A study on the maternal and Perinatal outcome of Obstetric analgesia during labour

INTRODUCTION: The birth of an neonate to the pain free parturient will be the most rewarding moment in Obstetric practice. The most painfull experience in a woman s life is labour. Quite unbearable is the pain of child birth and its related agony at times is beyond description. The mother of yesterday is no more the mother of today”. Complex, psycological, physiological interactions are involved in labour. Multiple system like gastrointestinal, cardiovascular, respiratory, genito urinary, neuro endocrine may be affected if pain not adequately controlled, blood flow to the placenta which may be reduced due to pain lead to altered fetal homeostasis. These consequences are avoidable by effective analgesia during labour. There are several methods that can be employed in labour pain control like intravenous anesthesia’ opiod analgesics local anesthetics inhalational anesthetics regional anesthetics, lumbar epidural analgesics The most effective and least depressant treatments for labor pain are the neuraxial techniques allowing for an alert and participating mother [ACOG]. AIMS AND OBJECTIVES: The study aim is to analyse the maternal and perinatal outcome of obstetric analgesia during labour. The study also compares with outcomes of those who did not receive analgesia. The study was conducted at Institute of Social obstetrics and Government Kasturba Gandhi Hospital, Chennai from the period of November 2012 to November 2013. OBJECTIVES: To study the effects of obstetric [epidural] analgesia in the following aspects: 1. Effectiveness of pain relief in terms of maternal comfort satisfaction. 2. Duration of labour its influence on all three stages and the initiation of analgesia to delivery interval. 3. Mode of delivery –spontaneous vaginal instrumental and LSCS. 4. Maternal complications like hypotension, pyrexia, backache, headache, bladder dysfunction and third stage complication like retained placenta, PPH, urinary retention. 5. Neonatal outcome in the form of Apgar scores intrapartum post partum and early neonatal complications and birth weight. MATERIALS AND METHODS: This study was carried out in 70 women who were admitted with labour pain for safe confinement in the department of Obstetrics and gynecology at Institute of Social Obstetrics and Government Kasturba Gandhi Hospital, Chennai during the period October 2012 to November 2013. Study Design : Descriptive case study. Institutional ETHICAL COMMITTEE Clearance obtained METHODOLOGY: 70 Pregnant women who received epidural analgesia in labour were enrolled in this study. The patients with similar profile as study group were enrolled as control groups. Inclusion Criteria: 1. Women with gestational age more than 37 weeks maturity confirmed by Ultra sound in established labour with regular uterine contractions (3 -4 in 10 minutes lasting 45 seconds) with cervical effacemet more than 50 % and dilatation > 3 cms with cephalic presentation. 2. Age > 18 years < 35 years. 3. Height >145 – 160 cms. 4. Weight 50 -65 Kgs. 5. No fetal distress. Exclusion Criteria: 1. Patient refusal. 2. Known case of allergic reaction to local anesthetics 3. Women with cephalo pelvic disproportion and contracted pelvis and Malpresentation. 4. Coagulation problems and thrombocytopenia. 5. Aspirin within 3 days Platelets less than 80000. 6. Severe Preeclampsia-abruption HELP Syndrome. 7. Placenta previa with hemodynamic instability. 8. Severe Anemia. SUMMARY: In my study on obstetric analgesia using low dose epidural analgesia initiated with the help of anesthesiologist majority of paturients had effective pain relief with more than 70% had good to excellent comfort and satisfaction and more than 80% acceptance expressed their preference for the same in their subsequent pregnancies.The mean age 25 yrs and gestational age 39 weeks same as the controls. Regarding the onset of analgesia more than 55% showed rapid onset in less than 15 min of initiation and also had longer duration of analgesia. Regarding duration of labour patients with epidural analgesia had longer labours particularly of the second stage which showed significance with controls. Majority of patients delivered in 8 to 10 hrs of initiation of main dose of analgesic which was little lengthier than the controls Regarding mode of delivery 60% had spontaneous vaginal delivery consistent with the controls and 19% instrumental delivery and 21% caesarean consistent with the controls and showed no significance. The indication for caesarean was fetal distress in 3 patient which was not due to the direct result of epidural but due to cord around the neck and oligohydramnios. The indication for instrumental delivery was failure of maternal expulsive efforts in 60% that holds same for in the controls. The mean Apgar in 1 min and 5 min were 6 and 7 similar to the controls implying epidural had no adverse effect on neonatal outcome. The perinatal mortality was lesser in the study group compared to the controls. Regarding maternal complication, 2 patients had retained placenta successfully managed with manual removal under epidural analgesia without the need for general anesthesia and no curettage needed subsequentl. 2 patients who had urinary retention treated with continuous bladder drainage which occurred due to prolonged labour in one patient with instrumental delivery and the other with traumatic PPH which needed suturing. Other minor complications were managed symptomatically. None of them developed long term neurological deficits. CONCLUSION: In my study conducted in labour ward of ISO KGH for 70 parturients who requested and consented for epidural analgesia for pain relief I conclude that the use of low dose epidural with predominant Sensory block with preservation of motor function was effective with quick pain relief and excellent patient comfort and satisfaction and freely movable in the first stage without major adverse effect on maternal hemodynamics with more spontaneous vaginal delivery and the rate of instrumental and caesarean comparable to controls but with longer labours particularly of second stage and favourable neonatal outcomes. Lesser perinatal mortality and few manageable maternal side effects and proven safety to the mother and fetus in quality labour management offered by the dedicated obstetrician with the help of an experienced Anesthesiologist to our expectant mothers of today and tomorrow