Awareness and perception of epidural labor analgesia among pregnant women visiting antenatal clinic in National Referral Hospital

Aims: To assess the awareness and perception of labour epidural analgesia among pregnant women visiting the antenatal clinic. Methods: This was an observational cross-sectional study. Study participants included pregnant women visiting the antenatal clinic during 2nd and 3 rd trimester conducted from 21 st September 2018 till 20 th September 2019. Data were collected by using an interviewer-administered questionnaire. Ethics approval was granted by the research Ethics Board of health, Bhutan. Results: Total 450 parturients participated in this study; 61.4% of the participants knew that labour epidural services were available and 37.5% got information through media. A total of 57.3% of respondents had severe fear about labour pain; 62.4% had severe fear about delivery complication; 85.2% thought that epidural labour analgesia was a good method of pain relief; and 67% were willing to accept it for their current pregnancy. However, 86.6% would recommend epidural labour analgesia as an option of pain relief to other pregnant women. Conclusion: Awareness about the availability of labour epidural analgesia services needs to be improved, as a majority of the parturient was keen to avail epidural analgesia after the information about its availability was provided.

Maternal haemodynamics during labour epidural analgesia with and without adrenaline

Objectives Labour is one of the most painful experiences in a woman’s life. Epidural analgesia using low-concentration local anaesthetics and lipophilic opioids is the gold standard for pain relief during labour. Pregnancy in general, particularly labour, is associated with changes in maternal haemodynamic variables, such as cardiac output and heart rate, which increase and peak during uterine contractions. Adrenaline is added to labour epidural solutions to enhance efficacy by stimulating the α2-adrenoreceptor. The minimal effective concentration of adrenaline was found to be 2 μg mL−1 for postoperative analgesia. The addition of adrenaline may also produce vasoconstriction, limiting the absorption of fentanyl into the systemic circulation, thereby reducing foetal exposure. However, adrenaline may influence the haemodynamic fluctuations, possibly adding to the strain on the circulatory system. The aim of this study was to compare the haemodynamic changes after application of labour epidural analgesia with or without adrenaline 2 μg mL−1. Methods This was a secondary analysis of a single-centre, randomised double-blind trial. Forty-one nulliparous women in labour requesting epidural analgesia were randomised to receive epidural solution of bupivacaine 1 mg mL−1, fentanyl 2 μg mL−1 with or without adrenaline 2 μg mL−1. The participants were monitored using a Nexfin CC continuous non-invasive blood pressure and cardiac output monitor. The primary outcomes were changes in peak systolic blood pressure and cardiac output during uterine contraction within 30 min after epidural activation. The effect of adrenaline was tested statistically using a linear mixed-effects model of the outcome variables’ dependency on time, adrenaline, and their interaction. Results After excluding three patients due to poor data quality and two due to a malfunctioning epidural catheter, 36 patients (18 in each group) were analysed. The addition of adrenaline to the solution had no significant effect on the temporal changes in peak systolic blood pressure (p=0.26), peak cardiac output (0.84), or heart rate (p=0.91). Furthermore, no significant temporal changes in maternal haemodynamics (peak systolic blood pressure, p=0.54, peak cardiac output, p=0.59, or heart rate p=0.55) were associated with epidural analgesia during 30 min after epidural activation in both groups despite good analgesia. Conclusions The addition of 2 μg mL−1 adrenaline to the epidural solution is not likely to change maternal haemodynamics during labour.

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.