Epidural anaesthesia is a widely utilized method for pain management during labour and delivery, offering effective relief and enhancing maternal satisfaction. It involves the administration of local anesthetics and opioids into the epidural space, resulting in regional analgesia and anaesthesia. While epidural anaesthesia has proven efficacy in reducing labour pain, it is essential to evaluate its impact on various maternal and neonatal outcomes [1,2].

Intrapartum complications refer to any adverse events or complications that occur during labour and delivery. These may include prolonged labour, arrest of labour progress, fetal distress and the need for instrumental or caesarean deliveries. It is important to investigate whether the use of epidural anaesthesia is associated with an increased risk of such complications or whether it has a protective effect on labour outcomes [3-6].

Postpartum complications encompass a range of potential issues that may arise after childbirth. These can include postpartum hemorrhage, perineal trauma, wound infection and urinary retention. Understanding the impact of epidural anaesthesia on postpartum complications is crucial for providing appropriate care and ensuring optimal maternal recovery [3-6].

Furthermore, neonatal complications related to epidural anaesthesia are of significant concern. These may involve changes in fetal heart rate patterns, neonatal respiratory depression, low Apgar scores and the need for neonatal resuscitation. By examining the neonatal outcomes associated with the use of epidural anaesthesia, we can assess its safety for the newborns and identify any potential risks [3-6].

The study aims to evaluate the intrapartum, postpartum and neonatal complications associated with the use of epidural anaesthesia during childbirth. By comprehensively assessing these outcomes, we seek to provide valuable insights into the safety and effectiveness of epidural anaesthesia in our specific setting. By conducting the study in this setting, we can generate findings that are relevant and applicable to the local population, contributing to evidence-based decision-making in obstetric anaesthesia.

A prospective interventional study was conducted in the Department of Obstetrics and Gynaecology in collaboration with Department of Anaesthesiology at Dr. RPGMC Kangra at Tanda after the approval of review protocol committee and ethical committee of the institution. The women who were in early active phase of labour and met the inclusion criteria were explained about the study in detail and those women who were willing to participate were included in the study.

Inclusion Criteria

• Primigravida with full term singleton pregnancies (37-42 weeks) with vertex presentation

• No obstetric or medical risk factors contraindicating epidural analgesia

• Normal fetal heart rate before the time of induction of epidural labour analgesia

• Women in early active phase of labour (3-4cm dilation of cervix)

Exclusion Criteria

• Multiparity

• Prematurity and post maturity

• Any contraindication for vaginal delivery like CPD or malpresentation

• Patient in latent phase of labour

• Non reassuring fetal heart rate

• Contraindication for epidural analgesia (coagulopathy, infection at local site, spine deformity, allergy to the study drug)

Sample Size

In order to calculate sample size, the incidence of operative and caesarean deliveries in Group 1 (cases) assumed 33% and 5% in Group 2 (controls) with 80% confidence interval and 5% level of significance. Total sample size calculated = 60.

Parturient reporting to labour room in early active phase of labour fulfilling the inclusion criteria were explained about the study and counselling regarding epidural analgesia was done. Those who were willing to participate in the study formed Group 1/Epidural group after taking informed written consent and Group 2/Non epidural group included women immediately next to epidural case with similar demographic characteristics who did not want epidural analgesia. These women received pain relief as per the standard protocol of our institution.

Complete detailed history was obtained and thorough clinical examination including general physical examination, systemic examination and obstetric examination (including per abdomen, per speculum and per vaginal examination) was done. All the investigations were recorded and any additional investigations were done as per requirement. The contraindications for epidural analgesia and vaginal delivery were ruled out. Cases consisted of 30 participants who underwent epidural analgesia and controls consisted of 30 participants in whom standard method of pain relief was used as per our institutional protocol.

All parturient were given trial walk in the presence of attendant to assess their ability to ambulate. Patient was instructed to pass urine every hour. Any adverse effects of epidural analgesia like hypotension, bradycardia, pruritic, nausea, vomiting, urinary retention if occurred were recorded by the anaesthetist.

Obstetric Management

The obstetric management was similar in both the groups as per the protocol of our institution. Throughout the procedure maternal heart rate, blood pressure, motor and sensory blockage levels were assessed. Maternal, fetal condition and progress of labour were monitored petrographically. Fetal heart rate was monitored using CTG and any evidence of fetal heart rate and liquor abnormalities were recorded. Level of pain was graded according to VAS score. Augmentation of labour was done by Oxytocin infusion if uterine contractions were inadequate (less than 3 in 10 minutes for 45 seconds). Decision regarding operative deliveries or instrumental vaginal was made according to maternal or fetal indications. Mode of delivery (normal vaginal/instrumental vaginal/caesarean) was noted. Duration of first stage of labour was calculated as the time interval between patient entering the active stage of labour and full dilatation of cervix. Duration of second stage of labour was calculated from full dilatation of cervix to delivery of the baby from the birth canal. Neonatal assessment was performed by assessing the APGAR score at 1 and 5 min and any NICU admission was noted. Labour and postpartum period was managed as per the standard protocol.

Statistical Analysis

All the data was collected, put into master chart and was analyzed using appropriate software.

A prospective interventional study was conducted in the Department of Obstetrics and Gynaecology in collaboration with Department of Anaesthesiology at Dr. RPGMC Kangra at Tanda after the approval of protocol review committee and ethical committee of the institution. The women who were in early active first stage of labour and met the inclusion criteria were explained about the study in detail. Those women who were willing to participate in the study formed Group 1/Epidural group (consisting of 30 women) and an informed written consent was taken from them.

Table 1: Intrapartum/Intraoperative Complications

Table 2: Postpartum Complications

Table 3: Neonatal Complications

‡ Fisher's Exact Test

Figure 1: Age Distribution, Booking Status, Residence, Education Status and Socioeconomic Status of Study Participants

Group 2/non-epidural group (NE): It consisted of 30 women immediately next to epidural case with similar demographic characteristics who received pain relief as per the standard protocol of the institution. Women in both the groups were comparable with regard to various demographic characteristics.

The mean age in Group 1 was 25.13 years with a standard deviation of 3.62, while in Group 2 it was 25.33 years with a standard deviation of 3.25. There was no significant difference between the two groups (p-value = 0.823). The majority of women in both groups were aged between 20-25 years, followed by 26-30 years.

In our study, a large percentage of women in both Group 1 (86.6%) and Group 2 (80%) were booked for healthcare services. There was no significant difference in the booking status between the groups (p-value = 0.731). Since our institute primarily serves rural populations, the majority of women in both groups belonged to rural areas. The distribution of area of residence was similar between Group 1 and Group 2 (p-value = 0.353).

Most women in both groups had received education up to the primary or matric level. In Group 1, 83.3% had education up to primary level, while in Group 2 it was 96.6%. The education status was comparable between the two groups (p-value = 0.210). None of the women in the study were illiterate. Please refer to Table 1c and Figure 1c for more details on the education status of women in both groups.

The majority of women in both groups belonged to the middle class. There was no statistical difference in socioeconomic status between Group 1 and Group 2 (p-value = 0.173). In Group 1, 3.33% belonged to the upper class, 70% belonged to the middle class (lower middle and upper middle) and 26.67% belonged to the lower class. In Group 2, 50% belonged to the middle class (lower middle and upper middle) and 50% belonged to the lower class. None of the women belonged to the upper class (Figure 1).

Among the various intaoperative/intrapartum complications in both the groups, Fetal distress was seen in three (10%) women of Group1 and two (6.66%) women of Group 2 with p-value = 1, NPOL was seen in one (3.33%) woman each of Group 1 and Group 2 with p-value = 1, PPH occurred in two (6.66%) women of Group 2 with p-value = 0.491. There was no statistically significant difference in both the groups regarding the complications in intraoperative/ intrapartum period (Table 1).

Among the various postoperative/postpartum complications in both the groups, puerperal pyrexia was seen in two (6.66%) women of Group 1 and one (3.33%) woman of Group 2 with p-value =1 and blood transfusion were required in one (3.33%) woman of Group 2 and none of Group1 (p-value = 1). The difference in both groups regarding the complications in postoperative/ postpartum period was not statistically significant (Table 2).

Distribution of neonatal complications was comparable between Group 1 and 2. APGAR score <7 at 5 minutes was found in only one neonate of Group 1 while none of the neonate of Group 2 had APGAR <7 at 5 minutes. Total three neonates were admitted to NICU out of which one belonged to Group 1 (duration of admission >72hrs) and two were of Group 2 (duration of admission 24-72 hrs and >72hrs). The reason of NICU admission in Group 1 was Birth asphyxia whereas in Group 2 was meconium aspiration and low birth weight (Table 3).

Epidural anaesthesia is commonly used for pain management during labour and delivery, providing effective relief and enhancing maternal satisfaction. This study aimed to evaluate the intrapartum, postpartum and neonatal complications associated with epidural anaesthesia in our specific setting. By comparing our findings with existing studies, we can gain a comprehensive understanding of the safety and effectiveness of epidural anaesthesia.

Intrapartum complications are important factors to consider when assessing the impact of epidural anaesthesia. Our study found no significant difference in intrapartum complications between the epidural (Group 1) and non-epidural (Group 2) groups. The occurrence of fetal distress and NPOL (non-progression of labour) was similar in both groups. These results are consistent with previous studies that have also reported no significant increase in intrapartum complications associated with epidural anaesthesia [7-14].

Postpartum complications are another crucial aspect to evaluate. Our study showed no significant difference in postpartum complications between the two groups. Puerperal pyrexia occurred in a small percentage of women in both groups and there were no cases of secondary postpartum hemorrhage, wound sepsis, or lactation failure. These findings align with previous studies that have not found a substantial association between epidural anaesthesia and increased postpartum complications [12-18].

Neonatal complications associated with epidural anaesthesia were assessed in our study. The majority of neonates in both groups had APGAR scores of 7 or higher at 5 minutes, indicating good overall neonatal well-being. There were a few cases of NICU (neonatal intensive care unit) admission in both groups, but the reasons varied. In Group 1, one neonate was admitted due to birth asphyxia, while in Group 2, the admissions were related to meconium aspiration and low birth weight. These findings suggest that the occurrence of neonatal complications was not significantly influenced by epidural anaesthesia. When comparing our results with other studies, several research papers have also reported similar findings regarding the safety of epidural anaesthesia in relation to neonatal complications [19-22].

Limitations

It is important to acknowledge the limitations of our study. Firstly, the sample size was relatively small, which may have limited our ability to detect rare complications. Secondly, our study was conducted in a specific setting and may not be representative of other populations or healthcare facilities. Future studies with larger sample sizes and diverse populations are warranted to validate our findings.

In conclusion, our study did not find a significant association between epidural anaesthesia and increased intrapartum, postpartum, or neonatal complications. These results align with previous studies indicating the safety and effectiveness of epidural anaesthesia for pain management during labour and delivery. Obstetricians and anaesthesiologists can use this information to make informed decisions regarding the use of epidural anaesthesia, considering the benefits it provides in terms of pain relief and maternal satisfaction, while being aware of the minimal impact on complications.

1. J.L. Hawkins "Epidural analgesia for labour and delivery." New England Journal of Medicine, vol. 362, no. 16, 2010, pp. 1503–1510.

2. J.L. Hawkins et al. "Anaesthesia-related maternal mortality in the United States: 1979–2002." Obstetrics and Gynecology, vol. 117, no. 1, 2011, pp. 69–74.

3. M. Balki and J.C.A. Carvalho. "Intraoperative and postoperative analgesia for labour and delivery." Anesthesiology Clinics, vol. 26, no. 1, 2008, pp. 153–171.

4. American Society of Anesthesiologists Task Force on Obstetric Anaesthesia. "Practice guidelines for obstetric anaesthesia: An updated report by the american society of anesthesiologists task force on obstetric anaesthesia." Anesthesiology, vol. 106, no. 4, 2007, pp. 843–863.

5. American College of Obstetricians and Gynecologists. "ACOG practice bulletin no. 209: Obstetric analgesia and anaesthesia." Obstetrics and Gynecology, vol. 133, no. 5, 2019, pp. e208–e225.

6. S.K. Sharma et al. "Caesarean Delivery: A Randomized Trial of Epidural versus Patient-Controlled Meperidine Analgesia during Labour." Anesthesiology, vol. 87, no. 3, 1997, pp. 487–494.

7. W.F. Mousa et al. "Epidural analgesia during labour vs no analgesia: A comparative study." Saudi Journal of Anaesthesia, vol. 6, no. 1, 2012, pp. 36–40.

8. J. Ren et al. "Risk factors and safety analyses for intrapartum fever in pregnant women receiving epidural analgesia during labour." Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, vol. 27, 2021, e929283.

9. T.H. Hung et al. "Differential effects of epidural analgesia on modes of delivery and perinatal outcomes between nulliparous and multiparous women: A retrospective cohort study." PLoS ONE, vol. 10, no. 3, 2015, e0120907.

10. S. Rabiei et al. "Comparison of the effects of epidural and spinal anaesthesia on analgesia and blood gases in neonates born by natural vaginal delivery: a clinical trial study." Biomedical Research and Therapy, vol. 7, no. 3, 2020, pp. 3686–3692.

11. D. Agrawal et al. "The effect of epidural analgesia on labour, mode of delivery and neonatal outcome in Nullipara of India, 2011–2014." Journal of Clinical Diagnosis and Research (JCDR), vol. 8, no. 10, 2014, pp. OC03.

12. J.L. Hawkins "Epidural analgesia for labour and delivery." New England Journal of Medicine, vol. 362, no. 16, 2010, pp. 1503–1510.

13. S. Gizzo et al. "Update on best available options in obstetrics anaesthesia: perinatal outcomes, side effects and maternal satisfaction. fifteen years systematic literature review." Archives of Gynecology and Obstetrics, vol. 290, no. 1, 2014, pp. 21–34.

14. J.A. Thorp et al. "The effect of intrapartum epidural analgesia on nulliparous labour: A randomized, controlled, prospective trial." American Journal of Obstetrics and Gynecology, vol. 169, no. 4, 1993, pp. 851–858.

15. S. Nafisi "Effects of epidural lidocaine analgesia on labour and delivery: A randomized, prospective, controlled trial." BMC Anesthesiology, vol. 6, no. 1, 2006, p. 15.

16. W.F. Mousa et al. "Epidural analgesia during labour vs no analgesia: A comparative study." Saudi Journal of Anaesthesia, vol. 6, no. 1, 2012, pp. 36–40.

17. B. Shrestha et al. "Effects of maternal epidural analgesia on the neonate: A prospective cohort study." Italian Journal of Pediatrics, vol. 40, no. 1, 2014, p. 99.

18. T.H. Hung et al. "Differential effects of epidural analgesia on modes of delivery and perinatal outcomes between nulliparous and multiparous women: A retrospective cohort study." PLoS One, vol. 10, no. 3, 2015, e0120907.

19. V. Sawant and A. Kumbhar. "Labour with low dose epidural analgesia: Maternal perception and fetal outcome." International Journal of Reproduction, Contraception, Obstetrics and Gynecology, vol. 7, no. 2, 2018, pp. 689–693.

20. Y. Naito et al. "The effect of labour epidural analgesia on labour, delivery and neonatal outcomes: A propensity score-matched analysis in a single japanese institute." JA Clinical Reports, vol. 5, no. 1, 2019, p. 40.

21. L. Wang et al. "Analgesic effects of epidural labour analgesia at different periods and its effects on maternal and infant outcomes and mirna-146b level." Journal of Healthcare Engineering, 2021, 2879678.

22. H. Yin and R. Hu. "A cohort study of the impact of epidural analgesia on maternal a.nd neonatal outcomes." Journal of Obstetrics and Gynaecology Research, vol. 45, no. 8, 2019, pp. 1435–1441.