Frequency and risk factors for acute pain during vaginal birth with epidural analgesia: a nationwide population-based study from the 2021 French National Perinatal Survey

Epidural analgesia is the gold standard for labor pain relief, but severe pain during childbirth can still occur. We assessed frequency and risk factors for acute pain at vaginal birth among women using epidural analgesia. Data were from the 2021 French National Perinatal Survey, a cross-sectional, nationwide, population-based study. Women who delivered vaginally with epidural analgesia were included. Pain at the time of birth was assessed using a numerical pain rating scale and categorized as (no/mild [0-3], moderate [4-6], or severe pain [7-10]). Determinants of moderate and severe pain were identified using multinomial multilevel logistic regression. Among 7211 women, 16.9% experienced moderate pain and 31.4% severe pain at birth. Risk factors for severe pain included maternal age <25 years (adjusted odds ratio 1.39; 95% confidence interval [1.14-1.70]), overweight (1.40 [1.20-1.63]), obesity (1.44 [1.19-1.73]), pushing effort >30 minutes (1.94 [1.60-2.36]), epidural-to-birth interval <1 hour (3.49 [2.50-4.87]) or ≥10 hours (1.68 [1.38-2.05]), self-reported partially effective (4.73 [4.07-5.49]) or ineffective (21.3 [14.3-31.8]), epidural analgesia and anesthesiologist not dedicated to maternity care (1.33 [1.11-1.58]). Protective factors included maternal age ≥35 years (0.82 [0.69-0.96]), high education (0.81 [0.68-0.96]), and patient-controlled epidural analgesia [PCEA] (0.70 [0.60-0.83]). The combined spinal epidural technique (CSE) was protective among women with effective epidural and exposed for at least 1 hour (0.22 [0.05-0.98]). One in 3 women who delivered vaginally reported severe pain at birth despite epidural analgesia. Expanding the use of PCEA and CSE technique could improve pain management. Increased vigilance is needed for young, overweight/obese women, and those with short or prolonged epidural-to-birth intervals.