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Postnatal depression affects about 10-15% of women after childbirth. Approximately 3-5% of women experience a moderate-to-severe depression that requires medical attention. This study aims to investigate the implication of pain relief choice in reducing the postnatal depression of women who deliver their babies.
If the patients have not decided on which pain relief method to be used, and would like to take part in this study, they will be assigned to either epidural or non-epidural pain relief for labour based on the study randomization result. Blood samples will be drawn to study the presence of known functional polymorphisms in candidate genes associated with depression, pain, stress and anxiety. Patients will be followed up with study questionnaires related to pain and postnatal depression screening during the study. For some of the patients, a discrete choice experiment (DCE) on pain relief choice will be conducted, and their preferences on epidural analgesia will be asked.
During any time of the labour period, the patient is allowed to switch the pain relief option upon request.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Epidural group | Experimental | Patients are assigned to receive epidural delivery system (fentanyl and ropivacaine) for labour as pain relief option. |
|
| Non-epidural group | Active Comparator | Patients are assigned to receive entonox (laughing gas), meperidine (pethidine) or remifentanil (Ultiva) for labour as pain relief option. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Epidural delivery system | Device | Epidural delivery system for maintenance of labour epidural analgesia using 0.1% ropivacaine (amide local anaesthetic) with 2mcg/ml fentanyl (opioid) as maintenance solution. |
| Measure | Description | Time Frame |
|---|---|---|
| The incidence of major postnatal depression in both groups | Edinburgh Postnatal Depression Scale (EPDS) score>=13 | 6-10 weeks after delivery |
| The incidence of (clinically significant, probable) postnatal depression in both groups | Edinburgh Postnatal Depression Scale (EPDS) score>=10 | 6-10 weeks after delivery |
| Measure | Description | Time Frame |
|---|---|---|
| The incidence of acquiring post-delivery persistent pain in both groups | Pain score>3 in the perineal, surgical scar or abdomen region that lasts for at least 6 weeks post-delivery | 6-10 weeks after delivery |
| Pain vulnerability in both groups (1) |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Ban Leong Sng, FANZCA | KK Women's and Children's Hospital | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| KK Women's and Children's Hospital | Singapore | 229899 | Singapore |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 37990597 | Result | Tan HS, Tan CW, Sultana R, Chen HY, Chua T, Rahman N, Gandhi M, Sia ATH, Sng BL. The association between epidural labour analgesia and postpartum depression: a randomised controlled trial. Anaesthesia. 2024 Apr;79(4):357-367. doi: 10.1111/anae.16178. Epub 2023 Nov 21. | |
| 42314868 | Derived | Tan CW, Wang S, Sultana R, Sia ATH, Sng BL. Associations of Pain, Analgesia Technique, and Psychological Factors with Central Sensitization after Childbirth. Anaesth Crit Care Pain Med. 2026 Jun 18:101881. doi: 10.1016/j.accpm.2026.101881. Online ahead of print. |
| Label | URL |
|---|---|
| Published data on the primary outcome on epidural labour analgesia and postnatal depression | View source |
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Cross over or switch to the other group of analgesia is allowed.
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| Entonox | Drug | Entonox will be given upon request in non-epidural group. |
|
|
| Meperidine | Drug | Intramuscular pethidine (75mg/1.5ml) will be given upon request in non-epidural group. |
|
|
| Ultiva | Drug | Intravenous patient controlled remifentanil (20-40mcg/ml) is only given when the patient rejects or cannot receive pethidine and entonox in non-epidural group.. |
|
|
| Fentanyl | Drug | Epidural delivery system for maintenance of labour epidural analgesia using 0.1% ropivacaine (amide local anaesthetic) with 2mcg/ml fentanyl (opioid) as maintenance solution. |
|
| Ropivacaine | Drug | Epidural delivery system for maintenance of labour epidural analgesia using 0.1% ropivacaine (amide local anaesthetic) with 2mcg/ml fentanyl (opioid) as maintenance solution. |
|
Assessment via Pain Catastrophizing Scale (PCS) questionnaire before and after delivery
| Upon recruitment until 6-10 weeks after delivery |
| Pain vulnerability in both groups (2) | Assessment via Central Sensitisation Inventory (CSI) questionnaire before and after delivery | Upon recruitment until 6-10 weeks after delivery |
| Pain vulnerability in both groups (3) | Assessment via Angle Labor Pain Questionnaire (A-LPQ) during first stage of labor when the participants experience labor pain | Upon recruitment till end of first stage of labor (1 day) |
| Psychological vulnerability in both groups (1) | Assessment via Fear-Avoidance Components Scale (FACS) questionnaire before delivery | Upon recruitment until 5 days after delivery |
| Psychological vulnerability in both groups (2) | Assessment via State Trait Anxiety Inventory (STAI) questionnaire before delivery | Upon recruitment until 5 days after delivery |
| Psychological vulnerability in both groups (3) | Assessment via Perceived Stress Scale (PSS) questionnaire before delivery | Upon recruitment until 5 days after delivery |
| Pain severity in both groups | Pain score>3 during labour | During labour till one day after delivery |
| Preferences for labor analgesia | Recruited patients will be administered a survey on Discrete Choice Experiment (DCE) and other questions on their preferences for labor analgesia. For DCE, nine tasks will be included in which parturients will choose one of four hypothetical forms of labor analgesia: 1) epidural analgesia, 2) pethidine, 3) Entonox (nitrous oxide-oxygen mixture), and 4) no labor analgesia, which varies with regards to six attributes: 1) pain intensity following treatment, 2) duration of second stage of labor, 3) risk of instrumental delivery, 4) risk of back pain, 5) risk of permanent nerve injury, and 6) out-of-pocket cost. | Prior to labor and delivery |
| Preferences for epidural analgesia | Recruited patients will be administered a survey on their preferences and opinions on epidural analgesia, including their concerns on possible risk of epidural analgesia e.g. instrumental delivery, prolonged duration of second stage of labor, back pain etc. | Prior to labor and delivery |
| Chinese version of Angle Labor Pain Questionnaire (A-LPQ) | Assessment via Angle Labor Pain Questionnaire (A-LPQ) during first stage of labor when the participants experience labor pain. The tool comprises 22 items divided into five subscales on the childbirth pain experience: the enormity of the pain, the fear and anxiety, uterine contraction pain, birthing pain, and the back pain/ long haul. Each item is scaled from 0 to 10, implying a range from non to worst possible or extremely (where applicable), and therefore has a total score ranged from 0 to 220. The higher the score, the greater the labor pain. | Upon recruitment till end of first stage of labor (1 day) |
| 42092800 | Derived | Tan CW, Liu Y, Sultana R, Sia ATH, Sng BL. Understanding maternal pain and psychological vulnerabilities associated with the development of sub-acute pain after childbirth. BMC Anesthesiol. 2026 May 7;26(1):385. doi: 10.1186/s12871-026-03885-x. |
| 42049811 | Derived | Tan CW, Sultana R, Chen HY, Chua TE, Ku CW, Sng BL. Investigating the association between pain and psychological vulnerabilities and postpartum depression. Sci Rep. 2026 Apr 28. doi: 10.1038/s41598-026-50140-x. Online ahead of print. |
| 40113655 | Derived | Chan JCY, Sultana R, Mathur D, Tan CW, Sng BL. The association of pain and psychological vulnerabilities with postpartum pain catastrophizing: a secondary analysis of a randomized controlled trial. Can J Anaesth. 2025 Apr;72(4):603-614. doi: 10.1007/s12630-025-02920-8. Epub 2025 Mar 20. |
| 39732915 | Derived | Ayuby NA, Ang MQ, Sultana R, Tan CW, Sng BL. Investigating the association between labor pain and cessation of breastfeeding. Sci Rep. 2024 Dec 28;14(1):31361. doi: 10.1038/s41598-024-82850-5. |
| 37491196 | Derived | Tan CW, Tan NY, Sultana R, Tan HS, Sng BL. Investigating the association factors of acute postpartum pain: a cohort study. BMC Anesthesiol. 2023 Jul 25;23(1):252. doi: 10.1186/s12871-023-02214-w. |
| ID | Term |
|---|---|
| D019052 | Depression, Postpartum |
| D000377 | Agnosia |
| ID | Term |
|---|---|
| D011644 | Puerperal Disorders |
| D011248 | Pregnancy Complications |
| D005261 | Female Urogenital Diseases and Pregnancy Complications |
| D000091642 | Urogenital Diseases |
| D003866 | Depressive Disorder |
| D019964 | Mood Disorders |
| D001523 | Mental Disorders |
| D010468 | Perceptual Disorders |
| D019954 | Neurobehavioral Manifestations |
| D009461 | Neurologic Manifestations |
| D009422 | Nervous System Diseases |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
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| ID | Term |
|---|---|
| C001147 | Entonox |
| D009609 | Nitrous Oxide |
| D008614 | Meperidine |
| D000077208 | Remifentanil |
| D005283 | Fentanyl |
| D000077212 | Ropivacaine |
| ID | Term |
|---|---|
| D009589 | Nitrogen Oxides |
| D005740 | Gases |
| D007287 | Inorganic Chemicals |
| D017672 | Nitrogen Compounds |
| D010087 | Oxides |
| D017601 | Oxygen Compounds |
| D007540 | Isonipecotic Acids |
| D000147 | Acids, Heterocyclic |
| D006571 | Heterocyclic Compounds |
| D010880 | Piperidines |
| D006573 | Heterocyclic Compounds, 1-Ring |
| D011422 | Propionates |
| D000144 | Acids, Acyclic |
| D002264 | Carboxylic Acids |
| D009930 | Organic Chemicals |
| D000813 | Anilides |
| D000577 | Amides |
| D000814 | Aniline Compounds |
| D000588 | Amines |
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