Perfusion Index Variability During Epidural Labor Analgesia

Overview

This prospective, single-centre observational study evaluates changes in the peripheral Perfusion Index (PI) - a non-invasive parameter derived from the pulse-oximetry photoplethysmographic waveform - in women receiving epidural, or combined spinal-epidural (CSE) with intrathecal opioid only, analgesia during vaginal labor. Epidural-induced sympathetic block causes vasodilation and compensatory changes in peripheral vascular resistance, which alter peripheral perfusion and therefore PI. PI is recorded together with routinely monitored haemodynamic, obstetric and analgesia-related variables (including pain intensity on the Numeric Rating Scale, NRS) from before block placement until after delivery. The aims are: to describe the pattern and magnitude of PI changes during labor analgesia and the parameter's usefulness in this dynamic clinical setting; to assess the correlation between PI changes and reported pain; and to evaluate whether PI (its change or the absence of change) can help identify ineffective blocks early - for example those caused by catheter malposition or by sacral sparing in the second stage of labor. All measurements are non-invasive and consistent with the current standard of perinatal care.

Background: The Perfusion Index (PI) is the ratio of the pulsatile (AC) to the non-pulsatile (DC) component of light absorption in the photoplethysmographic waveform recorded during pulse oximetry, expressed as a percentage. Originally used as an indicator of pulse-oximeter signal quality, PI is now recognised as a non-invasive measure of peripheral perfusion. Because both signal components are influenced chiefly by vascular tone and vascular-bed filling, PI changes across clinical states. Spontaneous vaginal labor involves changes in cardiac output, peripheral resistance and blood redistribution, and therefore in PI. Neuraxial (epidural) analgesia further modifies PI: the sympathetic block it produces causes vasodilation and compensatory changes in peripheral resistance in non-blocked regions, altering peripheral perfusion. These changes can be captured systemically by the finger pulse oximeter routinely used to monitor labor analgesia. Analysing PI during epidural monitoring may therefore provide clinically useful information about correct block placement, drug distribution in the epidural space across successive stages of labor, and thus analgesic effectiveness. Design and population: Prospective observational study. Participants are patients admitted to the labor ward of the Department of Obstetrics and Gynaecology, Gynaecologic Oncology and Gynaecologic Endocrinology, University Clinical Centre in Gdańsk, who receive epidural analgesia during vaginal delivery - either as the sole regional technique or as combined spinal-epidural (CSE) analgesia. For CSE, only intrathecal opioids may be administered (the standard approach in these patients); intrathecal local anaesthetic is an exclusion criterion. Both spontaneous-onset and induced labors are eligible. Recorded haemodynamic parameters: PI is recorded automatically together with peripheral oxygen saturation (SpO2). Additional parameters recorded with standard monitors are arterial blood pressure, maternal heart rate (HR) and fetal heart rate (FHR). Monitoring begins before placement of the regional block. Measurement schedule: Parameters are recorded every 5 minutes for the first 30 minutes after administration of local anaesthetic (LA) into the epidural space, and every 15 minutes thereafter. When bolus LA doses are given into the epidural space, 5-minute recording is resumed for 30 minutes from the time of administration. Data are archived as printouts from the labor-ward telemetry system. Regional block data: The type of block and the doses/volumes and concentrations of all administered drugs are recorded with exact times. For drugs given by infusion, the flow rate per unit time and the time range for each rate are recorded. Additional clinical data: Ramsay sedation score; correct block function assessed by cold sensation test; pain intensity on the Numeric Rating Scale (NRS); motor block on the Bromage scale; stage of labor and cervical dilation; body position; and any need to adjust catheter depth or replace the catheter. When reported pain exceeds NRS 4, pain location is additionally recorded. Intravenous drugs and fluids (dose and time), obstetric data (operative vaginal delivery with forceps or vacuum, episiotomy, conversion to caesarean section) and basic demographics (age, gestational week, number of previous pregnancies) are recorded, together with relevant comorbidities and medications to allow later subgroup analyses. Data are archived on a dedicated form or in the patient's anaesthesia chart. Recording duration: Recording runs from before placement of the regional block until 30 minutes after delivery. If delivery is completed by caesarean section, recording continues until the patient is transferred to the operating room. Non-invasive nature and standard of care: All recorded parameters are obtained non-invasively. PI - the study's object of interest - is recorded with the pulse oximeter that forms part of standard monitoring of patients receiving regional labor analgesia. The scope and frequency of monitoring are consistent with the applicable Polish organisational standard of perinatal care and with the procedures of the University Clinical Centre in Gdańsk.