Labour Analgesia-Epidural/Combined Spinal Epidural/Dural Puncture Epidural/Entonox - A Cafeteria Choice for the Patient or Just Research!

Most medical treatment choices are made via shared decision-making where the patients’ preferences and personal values are considered. This needs to be done while discussing multiple medically reasonable treatment options in concordance to the ethical principle of autonomy. The term patient autonomy in case of parturient reporting pain relief during labor would essentially mean her right to decide the modality of this pain relief without the anesthesiologist or the obstetrician making a choice on her behalf. In the developed world, it would be easier for the parturient to discuss all these issues, but this becomes tougher in the developing world where analgesia for labor is not as popular as in the developed countries. In the developing world, there are different challenges regarding such issues due to various languages and dialects spoken in the same region/country.^[1]

The choices for the parturient under ideal circumstances would be—non-pharmacological techniques like—transcutaneous electrical nerve stimulation (TENS),^[2] massage,^[3] acupuncture, and acupressure,^[4] pharmacological techniques that include parental pethidine, Entonox,^[5] and invasive techniques like simple epidural, combine spinal epidural (CSE), and dural puncture epidural (DPE). Often, a parturient requests for inputs on these from the obstetrician with whom her interaction is more frequent as compared to the anesthesiologist who happens to be the primary analgesia provider!

The choice of the technique of labor analgesia in centers where all facilities are available basically depends upon the standard modality of practice at that place—most often this being a continuous epidural or less frequently a CSE. A parturient is usually never offered a choice—explaining impartially the pros and cons of all the techniques. It is a standard practice to ‘push’ a technique that the obstetrician or an anesthesiologist prefers.

Among the regularly used techniques, Entonox was popular a few decades ago. It is safe for the baby, easy to use and inexpensive. However, it has certain disadvantages—main being dizziness, nausea, and vomiting—but these usually disappears soon after the gas is discontinued. The pain relief has been documented to be unreliable and not as effective as a continuous epidural. However, it is ideal for birthing centers where the parturient can have a homelike experience. It would also be ideal for parturient who prefers to have a natural childbirth experience and have reservations on getting an epidural. Further after a natural childbirth it could be ideal for episiotomy repair.^[6] Nitrous oxide may not be ideal, but it is still an option that needs to be given to a parturient. Usually, an anesthesiologist would lose interest in such a parturient—reasons being the fact that midwifes are supposed to use it and obviously the anesthesiologists is not paid for this kind of analgesia.

The choice between an epidural, combined spinal epidural and dural puncture epidural is often anesthesiologist dependent. Epidural has been time tested, considered to be a gold standard, however, has its issues that include back pain, and questionable prolongation of the duration of labor. It is popular not only because of the above-mentioned reason but also since globally anesthesiologists is familiar and experienced with this technique. Combined spinal epidural (CSE) came into vogue in early 2000 and the term walking epidural made it very attractive for the parturient, allowing her the possibility to ambulate with the epidural catheter. It offered rapid onset of analgesia, better sacral analgesia, reduced failure rates and higher maternal satisfaction. It is ideal when a parturient decides to shift from a non-pharmacologic technique to something more invasive when she finds pain unbearable as the onset of pain relief is quick. It has been described as more technically challenging and has a propensity to hemodynamic instability, fetal bradycardia due to side effects of local anesthetics and opioids that give immediate pain relief.

Dural puncture epidural technique (DPE) was advocated as a superior technique to an epidural in late 2015. Proponents of CSE and DPE have published numerous articles citing advantages—indirect confirmation of Tuohys needle placement in epidural, better midline placement confirmation in difficult anatomical landmarks, increased transfer of epidural medication into the intrathecal space, improving onset of analgesia, early bilateral sacral analgesia, lower incidence of asymmetric block, and fewer maternal and fetal side.^[7] However, data regarding the efficacy of this technique compared to standard epidural is sparse and conflicting^[8–12] though proponents insist that this is the ideal technique for labor analgesia. DPE involves intentional dural puncture with a spinal needle through the needle placed in the epidural space but without administration of intrathecal drug. It is possible that not many anesthesiologists would be comfortable in deliberately puncturing the dura followed by the instillation of the analgesic solution in the epidural space in a parturient. Besides, traditionally anesthesiologists have been taught that an accidental puncture of the dura mater would have a separate protocol to be followed due to high incidence of post-dural puncture headache. Hence, the idea of puncturing dura purposely is not well accepted yet.

In this era of patient autonomy, it is ideal that a parturient should be provided with all the information of the modalities available. In simple terms and the language that she understands well before the onset of labor so that she can discuss with her family, friends and medical personnel and decide what she would prefer.

Regarding the expertise of the anesthesiologists or the labor analgesia units there could be separate teams practicing or providing a particular technique so that the particular team could be summoned to provide analgesia to the parturient. This would not only lead to expert analgesia units that can manage better but lead to tremendous clinical data that could be collated after a given time to further suggest and frame guidelines. It is high time that research regarding labor pain relief is clinically utilized and the parturient can be allowed to choose what she prefers. However, there could be a possibility that the parturient finally leaves it to the obstetrician or the anesthesiologist for the decision!