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Original Research 


Alansari, 2018;2(3):86–91.

International Journal of Medicine in Developing Countries

Epidural analgesia and progress of labor, a retro and prospective study

Meaad Adel Alansari

Correspondence to: Meaad Adel Alansari

Royal Medical Services, Bahrain Defense Forces Hospital, Manama, Bahrain

Email: meaad.alansari@gmail.com

Full list of author information is available at the end of the article.

Received: 18 May 2018 | Accepted: 2 June 2018


ABSTRACT

Background:

Pain during labor is a severe pain that women experiences. Epidural analgesia is used to relieve this pain. As epidural showed efficacy and safety, it became the standard of care. However, there are conflicts regarding its influence on neonates, time of delivery, and other outcomes.


Methodology:

This prospective study included 100 females who were divided into two groups, the control and the epidural group, each of which had 50 females. The data about women, instruments used, and the recordings were collected, interviews were taken, and their opinions were investigated by survey.


Results:

There were significant differences regarding several side effects including; nausea (P-value = 0.02), itching (P-value < 0.001), shivering (P-value = 0.006), backache (P-value = 0.006), and sedation (P-value = 0.03). The higher mean of duration of stage 2 was significantly (P-value < 0.001) associated with the epidural group, appearance, pulse, grimace, activity.


Conclusion:

Epidural analgesia was associated < with few adverse effects and increased the duration of the second stage of labor. It had no effects on neonate and caused no post-delivery events which reflect its safety.


Keywords:

Epidural analgesia; Pain relief; Neonate outcomes; Maternal outcomes.

Introduction

Delivery pain is one of the most severe types of pain experienced by females in her lifetime [1]. For a long time, it was known that there were several adverse changes in the physiology and biochemistry of the mother resulting from painful labor, these changes can also influence the baby [2]. Epidural analgesia was evolved as the standard of care for relieving pain during pregnancy as it has few complications and it was found to be safe [1]. Epidural analgesia is a strategy that depends on central nerve blockage of painful impulses generated during labor, it is given by injection of local anesthetic into the lower region of the spine [3]. The epidural analgesia induces changes in mothers which also have impact on the baby, these changes include beneficial effects such as reduced hyperventilation, maternal stress hormones, and uterine vasodilatation [46], it also results in adverse events such as fever, prolonged labor and delivery, hypotension, instrumental delivery, and increased need for oxytocin [7,8]. Epidural analgesia was found to relieve pain during delivery and labor [7,9] effectively. Also, it was found that labor analgesia resulted in higher maternal satisfaction and lower pain [9]. However, a controversy exists regarding the impact of epidural analgesia on labor progression, neonates, and mode of delivery [10]. A study by Gizzo et al. [11] demonstrated that epidural analgesia did not affect the neonatal outcome and had little effect on the trend of labor. Another study found that epidural analgesia resulted in slow labor progression and indirectly adversely influenced the neonate outcomes [12]. The present study aims to assess the effect of epidural analgesia on the labor progression as well as its outcome regarding mother and neonate.

Subjects and Methods

This study is a retro and prospective study that was conducted in Bahrain Defense Force Hospital. The study included all female obstetric patients with and without epidural analgesia while those with chronic pain were excluded. The participants were divided into two groups each included 50 females, the first group (group A) included female obstetric patients with epidural analgesia using an infusion of bupivacaine 0.065% with fentanyl 2 micrograms/ml in normal saline if patient is <3cm dilated or Primigravida and bupivacaine 0.08% with fentanyl 2 micrograms/ml in normal saline if patient is > 3cm dilated or multigravida, the infusion was performed by slow injection of 10–20 ml of the usual initial dose followed by a continuous dose of 5–20 ml per hour if necessary. The other group (group B) was the control group which included female obstetric patients without epidural analgesia. The data about females, instruments used, and the recordings were collected; then, interviews were taken from all female subjects of the study.

An excel sheet was used to record the data. It was analyzed by using Statistical Package for Social Sciences (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. T-test was used for continuous variables.

Results

The present study included two groups; group A which administrated epidural analgesia and group B as the control group, each group included 50 females. The characteristics of the two groups are shown in Table 1. Regarding age, there was a significant difference between the two groups (P-value = 0.03), where the mean age of the epidural group was higher (28.5) than that of the control group (27.6). There was no significant difference between the two groups regarding Body mass index (BMI) and parity, whereas the mean of gravidity (3.5) and gestational age (38.9) of the control group were significantly (P-value = 0.007, 0.001, respectively) higher than that of the epidural group (2.3, 38.2 for gravidity and gestational age, respectively). 20% of the control group had suffered previous abortion, while no one from the epidural group had a history of abortion (P-value = 0.001). The range of cervical dilation of the epidural group was 2–5 cm with a mean of 3.4 ± 1 and the majority 74% had a 3–4 level of puncture. The vast majority of the control group (96%) didn’t have history of epidural analgesia (P-value < 0.001).

Side effects were investigated in both groups; the prevalence and comparison between these side effects among the two groups are shown in Table 2. Females in control group significantly suffered nausea (24%) and sedation (26%) (P-value = 0.02, 0.03, respectively), while itching (100%), shivering (16%), and backache (16%) were significantly more common among females of epidural group (P-value = 0.001, 0.006, 0.006, respectively).

The epidural analgesia did not influence delivery; there were no significant differences between the two groups regarding the need for oxygen (P-value = 0.6), oxytocin (P-value = 0.05), or delivery mode (normal/emergency/cesarean) (P-value = 0.3), Figure 1.

Table 1. Comparison between both groups regarding essential characteristics.

Characteristics Group A (n = 50) Group B (n = 50) P value
Age
Range 22–35 19–45
Mean ± SD 28.5 ± 4.3 27.6 ± 8.5 0.038*
BMI
Range 22.6–36.5 24–45.2
Mean ± SD 29.4 ± 4.5 30.1 ± 4.5 0.717
Gravidity
Range 1–6 1–8
Mean ± SD 2.3 ± 1.6 3.5 ± 2.3 0.007*
Parity
Range 0–5 0–7
Mean ± SD 1.3 ± 1.6 2 ± 2 0.118
History of previous abortion 0 (0) 10 (20) 0.001*
Gestational age
Range 37–41 36–40
Mean ± SD 38.2 ± 0.9 38.9 ± 1.3 0.001*
Cervical dilatation/cm
Range 2–5
Mean ± SD 3.4 ± 1
Level of puncture
3–4 37(74%)
4–5 13(26%)
Previous Labor with epidural anesthesia
Yes 25(50%) 2(4%) <0.001
No 25(50%) 48(96%)

*Significant values

Regarding stage1 duration, the mean in epidural group was 7.3 ± 4.3 hours, while in control group the mean time was 5.8 ± 3.6 hours, there was no significant difference between the two groups; however, regarding stage 2 there was a significant difference between the two groups (P-value < 0.001), the mean duration (19.1 ± 16.8) for epidural group was more than that of control group (8.1 ± 4.3). Regarding neonatal outcome, there was a significant difference regarding appearance, pulse, grimace, activity, and respiration (APGAR) score at 1 and 5 minutes (P-value = 0.003, 0.01, respectively), all participants of control group scored 9 at 1 minute, also at 5 minute the vast majority of the control group (88%) scored 9. Half of the females in the epidural group did not have any post-delivery events; there was a significant difference between the two groups (P-value = 0.02). Also, there were significant differences among the two studied groups regarding the experience of labor that was worse than expected (P-value = 0.007) and as expected (P-value = 0.005), control group tended to find it worse than expected (34%), whereas epidural group tended to find it as expected (32%). Regarding labor pain, there was a significant difference between the two groups (P-value < 0.001), the majority of females (82%) in the epidural group were entirely in control significantly (P-value = 0.009), while 20% females in the control group did not feel control at all (P-value = 0.001). Most females in epidural group (90%) were sick during labor (P-value = 0.03). There were significant differences regarding the degree of being sleepy during labor among the two groups, the majority of epidural group (84%) weren’t sleepy at all (P-value < 0.001), while some females in the control group were little sleepy (34%) and some felt a lot sleepy (36%) (P-value = 0.003, 0.001, respectively), Table 3 summarizes the comparison between the two groups regarding different outcomes.

Discussion

In the present study, two groups were included; the control group in which females did not administer epidural analgesia and the epidural group in which females were given epidural analgesia. Regarding characteristics of participants, there were significant differences between the two groups regarding age (P-value = 0.03), gravidity (P-value = 0.007), history of abortion (P-value = 0.001), and gestational age (P-value = 0.001). The epidural group had a high mean age than the control group, whereas the control group had a higher mean of gravidity, gestational age and 20% of them had a history of abortion and only 4% had have previous epidural analgesia. Previous studies [1113] demonstrated that there were no significances between epidural and control group regarding maternal age and gestational age. By studying the side effects that may result from epidural analgesia, it was found that five side effects significantly differed among control and epidural groups. It was found that itching, shivering, and backache was significantly associated with administrating epidural analgesia, while nausea was more prevalent in the control group and significantly associated with no analgesia. A previous study showed that hypotension and compensatory tachycardia occurred in 2% of the patients, while no other adverse effects were observed [1]. In stage 1, there was no significant difference between the two groups and the role of epidural analgesia was absent; however, in stage 2, the mean time for the epidural group was significantly (P-value < 0.001) higher than that of control group. The epidural analgesia resulted in increased duration in the second stage of labor. Two previous studies revealed that there was no significant difference in the mean duration of first and second stage among the epidural and the control group [1,13]. Reynolds et al. [14] demonstrated that there was no adverse impact of epidural analgesia on fetal oxygen. Another study showed that oxytocin use did not differ between control and epidural groups as well as the mode of delivery [13]. In one study [12], it was concluded that epidural analgesia resulted in slow labor progression. In contrast to our findings, it was found in Nigerian study [15] that duration of first and second stage was significantly different among epidural and control groups, with increased mean duration in control group regarding the two stages. Regarding outcome, the birth weight did not differ significantly between the two groups (P-value = 0.4). Females in epidural groups had no post-delivery events significantly (P-value = 0.02). The experience of labor was significantly (P-value = 0.007) worse than expected in the control group, whereas it was significant (P-value = 0.005) as expected for the epidural group. Regarding pain, the control group remembered the pain significantly (P-value < 0.001). The large majority of females in the epidural group didn’t feel sleepy at all significantly, whereas the control group significantly felt sleepy by different degrees. In agreement with our findings, there were two studies [11,12] that found out that the neonate body weight did not differ between the two groups. The APGAR score and neonates outcome were found to be similar among epidural and control group in one study. However, the first stage of labor lasted for a significantly longer time in the epidural group [12]. Another study demonstrated that APGAR score did not differ among the two groups; one which administered epidural analgesia and the other which did not [13]. Nigerian study [15] revealed that post-delivery events did not differ between their two studied groups, 80% of the epidural group had experience of labor better than expected, while more females in control group remembered the pain and felt sleepy.

Table 2. Comparison between the two groups regarding side effects.

Side effects Group A (n = 50) Group B (n = 50) P value
Nausea 4 (8) 12 (24) 0.029*
Itching 50 (100) 5 (10) <0.001*
Shivering 8 (16) 0 (0) 0.006*
Urinary retention 46 (92) 45 (90) 0.727
Hypotension 0 (0) 0 (0) …..
Backache 8 (16) 0 (0) 0.006*
Dural puncture 0 (0) 0 (0) …..
Headache 0 (0) 0 (0) …..
Vomiting 0 (0) 0 (0) …..
Sedation 4 (8) 13 (26) 0.031*
Fetal bradycardia 0 (0) 0 (0) …..
Pruritus 4 (8) 0 (0) 0.117
Rigors 0 (0) 0 (0) …..
Pyrexia 0 (0) 0 (0) …..
Ringing in the ears 0 (0) 0 (0) …..

*Significant values

Figure 1. Comparison between both groups regarding the effect of epidural on delivery.

Table 3. Comparison between the two groups regarding different outcomes.

Outcomes Group A (N = 50) Group B (N = 50) P-value
Birth weight
Range 2.6–3.8 2.6–3.8 0.456
Mean ± SD 3 ± 0.3 3 ± 0.4
APGAR score At 1 minute
7 9 (18) 0 (0) 0.003
9 41 (82) 50 (100)
APGAR score At 5 minutes
9 34 (68) 44 (88) 0.016
10 16 (32) 6 (12)
Post-delivery events 0 (0) 4 (8) 0.117
Retained placenta 25 (50) 33 (66) 0.156
Episiotomy 25 (50) 13 (26) 0.023
No events
The overall experience of labor
Worse than expected 5 (10) 17 (34) 0.007
As expected 16 (32) 4 (8) 0.005
Better than expected 29 (58) 29 (58) 1.000
How much of the labor pain do you remember?
Nothing 41 (82) 4 (8) <0.001
Some 4 (8) 23 (46) <0.001
Everything 5 (10) 23 (46) <0.001
Did you feel in control
Not at all 0 (0) 10 (20) 0.001
Some control 9 (18) 12 (24) 0.624
Completely in control 41 (82) 28 (56) 0.009
Were you actually sick during labor?
Yes 5 (10) 13 (26) 0.037
No 45 (90) 37 (74)
How sleepy are you during labor?
Not at all 42 (84) 15 (30) <0.001
A little 4 (8) 17 (34) 0.003
A lot 4 (8) 18 (36) 0.001
Where you worried about the effect of The pain relief on your baby?
Not worried 50 (100) ……
Somewhat worried 0 (0) ……
Extremely worried 0 (0) ……
How would you grade pain relief during labor?
Adequate 46 (92)
Not adequate 4 (8)
Not sure 0 (0)

Conclusion

Epidural analgesia was associated with few adverse effects including itching, shivering, and backache; also, it increased the duration of the second stage of labor. It had no effects on neonate and caused no post-delivery events.

Acknowledgement

None.


Disclosure statement

None.


List of Abbreviations

APGAR Appearance, pulse, grimace, activity, and respiration


Funding

None.


Declaration of conflicting interests

None.


Consent for publication

Informed consent form was taken from the participant prior to the study.


Ethical approval

Approval was obtained from Bahrain Defense Force Hospital Research Center.


Author details

Meaad Adel Alansari

  1. Royal Medical Services, Bahrain Defense Forces Hospital, Manama, Bahrain

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How to Cite this Article
Pubmed Style

Meaad Adel Alansari. Epidural analgesia and progress of labor, a retro and prospective study. IJMDC. 2018; 2(3): 86-91. doi:10.24911/IJMDC.51-1526648801


Web Style

Meaad Adel Alansari. Epidural analgesia and progress of labor, a retro and prospective study. http://www.ijmdc.com/?mno=299562 [Access: November 21, 2018]. doi:10.24911/IJMDC.51-1526648801


AMA (American Medical Association) Style

Meaad Adel Alansari. Epidural analgesia and progress of labor, a retro and prospective study. IJMDC. 2018; 2(3): 86-91. doi:10.24911/IJMDC.51-1526648801



Vancouver/ICMJE Style

Meaad Adel Alansari. Epidural analgesia and progress of labor, a retro and prospective study. IJMDC. (2018), [cited November 21, 2018]; 2(3): 86-91. doi:10.24911/IJMDC.51-1526648801



Harvard Style

Meaad Adel Alansari (2018) Epidural analgesia and progress of labor, a retro and prospective study. IJMDC, 2 (3), 86-91. doi:10.24911/IJMDC.51-1526648801



Turabian Style

Meaad Adel Alansari. 2018. Epidural analgesia and progress of labor, a retro and prospective study. International Journal of Medicine in Developing Countries, 2 (3), 86-91. doi:10.24911/IJMDC.51-1526648801



Chicago Style

Meaad Adel Alansari. "Epidural analgesia and progress of labor, a retro and prospective study." International Journal of Medicine in Developing Countries 2 (2018), 86-91. doi:10.24911/IJMDC.51-1526648801



MLA (The Modern Language Association) Style

Meaad Adel Alansari. "Epidural analgesia and progress of labor, a retro and prospective study." International Journal of Medicine in Developing Countries 2.3 (2018), 86-91. Print. doi:10.24911/IJMDC.51-1526648801



APA (American Psychological Association) Style

Meaad Adel Alansari (2018) Epidural analgesia and progress of labor, a retro and prospective study. International Journal of Medicine in Developing Countries, 2 (3), 86-91. doi:10.24911/IJMDC.51-1526648801