Upper back, neck, and shoulder pain during labor epidural analgesia: a quality improvement initiative

Severe upper back/interscapular, neck and shoulder pain during labor epidural analgesia (PLEA) is not uncommon. The objective of this quality initiative was to evaluate the incidence, demographic associations and management of PLEA.

An eight-month, single-center quality improvement initiative was performed for the detection and management of PLEA. After survey-based consensus among obstetric anaesthetist attendings and fellows, a three-step PLEA treatment protocol with interventions and numeric rating scale (NRS, 0 - 10 scale) pain assessments was introduced. Demographic data and outcomes were compared among parturients with and without PLEA.

Among 2888 women who received labor epidural analgesia from October 2022 through May 2023, 36 (1.2% [95% CI 0.9% to 1.7%]) reported PLEA. Women with PLEA were younger, more likely to be nulliparous, and had a higher body mass index (BMI) than women without PLEA (p < 0.05 for all). A total of 72.2% (26/36) of women with PLEA received at least one protocol treatment. Twenty-three women received first-line therapy, with pain relief in 91.3% (21/23). The median NRS score decreased from 9 [IQR 8-10] to 3 [1-4]. Women with PLEA had a higher incidence of cesarean delivery (CD) and a longer interval between epidural placement and delivery; 52.8 vs. 17.5% (p < 0.001) and 16.5 vs. 6.9 hours (p < 0.001), respectively.

The incidence of PLEA was higher than previously reported. Patients with PLEA were younger, more commonly nulliparous, had higher BMI, longer epidural infusion times and higher CD rates. A three-step treatment protocol was successful in managing PLEA.