeated in most of the other measures for maternal analgesia. There was no difference in maternal sedation, but the incidence of vomiting within 60 minutes was lower for women who received diamorphine (P = 0.02). Pethidine was associated with lower Apgar scores at 1 minute (P < 0.05). CONCLUSION: Intramuscular diamorphine in labour appears to have some benefits, compared with intramuscular pethidine, but the trial was small and further research, particularly into alternative opioids and long term effects on the infants is still needed.     

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.