Epidural analgesia in labor: A narrative review

Abstract

Lumbar epidural is considered the gold standard for analgesia in labor and is recommended by WHO, with estimates of use in the range of 10%-64% in high-income countries. 1 During labor, uterine contraction and cervical dilatation stimulate nociceptive afferent fibers that travel to spinal nerves T10-L1, producing poorly localized visceral pain. As the fetal head descends, stretching the perineum and vagina, pain fibers via the pudendal nerve and spinal roots S2-4 are also activated. 2 To modify these afferent pathways and achieve analgesia, local anesthetics, opioids, and other adjuvants can be administered to the epidural space by an epidural catheter. Despite widespread use, there are many uncertainties regarding the optimal epidural regime. Different combinations and concentrations of drugs administered epidurally have been shown to have varying effects in both the partum and postpartum periods. With so many variables surrounding childbirth, it can be difficult to separate association and causation. Epidurals are associated with, but probably do not cause, prolonged labor and increased risk of operative delivery. 3 These factors directly affect obstetric decision making. For certain maternal conditions that may be decompensated by labor and delivery, such as pre-eclampsia or cardiac disease, labor epidural is indicated. In cases where epidural is contraindicated (such as severe thrombocytopenia, coagulopathy, or sepsis) other analgesic regimes (e.g. patient-controlled remifentanil) may be available.Improving communication and understanding between anesthetists and obstetricians is mutually beneficial. The aim of the present narrative review was to provide an overview of epidural literature for the obstetric audience, incorporating techniques of insertion, medications used, and associations with maternal and neonatal outcomes.Spinal anesthesia, and the use of epidural anesthesia for cesarean/ operative delivery are outwith the scope of the present review. | ME THODS | Search strategyA literature search without language restriction was conducted (MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, and Cochrane Central Register of Controlled Trials [CENTRAL]) from date of inception to October 5, 2020. Randomized controlled trials (RCTs), reviews, and relevant references were included. Search terms were "neuraxial analgesia," "epidural," "peridural," "combined spinal-epidural," "CSE,"

Knowledge and Practice of and Attitude Toward Epidural Analgesia Among Pregnant Women in Jazan Region of Saudi Arabia

“…EA is performed by inserting an indwelling catheter into the epidural space, after which the patient receives continuous or multiple infusions of local anesthetics and opioids [ 5 ]. The need for EA is significant to avoid other adverse outcomes of labor pain when giving birth such as hypertension, longer labor time, and postpartum depression [ 6 - 7 ]. The immediate result of EA is pain relief during labor and delivery [ 8 ].…”

Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement Over Conventional Labor Epidural Analgesia?

“…While the DPE technique may be appropriate in selected cases, there are other strategies to consider for difficult epidural insertions. Meta-analyses have found preprocedural ultrasound significantly improves the accuracy and efficacy of neuraxial techniques, and its use is endorsed by the National Institute for Health and Care Excellence in the United Kingdom 4. If faster onset of labor analgesia is desired, CSE is a more appropriate technique, although the benefit is found to be modest (on average about three minutes faster than a standard epidural) in the most recent Cochrane review 5…”

The impact of epidural analgesia on delivery mode in Robson class 1 women: a retrospective cohort study

“… 1 However, controversies are rising on the routine use of EA. 2 Attention has been focused on the impact that EA might have on the progress of labor and the mode of delivery, namely, the incidence of cesarean delivery (CD) and operative vaginal delivery (OVD). 3 Moreover, the maternal (ie, postpartum hemorrhage [PPH] and vaginoperineal severe injuries) and neonatal (ie, 5-minute Apgar score, need for resuscitation, and neonatal intensive care unit [NICU] admission) outcomes of women choosing EA have been closely analyzed as well.…”