Abstract
Purpose
To determine the causes of failure of epidural analgesia during labour and delivery.
Methods
During six months, pregnant patients receiving epidural analgesia and delivering vaginally were studied prospectively. Bupivacaine 0.125% was used for the initial bolus dose and subsequent continuous infusion. Top-ups of the same solution were used for inadequate pain relief assessed using a visual analogue pain score (VAPS) and/or by clinical examination. Inadequate pain relief was defined as the need for ≥ 2 top-ups in addition to epidural infusion and failure during delivery as VAPS ≥ 30 mm during the expulsion phase.
Results
1009 patients delivered during this period, 596 had epidural analgesia for vaginal delivery of a live infant and data were complete in 456. Inadequate pain relief during labour and during delivery were found in 5.3% and 19.7% of patients. Risk factors of inadequate pain relief included: inadequate analgesic efficacy of the first dose (Odds ratio: 3.5, P = 0.001) and posterior presentation (Odds ratio: 5.6, P = 0.001). Radicular pain during epidural placement was associated with failure during labour (Odds ratio: 3.9, P = 0.05). Duration of epidural analgesia > six hours (Odds ratio: 9.1, P = 0.001) was a risk factor for insufficient pain relief during labour whereas duration of epidural analgesia < one hour was associated with pain during delivery (Odds ratio: 18.3, P = 0.001).
Conclusion
Several obstetrical and epidural-related factors increase the risk of inadequate epidural analgesia. For some, simple changes of practice pattern may lead to improved pain relief.
Résumé
Objectif
Déterminer les causes d’insuffisance de l’analgésie péridurale obstétricale.
Méthodes
Pendant 6 mois, toutes les patientes en travail ayant reçu une analgésie péridurale ont été évaluées prospectivement. La bupivacaïne 0,125 % a été utilisée pour l’injection péridurale initiale et pour la perfusion continue de même que pour les réinjections qui ont suivi l’évaluation de la douleur par l’échelle visuelle analogique (EVA) et la vérification du bloc. Une insuffisance d’analgésie pendant le travail a été définie par le besoin d’au moins deux réinjections (en plus de la perfusion péridurale continue) et lors de l’accouchement par une EVA 30 mm.
Résultats
Parmi les 1009 patientes étudiées, 596 ont reçu une analgésie péridurale pour donner naissance à un enfant vivant par voie vaginale et les données étaient complètes pour 456 d’entre elles (76,5 %). Une insuffisance d’analgésie a été constatée pendant le travail chez 5,3 % des patientes et, lors de l’accouchement, chez 19,7 %. Plusieurs facteurs de risque d’insuffisance d’analgésie ont été communs aux phases de dilatation et d’expulsion: insuffisance analgésique du premier bolus (coefficient de risque CR: 3,5; P = 0,001) et présentation postérieure (CR: 5,6; P = 0,001). La survenue d’une radiculalgie pendant la ponction était associée à un risque d’analgésie insuffisante pendant le travail (CR: 3,9; P = 0,05). Une durée d’analgésie péridurale > 6 h (CR: 9,1; P = 0,001) était un facteur de risque d’insuffisance pendant le travail alors qu’une durée < I h était associée à un risque accru d’échec lors de l’expulsion (CR: 18,3; P = 0,001).
Conclusion
Plusieurs facteurs obstétricaux ou liés à la technique péridurale sont asssociés à un risque accru d’analgésie inadéquate. Pour certains facteurs techniques, des modifications simples des pratiques pourraient conduire à une amélioration notable de l’analgésie.
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Le Coq, G., Ducot, B. & Benhamou, D. Risk factors of inadequate pain relief during epidural analgesia for labour and delivery. Can J Anaesth 45, 719–723 (1998). https://doi.org/10.1007/BF03012140
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DOI: https://doi.org/10.1007/BF03012140