Frequency and risk factors for acute pain during vaginal birth with epidural analgesia
Introduction: Epidural analgesia is the gold standard for labour pain relief, but severe acute pain during childbirth can still occur. Findings from the last edition of the French National Perinatal Survey revealed that women undergoing vaginal birth experienced severe acute pain at the time of birth. Given this unexpectedly high rate of severe pain despite the use of epidural analgesia, we aimed to assess the frequency and risk factors for acute pain at the time of vaginal birth with epidural analgesia
Methods: Data were from the National Perinatal Survey (Enquête Nationale Périnatale), a cross-sectional, nationwide, population-based study conducted in France in March 2021. Women who delivered vaginally with epidural analgesia were included. The intensity of acute pain at the time of childbirth was assessed using a numerical pain rating scale ranging from 0 (no pain) to 10 (unbearable pain), and categorized into 3 groups: no/mild pain [0-3], moderate pain [4-6], or severe pain [7-10]. Risk factors for moderate and severe pain were identified using multilevel multinomial logistic regression to account for confounding factors and the lack of independence among women cared for in the same maternity unit.
Results: The study included 7,211 women who delivered vaginally with epidural analgesia. Among them, 1,217 (16.9%) experienced moderate pain and 2,267 (31.4%) severe pain at the time of birth. Independent risk factors for severe pain were maternal age < 25 years, overweight/obese status, prolonged pushing efforts, 1st or 2nd degree tears, short or long duration of epidural analgesia, self-reported partially effective or ineffective epidural analgesia, and non-dedicated to obstetric care or temporary anaesthesiologists. Severe pain was more likely experienced for nulliparous women with operative birth as compared with nulliparous women with spontaneous birth. Maternal age ≥ 35 years, educational level ≥ 5 years post-graduation, and PCEA use were protective factors for severe pain. One in six women reported moderate pain, and risk factors were the same as for severe pain, except for obesity, 1st or 2nd degree tears, operative birth among nulliparous women and temporary anaesthesiologists.
Conclusion: In this nationwide, population-based analysis, despite the use of epidural analgesia, 1 in 3 women reported severe pain and 1 in 6 reported moderate pain at the time of vaginal birth. We identified clinical situations requiring increased vigilance regarding the quality of epidural analgesia, particularly in young, overweight or obese women, and in those with a short or prolonged labour. Several modifiable risk factors were also identified that suggest optimisation strategies, particularly the use of PCEA for all women, expanding the use of the CSE technique, and increasing the proportion of anaesthesiologists dedicated to obstetric care.
By Clara Rollet, Anne Chantry, Marie-Pierre Bonnet
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