Key findings:

Key findings from the study on the effect of Vedic chants on laboring parturients with ambulatory epidural labor analgesia include: Comparable cervical dilatation at epidural insertion, similar duration of labor, and mode of delivery between the group listening to Vedic chants and the control group. No maternal complications like hypotension or bradycardia were reported in either group.

What is known and what is new?

The known aspect in this abstract is the use of epidural analgesia for pain relief during labor. The new contribution is the evaluation of the effect of Vedic chants on labor progression, mode of delivery, and maternal complications in laboring parturients receiving ambulatory epidural analgesia, which has not been extensively studied before.

What is the implication, and what should change now?

The implication of the study on the effect of Vedic chants on labor progression, mode of delivery, and maternal complications in laboring parturients with ambulatory epidural labor analgesia suggests that listening to Vedic chants did not significantly impact labor outcomes or maternal complications. Changes needed include further research to explore alternative methods for enhancing labor experiences and outcomes in a more diverse population.

INTRODUCTION

Labor pain can be described as a paradoxical experience; one that is excruciating and yet desirable because of its positive outcome — the birth of a child [1,2],  It is often described as the most challenging and intense pain experience a woman may go through, and yet enormous variations in women’s perceptions of this pain exist. [2,3] 

Primary advantage of ambulation in labor includes parturient freedom of mobility, autonomy and self-control in labor, increased uterine activity and intensity of contractions, decreased frequency of contractions, decreased pain and duration of the first stage of labor, fewer incidences of fetal heart rate abnormalities and decreased incidence of operative and/or assisted deliveries. [4]

Recently, the role of cultural chants in reducing pain in labor has been reported. Chanting and deep breathing experiences as music therapy during the latent stage of labor may reduce pain perception and pain behaviors. Due to well-known limitations and serious side effects of painkillers, nowadays non-pharmacological methods such as music therapies are being broadly recommended. There are a few studies that analyze the effect of Vedic chants on anxiety and pain during labor. Listening to Vedicchants and Indian classical instrumental music has beneficial effects on alleviating anxiety levels induced by apprehension of invasive procedures and can be of therapeutic use. [5-6] 

Listening to Vedicchants is thought to increase pain tolerance through a number of mechanisms, including the reduction of anxiety and apprehension, decreased catecholamine response, increased uterine blood flow, and decreased muscle tension during labor. [7-8]

Recently, the role of cultural chants in reducing pain in labor has been reported. Chantsing and deep breathing experiences as music therapy during the latent stage of labor may reduce pain perception and pain behaviors and beneficial effect on labor progression. [9]

There is insufficient evidence to make a judgment about whether or not Vedicchants are effective for pain and anxiety relief in labor. In the present study, we aimed to evaluate the effect of Vedic chants on labor progression, mode of delivery and Maternal complications in Laboring Parturients with Ambulatory Epidural Labor Analgesia.

Aim & Objectives:

To evaluate the effect of Vedic chants on labor progression, mode of delivery and Maternal complications in Laboring Parturients with Ambulatory Epidural Labor Analgesia

• Study Site: Departments of Anaesthesia, and Obstetrics & Gynaecology, Dr. RPGMC Kangraat Tanda (rural), Himachal Pradesh.

• Study Design: Prospective randomized controlled study.

• Study Duration:

The study was conducted over the period of 18 months including data collection, data organization, presentation, analysis, and interpretation.

• Sample Size:

Sample size was calculated to a total of 80 patients (40 patients in each group). But due to COVID-19 pandemic limitations, only 38 patients (16 in Group A and 22 in Group B) were included in the study. 

• Inclusion Criteria:

Term live cephalic singleton pregnancy in active labor who were having contractions at least once in 5 min with cervical dilation 0–4 cm with a request for ambulatory labor analgesia were included in the study.

• Exclusion Criteria:

• Patient refusal for the procedure.

• Local infection at site of epidural catheter placement.

• Thrombocytopenia.

• Coagulopathies.

• HELLP syndrome.

• Sepsis.

• Deafness.

• Spinal column deformities and spine surgery.

• Patient having hypersensitivity to the study drug.

• In case of Intrathecal catheter placement.

• In case of accidental dural puncture.

• Non-reassuring fetal heart rate.

• Prematurity and post-maturity.

• Methodology:

After the intimation from the obstetrician, the information regarding the epidural labor analgesia was explained to the laboring parturient and thereafter written consent for epidural labor analgesia was taken by the anesthetist on duty. Before commencing the procedure, a case record form was filled for each patient. After that the patient was taken to the labor analgesia room in the maternity complex. Patients were coloaded with 10 ml/kg of ringer lactate over 15 minutes, after securing intravenous line and all standard monitors like BP, SPO2, ECG attached, and vitals were recorded in case record sheet. Patient was positioned in the left lateral or sitting position and the procedure was carried out under all aseptic precautions. Skin was infiltrated with 2 ml of 2% xylocaine at L2-3 or L3-4 intervertebral space. Epidural space was identified using a loss of resistance technique to normal saline with an 18G Tuohy’s needle and 20-gauge multi-orifice catheter was threaded through the cephalad directed tip of the epidural needle to a depth of 5 cm into the epidural space. The catheter was secured and the patient was placed in the supine position.

• Drug preparation for Epidural Activation:

Epidural drug was prepared by taking two, 10 ml of syringes. In each syringe 5ml of 0.2% ropivacaine with 3.5ml of 0.9% normal saline and 1.5 ml of fentanyl (10µg/ml) was added to it. Thus, a total of 20 ml of drug was prepared with a final concentration of 0.1% ropivacaine and 1.5ug/ml of fentanyl in it for loading the epidural space.

• Activation of Epidural Catheter for Labor Analgesia:

The prepared drug was given in increments of 3 ml and each increment was considered as the test dose given after negative aspiration for blood and CSF and time was noted every time the increment was given. The adequacy of analgesia was assessed 5 min after the increment of drug administered. Analgesia was considered adequate if pain score was<3. 

Patient was instructed to pass the urine as and when required by her, accompanied by attendants.

• Vedic Chanting Procedure:

Randomization was done by computer generated random sequence number method to randomly divide them in two groups A and B. In group A, 16 and in group B, 22 patients were taken due to covid -19 pandemic limitations.

• Group A:

All the patients listened to an already downloaded Vedic chants (Gayatri mantra) in mobile phone [Moto G2 (which belong to primary investigator) by earphones or by playing it in the background depending upon the patient’s choice] in 4 sessions of 30 minutes each with 15 minutes break in between after established epidural labor analgesia and consent of the patients.

• Group B:

All the patients got only epidural labor analgesia and did not listen to Vedic chants (Gayatri mantra).

Labor was managed according to the Obstetric department’s standard protocol. Mode of delivery (normal/instrumental delivery/cesarean delivery) was noted. The epidural catheter was removed after normal or cesarean delivery.

• Ethical Consideration:

The study was initiated following approval from Institutional Ethics Committee (IEC) at Dr. RPGMC Kangra at Tanda. Consent form was collected from each enrolled study subject. 

The data was entered in Microsoft excel spreadsheet. Statistical analysis was done using Microsoft excel and exported into SPSSv21.0 and online ‘social science statistics’ software. The quantitative data was analyzed and expressed as mean±SD and percentages. Student’s t-test was used for comparing continuous variables between the two groups. Chi square and Fisher’s exact test was used for comparing the categorical data between the two groups.

The present study compared the effect of ambulatory epidural labor analgesia with Vedicchants (EA+VC) and ambulatory epidural labor analgesia (EA) alone in patients on labor progression, mode of delivery and Maternal complications. A total of 38 patients were included in the study at the Department of Anaesthesiology and the Department of Obstetrics & Gynaecology, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda. Results of the study have been presented below:

• Treatment Arms:

Patients were randomly divided into two groups. The patients in group A were made to listen to Vedicchants (Gayatri mantra) after established epidural labor analgesia and patients in group B received only epidural labor analgesia.

Table 1: Treatment arms

Mean age of the patients in group A (25.1±4.8) was comparable to that in group B (25.6±3.3); p=0.69. Mean height of the patients in group A was comparable to that in group B (156.9±3.5 vs. 157±3.2; p=0.955). Mean weight of the patients in group A was comparable to that in group B (61.4±7.9vs. 62.6±6.5; p=0.623).Mean BMI of the patients in group A was comparable to that in group B (22.5±4.4 vs. 21.1±4.2; p=0.170). Mean POG of the patients in group A was comparable to that in group B (39.1±0.8 vs. 39.1±0.9; p=0.914). ( Table 1)

Table 2: Comparison of socio-clinical variables between two groups

Mean cervical dilatation of the patients in group A was comparable to that in group B (3.9±0.6 vs. 4.1±0.6; p=0.331), at time of epidural insertion. One contraction per 5-minutes was noted in all the patients in two groups at time of epidural insertion. ( Table 2)

In Group A 14 (87%) of women delivered through normal vaginal delivery (NVD) and 2 (13%) through emergency lower segment caesarian section (ELSCS). In Group B 15 (68%), 5 (23%), 1 (4.5%) and 1 (4.5%) delivered through NVD, ELSCS, vacuum and forceps respectively.

Mean duration of labor of the patients in group A was comparable to that in group B (5.2±1.6 vs. 4.9±1.7; p=0.556).

Table 3: Comparison of mean duration of labor between two groups

None of the patients met with any complications like hypotension, bradycardia, nausea, vomiting& pruritus in the two groups. All the patients passed urine during ambulatory epidural labor analgesia. ( Table 3)

In our study we inserted epidural in laboring parturients, when cervical dilatation was between 0-4 cm and minimum one contraction per 5 min noted. We observed that the difference between mean cervical dilatation of the two groups was non-significant (P>0.331) and the difference in mean Contraction per 5-minutes was also non-significant (P>0.05).So both groups were comparable in terms of active labor.

In our study in Group A, 14 women had normal vaginal delivery (NVD) and 2 had emergency lower segment cesarean section (ELSCS). In Group B 15 women had normal vaginal delivery (NVD), 5 had emergency lower segment caesarean section (ELSCS) and one each had vaccum and forceps assisted delivery. Overall the difference in mode of delivery in patients between these groups was non-significant (P>0.05).So we concluded that ambulatory epidural labor analgesia did not affect the mode of delivery in laboring parturients.

Our study correlated with the study done by Deshmukh VL et al.,[10], in which50 women received epidural analgesia for relief of labor pain at 3–4 cm and 50 women served as control who did not receive epidural analgesia. They found that there was no increase in the rates of operative deliveries and instrumental deliveries. The results of their study were comparable.

Drzymalski et al.,[11]  in their study over laboring parturients with epidural labor analgesia in both groups and music as experimental group, found that there were no statistically significant differences between the music and control groups in the cesarean delivery rate (22% vs 8% ;p=0.09) or the instrumental vaginal delivery rate (7% vs 5%;p=0.68).

In our study we found that the mean duration of labor (hrs) of the patients in group A was 5.2±1.6 and in Group B it was 4.9±1.7. The difference in mean duration of labor (hrs) of the patients between two groups was non-significant (P=0.556). So we concluded that there was no prolongation of labor in any of the patients in two groups after receiving ambulatory labor analgesia.

Our study correlated with Dan M. Drzymalski et al.,[11] who conducted a study on laboring patients undergoing an epidural catheter placement with or without music. Participants in the music group selected their preferred genre of music. Classic music was most commonly selected by the participants. They observed no differences in the average duration (in hours:minutes) of the active phase of stage 1 (5:24 ± 2:35 vs 5:58 ± 3:17, P =0.47) and stage 2 of labor (1:00 ± 0:49 vs 1:17 ± 1:09, P = 0.31) in both groups after giving epidural labor analgesia.

In Simavli S et al.,[12] study music therapy decreased the duration of labor in the music group compared to the control group (p < 0.001). They gave an explanation for this result that women could experience increased pain and anxiety during childbirth as labor progresses. When their anxiety and pain increase, tolerance and control decrease, this may negatively affect active pushing and may cause a prolonged second stage of labor.

In our study none of the patients had any complications related to epidural labor analgesia such as hypotension, bradycardia, nausea, vomiting, pruritus, urinary retention etc. In both groups patients were able to ambulate and pass urine during the process of labor.

In our study, both groups were comparable according to Mean cervical dilatation at time of epidural insertion, Mean duration of labor and mode of delivery and none of the patients met with any maternal complications in both groups.

Funding: No funding sources.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of Civil Hospital, Tauni Devi, Hamirpur

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