Rate, Complications, and Satisfaction of Epidural Analgesia among the Parturient Population

By Sami Ur Rehman¹, Aleena Kashif¹, Arshad Taqi¹, Abdul Rehman², Affan Ahmad Khan¹, Maryam Inayat¹

Affiliations

1. Department of Anaesthesia (Kaul Associates), Doctors Hospital and Medical Centre, Lahore, Pakistan
2. Department of Urology, Combined Military Hospital, Lahore, Pakistan

doi: 10.29271/jcpsp.2025.08.1054

ABSTRACT
Objective: To determine the rate of labour epidural insertion, complications, and satisfaction among the parturient population admitted to the Department of Gynaecology, Doctors Hospital and Medical Centre, Lahore, Pakistan.
Study Design: A clinical audit.
Place and Duration of the Study: Maternity Unit, Doctors Hospital and Medical Centre, Lahore, Pakistan, from January 2021 to December 2023.
Methodology: A total of 242 parturient patients underwent parturition from January 2021 to December 2023. Exclusion criteria included patients who presented for emergency caesarean sections, had not given consent, as well as those with an elective caesarean section plan and with bleeding diathesis or coagulation disorders. Data were collected manually and then presented in the form of frequencies (percentages) in a tabulated form in the Microsoft Word Office 365. All collections were done manually.
Results: A total of 123 epidurals were administered during the study period. The epidural rate was 50.82% in this study, which is comparable to the rate in developed countries. There were no major complications such as death or respiratory distress. However, the minor complication rate was 14.6%, with the most common being hypotension, followed by shivering, dural tap, blood tap, and post-dural puncture headache.
Conclusion: The labour epidural rate can be improved with a collaborative approach between the anaesthetist and the gynaecologist to disseminate the required knowledge to the labouring population.

Key Words: Epidural analgesia, Dural tap, Blood tap, Post-Dural puncture headache, Maternal satisfaction.

INTRODUCTION

Labour pain is a severe pain, which has been described as being more intense than cancer pain or having amputation of a digit without anaesthesia.^1,2 Pain causes the sympathetic nervous system to release catecholamines and may have delirious effects on maternal physiology, especially in women with cardiac pathologies, as well as reducing the placental blood flow, with resultant foetal hypoxia and acidosis.^3,4 Pain also stimulates the respiratory drive, which results in an increased respiratory rate and a more respiratory alkalosis in the mother’s blood. This leads to a left side shift of oxygen dissociation curve, thereby impairing oxygen delivery to the foetus.⁵ Labour pain, if untreated, can have detrimental psychological effects leading to post-traumatic stress disorder, with subsequent effects on maternal well-being and maternal-foetal bonding.^6,7
 

There are two components of labour pain: Somatic and visceral pain. Visceral pain is carried by C-fibres associated with T10-L1 spinal nerves, and this pain is dull in character and is felt in the lower abdomen, sacrum, and back. The somatic pain is carried by A-delta fibres to S2-S4 nerve roots, and this pain is sharp in character and is localised to vagina, rectum, and perineum.

Lumbar epidurals are the gold standard for pain relief in labouring women.¹ In the absence of medical contraindications, maternal request is a sufficient medical indication for pain relief. In the USA and UK, the rate of labour epidurals is 61 and 49.3%, respectively.^8,9 In China, it was less than 1% in 2007, and this had increased to 50% in some hospitals following the No Pain Labour and Delivery Initiative. A collaborative approach is required between an anaesthetist and an obstetrician to disseminate the appropriate knowledge related to epidural analgesia.¹⁰

Labour epidurals are associated with an increase in the duration of the second stage and an increased risk of instrumental vaginal delivery.^11,12 They are the commonest cause of intra-partum pyrexia, which is strongly associated with poor neonatal outcome in the form of neonatal encephalopathy and cerebral palsy.¹³ Maternal hypotension in these circumstances is usually associated with aorto-caval compression. The complication rate after epidural analgesia was 0.6 per 100,000 cases in an audit by the Royal College of Anaesthetists in 2009 and less than 5 in 10,000 cases in an audit in France.^14,15

This audit was done in the Doctors Hospital and Medical Centre, Lahore, Pakistan, to find the rate, complications, and satisfaction of epidural insertion and to compare the results of this audit with the audits done worldwide.

METHODOLOGY

This retrospective, descriptive study was done in the Maternity Unit of Doctors Hospital and Medical Centre, Lahore, Pakistan, from January 2021 to December 2023. A total of 123 epidurals were administered during this period.

Study variables that were measured included the total number of women in labour, number of epidural analgesia procedures, patient demographics, indications, complications, epidural technique, anaesthesiologist’s experience, and patient satisfaction. After obtaining the approval from the Ethical Committee of the hospital, data were collected from epidural registers of the anaesthesia department and the labouring patients' monthly audit registers of the gynaecology department. All parturient patients who were inserted with epidural catheters for normal vertex delivery were included. Exclusion criteria include patients who presented for emergency caesarean sections, who did not give consent, those with an elective caesarean section plan, and those with bleeding diathesis or coagulation disorders.

Data were collected manually and then presented in the form of frequencies (percentages) in a tabulated form in Microsoft Word Office 365.

RESULTS

During the study period, 885 patients were managed for labour and delivery at the Department of Gynaecology, Doctors Hospital and Medical Centre, Lahore, Pakistan. Normal vertex deliveries and caesarean sections accounted for 242 and 643 of deliveries, respectively. A total of 123 epidurals were administered during this period. Data from all 123 patients were retrieved.

The mean age of patients was 28.5 years. The gravida status of patients was as follows: Primigravida (67, 54.4%), followed by Gravida-1 patients (19, 15.44%), Gravida-2 (22, 17.88%), Gravida-3 (10, 8.13%), and Gravida-4 (15, 12.19%). All of the epidurals were administered by a consultant anaesthetist. All epidurals were administered by midline approach (123, 100%), using different gauge epidural catheters, most common being 18G (104, 84.55%), followed by 16G and 20G (2, 1.62% each). Loss of resistance technique to air was used in 102 (82.92%) patients, and loss of resistance to saline was used in 21 (17.07%) patients. The most common space for epidural insertion was L3-L4, followed by L2-L3. One hundred and twelve (91.05%) epidurals were administered in sitting position and 11 (8.94%) in lateral position.

The complications encountered during labour analgesia were shivering (8, 6.5%), headache (2, 1.62%), dural tap (1, 0.81%), blood tap (1, 0.81%), and hypotension (3, 2.43%). One patient had severe hypotension following an epidural dose, which was managed by giving intravenous fluid boluses, and the patient was discharged a day later (Figure 1).

Table  I:  Demographics  and  details  of  labour  epidurals  in  this  study.

Variables	n, (%)
Demographics
Total deliveries	242
Total caesarean sections	643
Total epidurals performed	123
Epidural records retrieved	123
Gravida status of parturients who were inserted epidurals
Primigravida	67 (54.4%)
Gravida-1	19 (15.44%)
Gravida-2	22 (17.88%)
Gravida-3	10 (8.13%)
Gravida-4	15 (12.19%)
Professional designation / experience of anaesthesia individual
Consultant	123 (100%)
Postgraduate trainee	Nil
Medical officer	Nil
Epidural technique
Loss of resistance to saline	21 (17.07%)
Loss of resistance to air	102 (82.92%)
Drop technique	Nil
Epidural approach
Median	123 (100%)
Para-median	Nil
Position
Sitting	112 (91.05%)
Lateral	11 (8.94%)
Complications
Blood tap	1 (0.81%)
Dural tap	1 (0.81%)
Hypotension	3 (2.43%)
Shivering	8 (6.5%)
Motor block / paresis	Nil
Nausea / vomiting	1 (0.81%)
Numbness	2 (1.62%)
Pruritus	Nil
Pyrexia	Nil
Headache	2 (1.62%)
No complication	105 (85.3%)
Patient reported efficacy
Excellent	54 (43.9%)
Good	39 (31.70%)
Satisfactory	15 (12.19%)
Somewhat satisfactory	Nil
Unsatisfactory	Nil
Not recorded	15 (12.19%)
Mode of delivery
Caesarean section	11 (8.94%)
Normal vertex delivery	112 (91.05%)

Figure 1: Complications in patients who were inserted labour epidurals for  analgesia

Figure  2:  Patient's  satisfaction  with  labour  epidural  analgesia.

Regarding patients’ satisfaction scores, 54 (43.9%) were recorded as excellent, 39 (31.70%) as good, and 15 (12.19%) as satisfactory. Satisfaction level was not recorded in 15 (12.19%) cases (Figure 2). The results are summarised in Table I.

DISCUSSION

The rate of labour epidurals in this study was 50.82%, comparable to the labour epidural rates of 61% and 49.3% from the USA and the UK, respectively. Data from India show an audit rate of 11%.¹⁶ There are multiple reasons for the low labour epidural rates, including the smaller number of anaesthetists available, less education regarding epidural analgesia among the labouring population, and the cultural myths about labour epidurals. There is also a perception among the general population that labour epidurals increase the chances of caesarean sections, although the literature has the opposite take on it.¹⁷

Maternal request is the biggest indication of labour epidural in the absence of any contraindications. In this study, the most common indication was primigravida, which is in concordance with the recommendations of the American Society of Anesthe- siologists (ASA) and the American Society of Obstetrics and Gynaecology (ASOG).

The technique for identifying the epidural space was loss of resistance to air or saline, depending on the anaesthesiologist performing the procedure. One study showed that the loss of resistance to saline has better analgesia and less morbidity.¹⁸ Another study showed no significant difference in block success between the two techniques.¹⁹

Low dose local anaesthetic and opioid mixture — typically 10–15 ml of 0.1% bupivacaine or ropivacaine with 2 µg/ml fentanyl — were mostly used in the maternity units included in this study. However, each hospital follows its own institute- based labour analgesia protocols. Low-dose mixtures are considered to provide excellent analgesia while preserving motor function, with the mother to mobilise during labour or deliver without assistance.¹¹ Ropivacaine is generally preferred due to its lower cardiotoxicity and reduced motor blockade.

Major complications such as death, paraplegia, cardiac arrest, respiratory depression, seizures, and meningitis are very rare. There were no major complications during this study.

The minor complication rate was 14.6%. It included hypotension (2.43%), shivering (6.5%), dural tap (0.81%), blood tap (0.81%), headache (1.2%), and nausea (0.81%). These results are in accordance with a study conducted in Australia that showed 4.9% incidence of hypotension and 0.6% unintentional dural puncture.²⁰ The incidence of hypotension and headache was 0.73% and 0.49% in a study conducted in the USA.²¹

There was no documentation regarding the patient follow-up after the removal of the epidural catheter. Therefore, a proper patient follow-up within 24 hours and after 24 hours is recommended to maintain accurate records of the patients’ satisfaction and pain control.

A high level of patient satisfaction has been demonstrated in previous audits conducted worldwide.²² In the current audit, 54 patients reported their experience as excellent, 39 as good, and 15 as satisfactory; however, with no data were not documented in 15 cases. The undocumented number is big, and stringent protocols are needed to improve the documentation of patients’ satisfaction.

The first limitation of this study is the inclusion of patients who were on the elective list for caesarean sections, as these patients were not in labour and therefore were not a candidate of labour epidural. The second limitation is the lack of adequately completed epidural records.

CONCLUSION

The labour epidural rate in this study is comparable to the rate in developed countries. This labour epidural rate can be improved with a collaborative approach between the anaesthetist and the gynaecologist to disseminate the required knowledge to the parturient population. The complication rate in this audit is in accordance with the studies conducted in developed countries. The major area of improvement is adequate documentation of labour epidural analgesia in record registers, which will help in changing the practice of epidural analgesia in Pakistan.

ETHICAL  APPROVAL:
The approval was obtained from the Ethical Committee of the Doctors Hospital and Medical Centre, Lahore, Pakistan.

PATIENTS’  CONSENT:
Informed consent was waived due to the retrospective nature of the study.

COMPETING  INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’  CONTRIBUTION:
SUR: Selected the idea of audit, wrote introduction, discussion, and conclusion.
AK: Collected data from epidural registers and maternity unit registers,  and  proofread  the  study.
AR: Collected  the  data.
AAK: Analysed  the  data.
All authors approved the final version of the manuscript to be published.

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