Labour pain is a significant concern for women during childbirth and effective pain management strategies are essential to improve maternal satisfaction and overall birth experience. Epidural analgesia is a widely used method for pain relief during labour, offering effective and targeted pain control. It involves the administration of local anaesthetics and opioids into the epidural space, resulting in regional anaesthesia and analgesia. The use of epidural analgesia has been shown to provide superior pain relief compared to other methods, such as systemic opioids or non-pharmacological interventions like relaxation techniques or breathing exercises [1,2].

The Visual Analogue Scale (VAS) is a validated tool commonly used to assess the intensity of pain experienced by patients. It consists of a horizontal line with endpoints labeled as "no pain" and "worst pain imaginable," and patients are asked to mark their pain level on the line. The VAS score provides a quantitative measure of pain perception, allowing for objective comparisons between different pain management techniques. While epidural analgesia has been shown to effectively reduce labour pain, it is important to evaluate its specific impact on VAS scores. Understanding the effect of epidural analgesia on VAS scores can provide valuable insights into its efficacy as a pain management strategy during labour. Previous studies have reported conflicting results regarding the impact of epidural analgesia on VAS scores, with some studies demonstrating significant reductions in pain scores and others showing more modest effects [3,4]. This prospective comparative study aims to evaluate the effect of epidural analgesia on VAS scores for labour pain management. By comparing VAS scores between women who receive epidural analgesia and those who opt for alternative pain management methods, we can assess the effectiveness of epidural analgesia in achieving pain relief during labour. The findings of this study will contribute to the existing body of knowledge and help guide clinicians in making informed decisions regarding pain management option for labouring women.

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 postmaturity

• 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.

Parturients 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. Pain relief was recorded as per VAS (Visual analogue scale) score which ranged from 0-10 where 0 being no pain and 10 being maximum pain. Presence of motor block in lower extremities was assessed using a modified Bromage scale shown above (Table 1):

Pain score (VAS), sensory and motor block characteristics and vital parameters (pulse, mean arterial pressure, respiratory rate) were recorded at 0 (before epidural), 5, 15 min and then every 15 minutes till 1 hour and then every 30 minutes until the delivery. 

Table 1: Standard Method of Pain Relief

Statistical Analysis

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

Results and Observations

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 2).

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 (Table 3).

Mean±SD age (years) in group 1 was 25.13±3.62 and group 2 was 25.33±3.25 with no significant difference between them. (p value = 0.823) Majority of the women in both the groups were between 20-25 years (Group1 = 60% and Group 2 = 63.33%) followed by 26-30 years (Group 1 = 36.67% and Group 2 = 30%).

In present study, most of the women of Group 1 (86.6%) and Group 2 (80%) were booked. There was no significant difference in booking status (p value = 0.731) As our institute mainly caters to rural population so most women in our study belonged to rural area (Group1 = 86.6% and Group 2 = 96.6%). Distribution of area of residence was comparable between Group 1 and 2 (p value = 0.353). Most of the women in our study in both the groups were educated upto primary or matric level (Group 1 = 83.3% and Group 2 = 96.6%). Education status of women was comparable in both the groups (p value = 0.210). None of the women under study was illiterate. Table 1 shows the education status of women in both the groups. In group 1, 12 (40%) women were educated upto primary level, 13 (43.33%) upto matric, 5 (16%) of them were graduate/postgraduate. In Group 2, 17 (56.67%) women were educated upto primary level, 12(40%) upto matric and 1(3.33%) of the patient was graduate/postgraduate. Most of the women in both groups belonged to middle class (Group 1 = 70% and Group 2 = 50%) No statistical difference regarding socioeconomic status was found between Group 1 and 2 (p value = 0.173). In Group 1, one (3.33%) woman belonged to upper class, 21 (70%) belonged to middle class (lower middle & upper middle) and 8 (26.67%) women belonged to lower class. In Group 2, 15 (50%) women belonged to middle class (lower middle & upper middle) and 15 (50%) women belonged to lower class. None of the women belonged to upper class.

In the present study, no significant difference was seen in VAS score before administration of epidural analgesia between both the groups (p value = 0.753). After administration of Epidural analgesia, significant difference difference was seen in VAS score at 15 minutes after analgesia as well as during second stage of labour between group 1 and 2. (p value <0.05). Mean of VAS score at 15 minutes after analgesia in Group 1 was 3.3±0.95 and in Group 2 was 7.77±0.5. Similarly, VAS score during second stage of labour in Group 1 was 4.47±1.38 and in Group 2 was 8.77±0.86. So, the mean VAS score after administration of epidural analgesia at 15 minutes as well as during second stage of labour was significantly higher in Group 2 as compared to Group 1 (p value<0.0001).

VAS Score According to Severity

All the women had VAS score in similar range (7-10) before administration of analgesia. At 15 minutes after administration of analgesia, 25 out of 30 women had mild VAS score and remaining five women had moderate VAS score in Group 1 whereas in Group 2, 12 women had moderate VAS score and 18 had severe pain. None of the women in Group 2 had mild VAS score after 15 minutes of analgesia (Table 4).

During second stage of labour, all the women in Group 1 had either mild or moderate pain score whereas all the 30 women in Group 2 had severe pain with VAS between 7-10.

Table 2: Age Distribution, Booking Status, Residence, Education Status, and Socioeconomic Status of Study Participants

^* Independent t test, ^‡ Fisher's Exact Test

Table 3: Mean VAS Score

^† Mann Whitney Test

Table4: VAS Score According to Severity

In the present study VAS score was assessed in both the groups at different time intervals i.e. before analgesia, at 15 minutes after administration of analgesia and during second stage of labour. Before administration of epidural analgesia, pain VAS score was comparable among the two groups. In Group 1, the mean VAS pain relief score was 7.67±0.71 and in Group 2 was 7.57±0.5. Similarly, the VAS score before analgesia was comparable in both the groups in a study by Deshmukh V. et al. [5] where VAS score in Group 1 was 7.94±0.91 and Group 2 was 7.80±0.88.

At 15 minutes after epidural analgesia, in our study there was significant decrease in VAS score in Group 1 from 7.67±0.71 to 3.3±0.95 whereas VAS increased to 7.77±0.5 from 7.57±0.5 in Group 2. This finding was similar to Deshmukh V. et al. [5] where VAS score decreased significantly from 7.94±0.91 to 2.68±0.86 in Group 1 and increased to 7.92±0.92 from 7.80±0.88 at 15 minutes after administration of epidural analgesia.

During the second stage of labour, in our study the mean VAS score was significantly higher in Group 2 (8.77±0.86) as compared to Group 1 (4.47±1.38). Similarly, VAS score in study by Deshmukh V et al⁵ was significantly higher in Group 2 (8.62±1.06) as compared to Group 1(1.94±0.61). However, the difference in VAS score between Group 1 and Group 2 was much more in study by Deshmukh et al. [5] as compared to our study. 

During the second stage the severity of pain was significantly more in Group 2 as compared to Group 1. In present study, during second stage of labour, 73.33% of women had moderate pain and 26.6% women had mild pain in Group 1 while none had severe pain as compared to Group 2 where all women had severe pain (VAS score 7-10) during second stage of labour.

Sawant V. et al.[6] showed similar results in Group 1 where no women had severe pain. However, 93.33% had mild pain and only 6.66% had moderate pain. In Group 2 contrasting results were seen as 63.33% women had severe pain as compared to 100% women in our study.

These findings suggest that epidural analgesia is effective in reducing labour pain, as evidenced by lower VAS scores, compared to standard pain relief protocols. The use of epidural analgesia resulted in a significant decrease in pain intensity and improved pain management during labour.

In conclusion, based on the results of this study, epidural analgesia is recommended as an effective pain management option for labouring women. It provides substantial pain relief, as indicated by lower VAS scores, compared to non-epidural methods. The findings of this study contribute to the existing body of knowledge and provide valuable insights for healthcare professionals involved in labour pain management.

1. Wong, C.A. et al. “The risk of cesarean delivery with neuraxial analgesia given early versus late in labour.” The New England Journal of Medicine, vol. 352, no. 7, 2005, pp. 655–665.

2. Anim-Somuah, M. et al. “Epidural versus non-epidural or no analgesia for pain management in labour.” Cochrane Database of Systematic Reviews, no. 5, 2018, article CD000331.

3. Anim-Somuah, M. et al. “Epidural versus non-epidural or no analgesia in labour.” Cochrane Database of Systematic Reviews, no. 4, 2005, article CD000331.

4. Torvaldsen, S. et al. “Epidural analgesia, duration of labour, and intrapartum maternal temperature elevation.” Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 45, no. 6, 2005, pp. 420–425.

5. Deshmukh, V.L. et al. “Effects of epidural labour analgesia in mother and foetus.” Journal of Obstetrics and Gynecology of India, vol. 68, no. 2, 2018, pp. 111–116.

6. Sawant, V. 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.