Quality of labor epidural analgesia at a high-volume tertiary care obstetric unit: a before-and-after study

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.