Which position is best? A randomized clinical trial on the effect that position has on walking labour epidural analgesia

By: Alex Stathakis, Dr. Monica San Vicente & Dr. Jennifer O'Brien

Background: Epidurals are one of the most common procedures for labour analgesia. Current protocols involve patients remaining supine with left uterine displacement with a wedge or pillow for 15-30 minutes after epidural insertion for anesthetic spread, despite this possibly being suboptimal for comfort and fetal heart rate monitoring. Much of the research supporting this practice is outdated and involved more concentrated local anesthetic solutions than what is used today. It remains unknown whether positioning has an effect on epidural spread at these lower concentrations.

Research Questions: Does patient position after securing an epidural change its effectiveness when using our current dilute anesthetic solutions? Is there any significant impact on maternal hemodynamics and fetal heart rate between these positions?

Methods: The study will be a randomized clinical trial involving 216 patients distributed across four treatment groups: left uterine displacement (n=54), left side down (n=54), right side down (n=54), or seated upright (n=54). After receiving an epidural, patients will be positioned for 20 minutes while being bolused a standard 20 cc of epidural solution. Following 20 minutes, patients will be returned to a position of their choosing while remaining on a standard epidural infusion. The primary outcome will be pain scores with contractions. Pain will be assessed using a verbal rating scale (VRS) at 0 minutes, 20 minutes, and 40 minutes after epidural insertion. The secondary outcomes will be maternal and fetal hemodynamics, and the quality of the sensory block achieved by the epidural. Maternal blood pressure, fetal heart rate, and sensory block will be assessed as per current departmental nursing protocols.

Implications: If position is found to have no significant effect on epidural effectiveness, this can lead to protocol changes that would improve comfort and the overall experience for labouring patients receiving an epidural.

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