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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 382-386

Effect of epidural labor analgesia on fetal heart rate and neonatal outcome


Department of Obstetrics and Gynecology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission18-May-2020
Date of Decision10-Jun-2020
Date of Acceptance30-Jul-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Harsha Shekhawat
Department of Obstetrics and Gynecology, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_194_20

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  Abstract 


Introduction: Epidural analgesia does not affect the neonatal outcome as shown in this study by the similar APGAR scores and neonatal intensive care unit (NICU) admissions when compared with normal delivery without epidural analgesia. Aims: This study aims to find the fetal heart rate variability and neonatal outcome in women, who are opting for epidural anesthesia in comparison to women without any pain reliving modality. Subjects and Methods: The present study was conducted in the Department of Obstetrics and Gynaecology at Datta Meghe Institute of Medical Sciences, Wardha, over period of 2 years from September 2017 to August 2019 after taking approval from Institutional Ethical Committee. One hundred women who fulfilled the inclusion criteria were included in the study, 50 women received epidural analgesia for relief of labor pain at =4 cm and 50 women were left for spontaneous delivery. The factors studied were fetal heart rate (FHR) variability and NICU admissions in both the groups. Statistical Analysis Used: SPSS version 19; Chi-square test and Student's t-test. Results: Epidural analgesia was associated with transient fetal heart variability which however was not statistically significant and was comparable with nonepidural group. Conclusions: Epidural analgesia is an effective method of pain relief and it must be an option available to all laboring women. There are no significant effects on FHR variability and does not affect neonatal outcome.

Keywords: APGAR scores, epidural labor analgesia, fetal heart rate, neonatal intensive care unit admission, neonatal outcome


How to cite this article:
Shekhawat H, Shrivastava D, Dhurve K, Shelke U, Deo A. Effect of epidural labor analgesia on fetal heart rate and neonatal outcome. J Datta Meghe Inst Med Sci Univ 2020;15:382-6

How to cite this URL:
Shekhawat H, Shrivastava D, Dhurve K, Shelke U, Deo A. Effect of epidural labor analgesia on fetal heart rate and neonatal outcome. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 4];15:382-6. Available from: http://www.journaldmims.com/text.asp?2020/15/3/382/308555




  Introduction Top


“Childbirth is virtually the rebirth of a mother.”

Epidural analgesia use during labor helps the mother to not only be conscious but also be relatively pain free without affecting the fetus. Effective pain control in labor should be a good medical practice and in fact an act of kindness for the mother. Additional advantages provided by epidural analgesia is the way it helps in overcoming the adverse ventilatory efforts of pain resulting in an increase in oxygen tension in both mother and fetus, which may be beneficial especially when additional conditions contributing to fetal or maternal hypoxia are also present.

With the advancement in the field of science, various pain relief methods have now been proposed that make pain-free delivery possible. In comparison to other methods of pain relief in labor, epidural analgesia is safer and is useful to minimize the chances of respiratory distress which is possible with systemic opioid. Epidural analgesia also shows beneficial effects when used in cases of severe preeclampsia where it improves the uteroplacental blood flow.[1] Despite these advantages, the use of epidural analgesia in labor is always associated with fear of the pregnant lady about her neonatal outcome. However, this controversy needs to be resolved by evidence-based medicine.

An important parameter in the diagnosis of fetal distress is the baseline fetal heart rate (FHR) variability when electronically monitoring the fetus.[2] Normal FHR variability is generally associated with fetal normoxia. After the administration of epidural labor analgesia, slight variability in FHR occurs which is usually transient and benign; and it does not affect the neonatal outcome as such.[3]

Despite facilities for reducing labor pain being available at tertiary set ups, the rural population is quite hesitant to adopt the painless mode of delivery due to myths and fear about neonatal outcome. Since the time of usage of regional analgesia for labor pain relief was invented, the debate has continued to know its impact on the labor and its effects on the neonate. To disentangle the controversy, the fetal outcome amongst both groups should be compared by evaluating APGAR scores and neonatal intensive care unit (NICU) admissions. Therefore, in this study evaluation in terms of FHR variability and on neonatal status after the administration of epidural analgesia in parturient compared with the nonepidural group.


  Subjects and Methods Top


This observational study was conducted in the Department of Obstetrics and Gynecology over a period of 2 years from September 2017 to August 2019 after obtaining clearance from the Institutional Ethics Committee (Ref No. 6670). Statistical analysis was done with SPSS version 22.0 software (SPSS Inc., Chicago, Ill., USA). Chi-square test and Student's t-test used for calculation of the data. P < 0.05 was considered as level of significance.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Sharad Pawar Dental College, Sawangi(M), Wardha. Date: 10th Feb 2017 with Reference no DMIMS(DU)/IEC/2017/125


  Results Top


The present study was conducted in the Department of Obstetrics and Gynecology, Datta Meghe Institute of Medical Sciences, Wardha, to study effect of epidural analgesia on fetal heart variability and neonatal outcome when compared with parturients not receiving epidural analgesia. The mean age of women in the epidural group of our study was 25.66 ± 3.49 years against a mean of 24.62 ± 3.11 years in nonepidural group which was not significant and was comparable to the study done by Agrawal et al.[4] where mean age was 28.17 ± 3.90 years in epidural group and 26.18 ± 4.08 years in nonepidural group. The mean age in different studies done by Lim et al., and Yin and Hu in 2019 showed mean age group of 28.66 ± 2.95 in epidural group and 28.67 ± 3.11 in nonepidural group which was similar to our study.[5],[6]
Figure 1: Comparison of parturients according to fetal heart rate range in Group A before epidural analgesia with Group B

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Figure 2: Comparison of FHR variability in Group A

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This study showed that the mean gestational age was comparable in both the groups. In epidural group, the mean value was 38.28 ± 1.44 while in nonepidural group, it was 38.70 ± 1.11 which was comparable to study done by Yin and Hu who had observed similar mean gestational age, 39.36 ± 2.81 in the epidural group while it was 39.04 ± 3.10 in nonepidural group.[6]

In epidural group, it was noticed that within 30 min of epidural drug administration, the FHR dropped from the baseline by 20–30 bpm in few paturients, however, in next 30 min to 2 h of epidural initiation, majority of the FHR baseline regained their normal pattern. Few patterns of nonreassuring cardiotocography (CTG) which did not improve until 2 h, had regained its pattern after 2 h of epidural drug administration.

Capogna[7] reviewed the FHR changes in different studies and concluded that the FHR changes that occur were neither predictable nor produce any fetal morbidity and also stated that FHR changes are contributed by various other factors as well, like rapid fetal descent or relaxation of perineal muscles. Similar study was done by Lavin[8] that showed pathological change on CTG which usually became normal within 2 h.

Other study done by Yang et al.[9] stated that within 10 min of epidural analgesia, there occurs fetal bradycardia (FHR <70 bpm) which is normalized in 10 min of epidural analgesia. In a research analysis done by Mardirosoff et al.,[10] seventeen trials (2081 women) had given a report of FHR abnormalities. Nine out of all the trials (927 women) reported dichotomous data on fetal bradycardia within 1 h of labor analgesia.

The mechanism of fetal bradycardia was explained by Clarke et al.[11] which was again reviewed by Riley[12] in 2003 where the proposed mechanism was evaluated with other studies as well. The reason for fetal bradycardia as proposed was:

  • Pain relief decrease in the sympathetic nervous system output significant decrease in circulating epinephrine level after labor analgesia induction.


Epinephrine acts as a tocolytic. Decrease in epinephrine increased uterine tone decreased placental blood flow subsequent fetal bradycardia.

In the recent study done by Kesavan et al.[13] in 2018, showed similar result where they found only 2 out of 60 women had fetal bradycardia which did not cause a significant difference in the results. The review done by Nicole Maria et al.[14] in 2011 also showed comparable findings with other studies showing that the fetal bradycardia occurred within 20 min of anesthetic administration which however did not influence the neonatal outcome in any. In the study conducted by Korebrits et al.,[15] 24% of CTGs showed variable decelerations before and 35% showed decelerations after epidural analgesia.

This study showed that APGAR score at 1 min and 5 min in epidural group and nonepidural group were comparable and was not significant statistically. As per the World Health Organization recommendation,[16] epidural analgesia in labor does not cause difference in APGAR score. This was also stated by Duarte and Figueira[17] where they concluded that there was no significant difference in both the groups with results of APGAR score in both the groups comparable [Table 1],[Table 2],[Table 3],[Table 4].
Table 1: Comparison of parturients according to fetal heart rate range in Group A before epidural analgesia with Group B

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Table 2: Comparison of fetal heart rate variability in Group A

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Table 3: Comparison of Group A and Group B according to mean Apgar scores at 1 and 5 min by independent t-test

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Table 4: Comparison of Group A and Group B according to the indication for neonatal neonatal intensive care unit admission

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  Discussion Top


As per the study on neonatal effects of labor analgesia done by Gaiser,[18] in patients with epidural analgesia, pediatricians were more likely to intervene and assign low APGAR scores, and they also stated that the adverse neonatal effects were transient and APGAR at 5 min were normal. Similar findings published by Cochrane data-based study[19] in 2012 stated that there was no significant difference in APGAR score or neonatal status in both the groups. Similar findings were also found in studies done by Agrawal et al.[4] and Anwar et al.[20] where they concluded that APGAR scores were comparable in both the groups and stated that epidural analgesia does not affect the neonatal status or outcome. The study concluded that the NICU admission in both the groups were insignificant and did not depend on type of delivery. This was similar to the study done by Kumar and Kumar[21] in 2019 and a prospective study done by Shrestha et al.[22] in 2014 which showed no significant association of epidural analgesia with birth asphyxia and NICU admission. Also as per the WHO[16] recommendation given in 2018, epidural analgesia did not cause any fetal morbidities or any significant difference than normally delivered babies. In the present study, we found no significant difference in outcome of the neonate later in the fetuses born with mothers who received epidural analgesia.

The various clinical conditions leading to NICU admission was also studied in the present study. Different clinical conditions associated were transient tachypnea of newborn, birth asphyxia, shoulder dystocia, and neonatal sepsis. No neonatal mortality was reported in any Groups. This finding was similar to study done by Hasegawa et al.[23] who stated the short-term adverse neonatal outcomes are mainly because of instrumental deliveries rather than epidural analgesia itself. In addition, other study done by Reynolds[24] stated that there is no significant effect on neonatal outcome due to epidural analgesia as such in the study population.[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34]


  Conclusions Top


By the present study, we conclude that, induction of epidural analgesia can result in transient FHR changes mostly for 30 min in 34% of cases but the changes were insignificant as they were normalized after 30 min of epidural analgesia and hence epidural analgesia did not affect the neonatal outcome as evidently shown in this study by the similar APGAR scores and NICU admissions in both the groups.

Limitations of this study can be attributed to negative mindset of rural people toward epidural analgesia affecting outcome of neonate or adverse effects of epidural analgesia as such.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: A randomized, controlled, prospective trial. Am J Obstet Gynecol 1993;169:851-8.  Back to cited text no. 1
    
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