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Quality of labor epidural analgesia at a high-volume tertiary care obstetric unit: a before-and-after study
  1. Robert G Easther1,
  2. Kristi Downey1,
  3. Nancy Watts2,
  4. Xiang Y Ye3 and
  5. Jose C A Carvalho1
  1. 1Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Nursing, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
  3. 3Maternal-Infant Care Research Center, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Robert G Easther, Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, M5G 1X5, Canada; robert.easther{at}


Introduction We wanted to better understand the quality of our labor epidural practice at a large urban academic medical center. Several practice changes were implemented between 2011 and 2017, namely a more uniform epidural loading dose of local anesthetic that includes fentanyl, an increase in both the hourly baseline offer and maximum allowed hourly amount of bupivacaine, and the change from a continuous epidural infusion to a programmed intermittent epidural bolus (PIEB) regimen. We aimed to assess the impact of those changes on the quality of labor analgesia.

Methods We performed two separate audits representing before-and-after groups. The audits were performed in November 2011 (before group) and November–December 2017 (after group). The data for 2011 were extracted from a previously published study. Hence, we conducted a similar audit in 2017, including only outcomes that were included in the previous audit. The primary outcome was the presence of pain >3 (Numerical Rating Scale 0–10) at any time during first or second stage of labor. Secondary outcomes included top-up requirements, and women’s pain perception during the first and second stage of labor according to a postpartum questionnaire.

Results We studied 294 and 247 women in the before-and-after groups, respectively. The proportion of women reporting pain >3/10 at any time during labor and delivery significantly decreased in the after group (30% vs 41%; p<0.01). In an adjusted analysis, there was a 35% reduction in the likelihood of pain scores>3 for the after group (OR 0.65, 95% CI 0.46, 0.94). Women in the after group received fewer top-ups by nurses (3% vs 24%, p<0.001). Most women in both cohorts (85% before and 87% after) were satisfied with the overall quality of analgesia.

Discussion A bundle of practice changes implemented in our clinical practice, including the PIEB regimen, has resulted in a significant improvement in the quality of labor analgesia. However, despite all the implemented changes, 30% of women still experience pain during labor and further optimization of our practice is warranted.

  • analgesia
  • pain management
  • obstetrics

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This was an observational before-and-after study approved by the Mount Sinai Hospital Research Ethics Board (REB 17–0262-E, approved November 15 2017, chairperson Dr Ronald Heslegrave). The Mount Sinai Hospital Research Ethics Board approved the reuse of such data in the before-and-after study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author, RGE, on reasonable request. Deidentified digital and non-digital data supporting this study are securely curated at Mount Sinai Hospital, Toronto.