A Protocol on Comparative Evaluation of Epidural and Spinal Technique of Labour Analgesia in Rural Women of Central India and their Perceptions Regarding Pain Relief in Labour

Background: Labour pain while giving birth is one of the most excruciatingly painful and emotionally stressful experience for a woman that has piqued the interest of several academicians. Labour pain is induced due to the uterine ischemia, expansion of vagina and birth canal, muscle contractions, and pressure on the bladder. To relieve the severe pain during labour, analgesia is required, which offers pain relief without the loss of consciousness. Regional analgesia (Epidural and spinal) are most commonly used for offering pain relief to women. Aim: To evaluate whether low dose spinal analgesia is a better alternative to lumbar epidural analgesia for pain relief in labour. Objectives - Primary objective is to evaluate efficacy of lumbar epidural and spinal analgesia for pain relief in labour. Secondary objective is to evaluate the perceptions of women towards the use of labour analgesia, to evaluate the maternal and fetal outcome and to evaluate the barriers affecting the use of lumbar epidural and spinal analgesia for women during labour. Methods: In this randomized control trial study, where 60 patients are present in each group. Patients in GROUP E, epidural analgesia will be given using 18-gauge Touhy epidural needle by a loss of resistance to air technique, and after confirmation of space, an epidural catheter will be inserted cranially in L3 - L4 or L4-L5 interspace, and a dose of 15ml of 0.125% bupivacaine with 25µg of fentanyl would be given slowly. Group S patients will receive subarachnoid block using 25-gauge needle inserted and directed to reach the intrathecal space between L3 - L4 or L4 - L5 intervertebral space. After a successful Dural puncture with acceptable CSF flow, 0.1% bupivacaine 2ml with 25µg fentanyl will be given via spinal needle. Throughout the duration of delivery, hemodynamic monitoring including SPO2, ECG, heart rate and blood pressure of mother and fetal heart rate would be monitored under the guidance of obstetrician and anesthesiologists. Patient will be assessed every 5min for the first 15 min, and then every 15 minutes until additional analgesia was requested. The severity of labour pain would be assessed using visual analogue scale. (0 = no pain; 10 = severe pain). Within the first 24 - 48 hours postpartum patient will fill the self-administered questionnaires. Results: The groups are expected to be similar. However, Low dose spinal analgesia may be a better alternative to lumbar epidural analgesia in providing effective pain relief for women in labour in terms of cost effectiveness. There are no results found as it is just a protocol. Results are yet to come. Conclusions: The study would offer new insights and knowledge into the use of epidural and spinal analgesia in India, particularly Wardha. The perceptions of women, towards labour analgesia, its consequences or side effects, and the myths associated with its use will be comprehended.

A pilot study comparing dural puncture epidural with 27G Whitacre needle and conventional lumbar epidural labor analgesia

Background The dural puncture epidural (DPE) technique is relatively a new technique of labor analgesia and has been advocated with the advantage of faster onset of pain relief. However, there are differences of opinion regarding the efficacy of the DPE technique and the size of the spinal needle to be used for the DPE. Various studies have suggested that DPE can only be done with a larger gauge of a spinal needle; however, recent studies have variable observations. We have compared the conventional lumbar epidural analgesia and DPE using a 27G pencil-point needle to assess the efficacy of DPE and its possible side effects. Results The time to achieve a 50% reduction in VAS was 7.06 ± 0.79 min in group CLE (n = 15) and 5.0 ± 1.06 min in group DPE (n = 15) (difference of two means was 2.06, 95% CI [1.36, 2.75], t = 5.99, p < 0.0001). The time to achieve VAS < 3 in group CLE was 14.93 ± 1.98 min, and in the group DPE, it was 10.13 ± 1.45 min (difference of two means was 4.8, 95% CI [3.52, 6.09], t = 7.55, p < 0.0001). The mode of delivery, APGAR scores, and side effects were comparable (p > 0.05). Conclusions DPE provided faster relief of labor pain than the conventional labor epidural analgesia. There were no added side effects by DPE in conventional lumbar epidural analgesia for labor. A 27G Whitacre pencil-point needle can be used for DPE. Trial registration CTRI, CTRI/2020/08/027060. Registered on 10/08/2020. Trial registered prospectively. CTRI website URL: http://ctri.nic.in

Pneumocephalus following labour epidural analgesia, a rare case report

The lumbar epidural analgesia is commonly used for labour analgesia. The “loss of resistance to air” LORA technique is commonly used for recognition of epidural space. One of the rare complications of this technique is Pneumocephalus (PC). We want to present a case of Pneumocephalus which the mother developed during epidural analgesia in labour. The patient complained of severe headache immediately after attempt at epidural catheter insertion. The symptoms progressively worsened following delivery. A postnatal anaesthetic review was performed and an urgent CT scan of the brain was arranged that showed pneumocephalus. A conservative management pathway was followed with liberal analgesia, oxygen inhalation and keeping the patient mostly in supine position. Her symptoms regressed in severity over the next three days and subsided after one week. We believe that the amount of air used for LORA should be minimized; LORA should not be used after dural puncture and the use of normal saline would alleviate the risk.

Informed Consent for Epidural Analgesia at the Time of Labor Pain, Seems Too Late!

Pain in the process of childbirth is the phenomenon mostly feared by every woman in her pregnancy, and is a major cause of dissatisfaction and embarrassing memories of labor. Usage of lumbar epidural analgesia as a very effective pain management option has solved this problem to a great extent, and its utilization has turned to common practice in most of the women hospitals worldwide. The use of lumbar epidural analgesia in labor is widespread due to its benefits in terms of effective pain relief in comparison with other labor pain treatment options [1]. Vaginal delivery is an extremely painful process accompanied with great emotional disturbance, which may not be possible for the laboring mother to focus and concentrate to understand the anesthetist explanations at that moment and sign the epidural analgesia informed consent properly. On one hand, the laboring mother expresses doubts because of uncertainty on her decision and on the other hand she desperately wants to get rid of the excruciating labor pain by any means possible. Therefore, the decision to have a neuraxial analgesia (epidural, combined spinal epidural) sounds obligatory on this condition. Each of these analgesic methods beside desirable effectiveness in pain management may have some side effects and it is obvious that each complication takes lots of time and patiently concentration for the mother to be precisely understood and the decision making is even beyond of it. Decision making process cannot get precisely completed just in labor time, so free of any upcoming complication, informed consent may not be ethically verified on labor time. Decision making capacity is a complex mental process involving both cognitive and emotional components. Sometimes this complex action is reduced to “understanding” alone. There are uncertainties about decision-making capacity (mental competence) of women in labor in relation to giving informed consent to neuraxial analgesia. Considering these parameters, sufficient information about pain management methods (advantages, side effects, the way each procedure is conducted) should be provided as part of prenatal education and the consent process must be carefully conducted to enhance mothers’ autonomy [2]. To utilize effective methods for presenting the mothers with (like multimedia modules, recorded video of the sample procedure and so on) in late pregnancy should be considered to achieve better understanding and right decision. Patient decision aids are beneficial in clinical anesthesia and studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression and decisional conflicts after using this method [3]. It has been demonstrated that using decision aids prior to the procedure can significantly reduce the decision conflict, and improve both autonomy and outcome as a united benefit in favor of laboring mothers [4]. It seems that pain-relieving methods (neuraxial and other treatment options) should be described in details at the second and third trimester of pregnancy by a team consist of midwife, anesthesia provider and obstetrician. The more time is spent on this process; the better informed consent is achieved finally. Also high quality decision aids can increase women’s familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflicts and increase knowledge [5]. Factors like parity, pain threshold, and estimated length of labor should be considered together in the decision process to individualize the best pain treatment option for mother [6].

Informed Consent for Epidural Analgesia at the Time of Labor Pain, Seems Too Late!

Pain in the process of childbirth is the phenomenon mostly feared by every woman in her pregnancy, and is a major cause of dissatisfaction and embarrassing memories of labor. Usage of lumbar epidural analgesia as a very effective pain management option has solved this problem to a great extent, and its utilization has turned to common practice in most of the women hospitals worldwide. The use of lumbar epidural analgesia in labor is widespread due to its benefits in terms of effective pain relief in comparison with other labor pain treatment options [1]. Vaginal delivery is an extremely painful process accompanied with great emotional disturbance, which may not be possible for the laboring mother to focus and concentrate to understand the anesthetist explanations at that moment and sign the epidural analgesia informed consent properly. On one hand, the laboring mother expresses doubts because of uncertainty on her decision and on the other hand she desperately wants to get rid of the excruciating labor pain by any means possible. Therefore, the decision to have a neuraxial analgesia (epidural, combined spinal epidural) sounds obligatory on this condition. Each of these analgesic methods beside desirable effectiveness in pain management may have some side effects and it is obvious that each complication takes lots of time and patiently concentration for the mother to be precisely understood and the decision making is even beyond of it. Decision making process cannot get precisely completed just in labor time, so free of any upcoming complication, informed consent may not be ethically verified on labor time. Decision making capacity is a complex mental process involving both cognitive and emotional components. Sometimes this complex action is reduced to “understanding” alone. There are uncertainties about decision-making capacity (mental competence) of women in labor in relation to giving informed consent to neuraxial analgesia. Considering these parameters, sufficient information about pain management methods (advantages, side effects, the way each procedure is conducted) should be provided as part of prenatal education and the consent process must be carefully conducted to enhance mothers’ autonomy [2]. To utilize effective methods for presenting the mothers with (like multimedia modules, recorded video of the sample procedure and so on) in late pregnancy should be considered to achieve better understanding and right decision. Patient decision aids are beneficial in clinical anesthesia and studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression and decisional conflicts after using this method [3]. It has been demonstrated that using decision aids prior to the procedure can significantly reduce the decision conflict, and improve both autonomy and outcome as a united benefit in favor of laboring mothers [4]. It seems that pain-relieving methods (neuraxial and other treatment options) should be described in details at the second and third trimester of pregnancy by a team consist of midwife, anesthesia provider and obstetrician. The more time is spent on this process; the better informed consent is achieved finally. Also high quality decision aids can increase women’s familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflicts and increase knowledge [5]. Factors like parity, pain threshold, and estimated length of labor should be considered together in the decision process to individualize the best pain treatment option for mother [6].

Pneumocephalus and Seizure in Patient after Epidural Lumbar Puncture: Case Report

Lumbar epidural analgesia is using widely as an alternative method for anesthesia. Although it has its benefits such as the low risk of complications in contrast with general anesthesia, also it has some adverse effects, for instance: headache, loss of consciousness, pneumocephalus, dizziness, and seizure. Pneumocephalus is a rare complication of lumbar epidural block. In this case of study, a patient represents stenosis in the site of anastomosis of colon and duodenum candidate for a repair surgery with the lumbar epidural block. Epidural catheter insertion was done in the sitting position; local anesthesia was administered at the 4th and 5th lumbar vertebral interspace. A 17-gauge Husted needle was inserted using the loss-of resistance (LOR) by air technique. Immediately the patient complained of headaches and then deteriorated to a tonic-clonic movement accompanied by post-seizure sleep, which ended up in termination of the procedure. The first-day CT-scan revealed multiple pneumocephalus. Supporting treatment was administered for 10 days; another CT-scan taken from the patient demonstrated improvement and the patient was discharged without any neurological deficit. Regional analgesia should be administered if possible under the superintendence of an expert, however, complications of an epidural catheter, such as accidental dural puncture, can postpone the recovery of the patient.