ANALGESIA FOR LABOUR AND DELIVERY USING INCREMENTAL DIAMORPHINE AND BUPIVACAINE VIA A 32-GAUGE INTRATHECAL CATHETER

Twenty mothers who had requested regional analgesia during labourhad a 32-gauge catheter inserted into the lumbar subarachnoidspace. The mean time to place the catheters was 116 s (range55–270 s) and there were no technical difficulties. Incrementaldiamorphine was given, up to a maximum initial dose of 0.5 mg.Analgesia was excellent in 11 mothers, good in seven and unsatisfactoryin two. The duration of initial analgesia from diamorphine was101 min (range 30–170 min). Eight mothers were able tomove about during the first stage, with effective analgesia.Side effects were common: 15 mothers had pruritis, 15 had nauseaor vomiting, and eight had mild sedation. No mother had a ventilatoryfrequency of less than 12 b.p.m. in the 12 h after the lastdose of intrathecal diamorphine. Intrathecal 0.5% bupivacainewas given to 16 mothers in the first stage because the analgesiaafter a top-up with diamorphine became insufficient later inthe labour. Fifteen mothers were pain free after bupivacaine;there was one failure. The initial effective dose of bupivacainewas between 0.25 ml and 2 ml. The maximum height of the blockafter bupivacaine was T9, and there was no hypotension. Ninemothers were given hyper-baric 0.5% bupivacaine 1–2 mlduring the second stage; all were pain free for the procedure.The maximum force needed to withdraw the catheters was 700 g;and all catheters were removed intact. There were no post-spinalheadaches.     

Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers

Epidural analgesia in labour is commonly associated with some degree of lower limb weakness often severe enough to be described as paralysis by the mother. We aimed to produce rapid reliable analgesia with no motor block throughout labour. We report a pilot survey of 300 consecutive women requesting regional analgesia in labour who received a combined spinal epidural blockade (CSE). The initial dose was given into the subarachnoid space and analgesia maintained via an epidural catheter. A subarachnoid injection of 2.5 mg bupivacaine and 25 mug fentanyl was successfully given in 268 women (89.3%). Completely pain-free contractions within 3 min of this injection occurred in 195 women (65%) and in all 300 within 20 min and there was no associated motor block in 291 (97%). 141 women chose to stand, walk or sit in a rocking chair at some time during labour. Only 38 women (12.6%) were immobile during the first stage of labour. Analgesia was maintained via the epidural catheter with bolus doses of 10-15 ml of 0.1% bupivacaine and 0.0002% fentanyl. The mean bupivacaine requirement was 9.5 mg/h throughout the entire duration of analgesia. The incidence of post lumbar puncture headache was 2.3%. Transient hypotension occurred in 24 women (8%) and was treated with 6 mg intravenous boluses of ephedrine. Complete satisfaction with analgesia and mobility was reported 12-24 h post partum by 95% of mothers. The use of this analgesic technique caused no alteration in obstetric management or post partum care of the women.     

Is continuous spinal analgesia via an epidural catheter appropriate after accidental subarachnoid administration of 15 mL of bupivacaine 0.1% containing fentanyl 2 micrograms/mL?

We report a case of accidental insertion of an epidural catheter into the subarachnoid space and accidental administration of 15 mL of bupivacaine 0.1% with fentanyl 2 micrograms/mL, in the sitting position, during labour. Within 5 min, the patient was unable to move her lower limbs. Although the upper level of the sensory block using ethyl chloride was found to be T5, there was no cardiovascular depression. The catheter was left in situ and used for continuous spinal analgesia. Further administration of the bupivacaine-fentanyl solution was not required until after 315 min. The patient was given five further 2- to 3-mL top-up doses of bupivacaine-fentanyl at intervals of 105 to 145 min. After 16 h, caesarean section was performed for failure to progress in the first stage of labour. This was conducted under spinal anaesthesia using 2 mL of hyperbaric bupivacaine 0.5% with fentanyl 20 micrograms. A healthy baby was delivered with Apgar scores of 10 and 10, at 1 and 5 min, respectively. There was no postdural puncture headache or any neurological complications.     

The addition of fentanyl to epidural bupivacaine in first stage labour

Epidural analgesia was studied in 100 healthy Chinese women with uncomplicated pregnancies in first stage labour. Patients were randomly allocated to receive 8 ml of one of the following five solutions: bupivacaine 0.125% with fentanyl 50 micrograms or fentanyl 100 micrograms, bupivacaine 0.25% plain, bupivacaine 0.25% with fentanyl 50 micrograms or fentanyl 100 micrograms. There was no difference in quality of analgesia among groups as measured by the reduction of visual analogue pain scores 20 minutes after the epidural dose. The duration of analgesia was similar among groups with the overall median duration being 105 minutes. There was no difference in method of delivery or neonatal Apgar scores. The least concentrated mixture providing good quality analgesia for the first stage of labour was the combination of bupivacaine 0.125% with fentanyl 50 micrograms.     

Comparison of continuous spinal and epidural analgesia for pain relief in labour

We have compared continuous spinal analgesia with continuous epidural analgesia for pain relief in labour. Twenty-six women were randomly allocated to receive either epidural 0.25% bupivacaine 5-10 ml via a 20 gauge catheter inserted through a 16 gauge Tuohy needle or intrathecal 0.25% bupivacaine 0.5-1.0 ml via a 32 gauge catheter inserted through a 24 gauge Sprotte needle. This was supplemented with fentanyl 5-10 mcg (spinal) or 1 mcg per kg (epidural) if analgesia was unsatisfactory. Outcome was measured by the success and timing of the procedure, time to analgesia, amount of drug given, visual analogue scoring of pain relief by the patient and an observer and degree of motor block. Onset time and dosage were significantly reduced in the continuous spinal group. Two catheters failed to feed in the spinal group. One catheter became displaced in each group. Pain relief was satisfactory in all patients and none had post-dural puncture headache. Continuous spinal analgesia may offer significant advantages over epidural analgesia but technical difficulties remain with the present equipment. The reasons for the withdrawal of the spinal catheters in the United States of America are discussed.     

Regional analgesia in early active labour: combined spinal epidural vs. epidural

We randomly allocated 93 women in early active labour and requesting epidural analgesia to receive either epidural ( n  = 48) or combined spinal–epidural analgesia ( n  = 45). For epidural analgesia 15 ml of bupivacaine 0.1% with 75 μg of fentanyl were injected into the epidural space. For combined spinal–epidural analgesia 1 ml of bupivacaine 0.25% with 25 μg of fentanyl were injected into the subarachnoid space. For both groups subsequent top-ups of 10 ml of bupivacaine 0.1% with fentanyl 20 μg were given using a lightweight patient-controlled epidural analgesia (PCEA) pump with a lockout time of 30 min. We assessed analgesia and the degree of motor blockade and found no significant differences in pain or maternal satisfaction scores between the two groups. The time to first top-up was significantly longer in the epidural group than in the CSE group (p = 0.01). The combined spinal–epidural group had significantly greater motor blockade at 30 min than the epidural group (p = 0.01), but there was no difference after this. The PCEA machine failed completely twice and temporarily many times. We conclude that the combined spinal–epidural technique confers no advantages in early active labour. Also, a lightweight PCEA pump needs to be more reliable before we can recommend its use.     

Alkalization of bupivacaine in the combination fentanyl-bupivacaine in epidural obstetrical analgesia

A randomized double blind study was carried out to determine whether alkalization of a 0.25% bupivacaine solution in a fentanyl-bupivacaine mixture hastened the onset, and increased the duration and quality, of extradural analgesia during labour. The study included 120 women with uncomplicated full-term gestation. Prior to the extradural injection, 0.1 ml of either 8.4% sodium bicarbonate or normal saline was randomly added to 20 ml of 0.25% bupivacaine. The patients were given 75 micrograms fentanyl with 12 ml of either alkalized or unaltered bupivacaine. Data for analysis were obtained in 106 parturients (bicarbonate group n = 54; control group n = 52). The pH of alkalized and unaltered bupivacaine were 7.07 +/- 0.01 and 5.56 +/- 0.01 respectively. There were no statistically significant differences between the bicarbonate and control groups with regard to the speed of onset of analgesia (7.08 +/- 0.7 min vs. 6.78 +/- 0.6 min), its duration (123.6 +/- 10.7 min vs. 113 +/- 6.6 min), and the number of cases of inadequate pain relief (6 and 3 respectively). The rate of maternal adverse effects, and neonatal status, were similar in both groups. It can be concluded that alkalizing a 0.25% bupivacaine solution in a fentanyl-bupivacaine mixture for epidural analgesia in labour has no clinical value.     

Intrathecal catheter insertion during labour reduces the risk of postdural puncture headache

Purpose

To describe the anaesthetic management and report the incidence of PDPH in three parturients who had experienced accidental durai puncture during labour and the subsequent deliberate intrathecal insertion of an epidural catheter.

Clinical features

Inadvertent durai puncture with a 16-gauge Tuohy needle occurred during the first stage of labour at 3–4 cm cervical dilatation in all three women. The 20-gauge epidural catheter was immediately inserted into the subarachnoid space after accidental durai penetration. Intermittent intrathecal injections of lidocaine or bupivacaine with fentanyl were administered to provide analgesia during labour and delivery. Two of the women had spontaneous vaginal deliveries, whereas Caesarean section was performed in one case due to acute fetal distress during the second stage of labour. The intrathecal catheter was left in-situ for 13–19 hr after delivery and the women were questioned daily for symptoms of PDPH. None of the three women developed PDPH after dural puncture and intrathecal catheterisation with the epidural catheter.

Conclusion

Immediate intrathecal insertion of the epidural catheter after accidental durai puncture during labour proved to be an effective prophylactic technique to prevent PDPH in these three parturients.     

Fentanyl added to bupivacaine 0.05% or ropivacaine 0.05% in patient-controlled epidural analgesia in labour

BACKGROUND AND OBJECTIVE: Epidural analgesia is the most effective method for pain relief during labour. The aim was to elucidate the efficacy of ropivacaine 0.05% and bupivacaine 0.05%, which were both combined with fentanyl 0.00015% to provide analgesia in labour. METHODS: Forty nulliparous females were enrolled into the study. After insertion of an epidural catheter, patients were randomly assigned into two groups. Once the os uteri had dilated to 4-5 cm, a bolus of bupivacaine 0.125% 10mL + fentanyl 50 microg (1 mL) in Group 1 patients, and ropivacaine 0.125% 10mL + fentanyl 50 microg (1 mL) in Group 2 patients was administered via the epidural catheter. Then, patient-controlled epidural analgesia was started with a basal infusion of bupivacaine 0.05% 10 mLh(-1) + fentanyl 0.00015% 1.5 pgmL(-1) in Group 1, and ropivacaine 0.05% + fentanyl 1.5 microgmL(-1) in Group 2. When needed, a 10 mL bolus infusion could be given and the lockout time was 20 min. Maternal and fetal haemodynamic variables were monitored before induction and subsequently at 5 min intervals. Using a visual analogue scale assessed the degree of pain. RESULTS: Maternal haemodynamic variables and Apgar scores were not different between the two groups. The second stage of the labour was shorter in Group 2 (P < 0.01). There were no significant differences in patients' assessment of motor block or mode of delivery between groups. CONCLUSIONS: An epidural infusion (10 mLh(-1)) of bupivacaine 0.05% or ropivacaine 0.05% together with fentanyl 1.5 microg mL(-1) provided good and safe analgesia during labour.     

Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function

BACKGROUND: This prospective, double-blind, randomized study was designed to examine whether the combined spinal-epidural technique without subarachnoid drug administration improved epidural catheter function when compared with the traditional epidural technique. METHODS: After institutional review board approval and informed consent, 251 healthy laboring parturients were randomly assigned to either group DP (combined spinal-epidural technique with 27-gauge Whitacre needle dural puncture but without subarachnoid drug administration) or group NoDP (traditional epidural technique). Patient-controlled epidural analgesia was initiated with 0.11% bupivacaine and 2 microg/ml fentanyl. Top-up doses in 5-ml increments of 0.25% bupivacaine were administered if needed. Previous power analysis revealed that a sample size of 108 patients/group was needed to show a clinically useful reduction of the catheter manipulation rate from 32% to 15%. RESULTS: In groups DP and NoDP, 107 and 123 evaluable patients, respectively, completed the study. Demographics and outcome variables measured, including epidural catheter manipulation and replacement rate, sacral sparing, unilateral block, number of top-up doses, average hourly epidural drug usage, highest sensory blockade level, and labor analgesia quality, were not different between groups. A subgroup of 18 patients without cerebral spinal fluid return during dural puncture had a higher catheter replacement rate than those of groups DP and NoDP, but it did not reach statistical significance. CONCLUSIONS: Dural puncture with a 27-gauge Whitacre needle without subarachnoid drug administration during combined spinal-epidural labor analgesia did not improve epidural labor analgesia quality or reduce catheter manipulation or replacement rate when compared with a traditional epidural technique.     

Treatment of Incomplete Analgesia after Placement of an Epidural Catheter and Administration of Local Anesthetic for Women in Labor

Background: Approximately 15% of women still have pain after placement of an epidural catheter and administration of local anesthetic for labor analgesia. Two techniques frequently used to treat this pain were compared: (1) withdrawal of the catheter 1 cm and repeated dosing with additional local anesthetic, and (2) repeated dosing with additional local anesthetic without any catheter manipulation.

Methods: Fifteen minutes after placement of a multiple-orifice epidural catheter 5 cm into the epidural space and administration of 13 ml 0.25% bupivacaine to the parturient in labor, the adequacy of analgesia was assessed. All women who had incomplete analgesia were randomized (first intervention) to receive and additional 5 ml 0.25% bupivacaine (local-anesthetic-only only group) or to receive 5 ml 0.25% bupivacaine after first withdrawing the epidural catheter 1 cm (catheter-manipulation group). If after 15 min the woman still bad pain, then (second intervention) the catheter was withdrawn 1 cm and an additional 5 ml 0.25% bupivacaine was administered to the local-anesthetic-only group, whereas 5 ml 0.25% bupivacaine was given to the catheter-manipulation group without further catheter manipulation. The success rate of the second intervention was assessed 15 min later.

Results: Seventy-eight women were enrolled in the study, 39 to each group. In the local-anesthetic-only group, 29 (74%) women were successfully treated with the first intervention and remaining 10 (100%) were successfully treated with the second intervention. In the catheter-manipulation group, 30 (77%) were successfully treated with the first intervention and 7 (100%; 2 patients were not studied because of investigator error) were successfully treated with the second intervention (P = NS).     

Continuous infusion epidural analgesia for obstetrics: bupivacaine versus bupivacaine-fentanyl mixture

Continuous infusion epidural analgesia (CIEA) using a mixture of bupivacaine and fentanyl was evaluated in this randomized, double-blind study involving 75 nulliparous women by comparing the mixture (Group I, Bupivacaine 0.125% and fentanyl 4 micrograms.ml-1 -24 patients) with two concentrations of bupivacaine alone (Group II, bupivacaine 0.25% - 24 patients; and Group III, bupivacaine 0.125% - 27 patients). Epidural anaesthesia was established in Group I with 6 ml 0.125% bupivacaine with fentanyl 50 micrograms and in both Groups II and III with 6 ml 0.25% bupivacaine. In the women whose pain score (Visual Analogue Scale) decreased by at least 50% within 15 min, CIEA was given until delivery. The initial infusion rate in all three groups was set at 7 ml.hr-1, but was decreased in the event of motor block or excessive sensory level. For inadequate analgesia, bupivacaine 0.25% in 3 ml supplements was given every 30 min, as required. During the first stage of labour, 88% of women in Group I reported excellent or good analgesia compared with 92% of women in Group II (NS) and with 59% in Group III (P less than 0.05). The proportion of women reporting excellent/good analgesia during the second stage was approximately 65% in all three groups. The total cumulative dose of bupivacaine in Group I was 54 +/- 36 mg, compared with 107 +/- 47 mg for Group II (P = 0.001), and 71 +/- 41 mg for Group III (NS). Group I patients required less supplementation with bupivacaine than either Group II or III patients during the first stage but only with Group III patients during the second stage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of obstetrical pain by a questionnaire of adjectives. Comparison of 2 epidural analgesia protocols

A French version of the McGill pain questionnaire, the "Questionnaire Douleur Saint Antoine" (QDSA), was assessed prospectively by comparing two epidural analgesia protocols using bupivacaine. One hundred women in labour who asked for epidural analgesia were randomly allocated to two groups and received either 0.25% or 0.5% bupivacaine (mean initial doses 32.5 and 50 mg respectively) with adrenaline 1 in 200,000. All the patients were then instructed to trigger a patient controlled analgesia (PCA) device for top-up doses of 0.25% bupivacaine with adrenaline 1 in 400,000 once they became aware of pain returning. This PCA device was preset to give on-demand injections of 12.5 mg with a lockout interval of 20 min, together with a continuous infusion rate of 10 mg.h-1. Pain was evaluated using four rating scales: QDSA, visual analogue scale (VAS), verbal rating scale (VRS) and behavioural scale (BS). Pain was measured at least four times: before analgesia (T0), 20 min after the initial injection (T20), before starting PCA (TRe), and immediately after delivery of the newborn (TEx). In addition, the level of anxiety was ranked at the beginning of labour with the Spielberger state trait anxiety inventory (STAI). In the 396 questionnaires completed by the patients, there was a significant correlation between the QDSA and the other scales (p less than or equal to 0.05), but at T0, BS was mostly correlated with the affective index of QDSA (p = 0.01), as well as with the STAI (p = 0.0001). At T20, in the group of women who had been given 0.5% bupivacaine initially, the decrease in QDSA score was significantly greater for the sensory index (p = 0.04); the first re-injection interval was longer than in the other group of women (p = 0.05). At TRe, the total QDSA score of all the patients was half that at T0, indicating the good sensitivity of this score. These results are in agreement with those reported by Melzack with the McGill pain questionnaire. The QDSA varies in the same direction as the other scales. On the other hand, the affective part of the score was only correlated with the level of anxiety and behaviour. The sensory part of this score was the only one to show a difference between the different initial doses given to the patients. The results obtained with this series of patients underline the value of a multidimensional assessment of labour pain.     

Intrathecal plainvs hyperbaric bupivacaine for labour analgesia: efficacy and side effects

Purpose

Baricity is an important determinant of block characteristics of the spinal component of a combined spinal epidural (CSE) for labour analgesia. This study compares the analgesic efficacy and side effects of intrathecally administered plain and hyperbaric bupivacaine (both with fentanyl) during active labour.

Methods

Sixty-two women in active labour (cervical dilatation >- 5 cm and pain score > 5) were randomized in a prospective, single-blinded fashion to receive 2.5 mg of either hyperbaric or plain bupivacaine both combined with 15 μg of fentanyl as the spinal component of a CSE. The primary outcome was failure of satisfactory analgesia within ten minutes of the intrathecal injection as defined by a verbal pain score > 3. Secondary outcomes included need for rescue analgesia, hypotension, respiratory depression, nausea and vomiting, pruritus and sustained fetal bradycardia.

Results

Sixty patients were analyzed. The failure rates were 20% in the hyperbaric groupvs 0% in the plain group (P = 0.024). The plain solution provided faster onset, higher sensory levels and less motor block at all times during the first 30 min. The incidence of both pruritus and sustained fetal bradycardia was 33% in the plain group and 10% in the hyperbaric group (P = 0.03).

Conclusion

A plain rather than hyperbaric solution of bupivacaine 2.5 mg with fentanyl 15 μg provides a faster onset of analgesia, higher sensory levels and less motor block, while demonstrating an increased incidence of pruritus and sustained fetal bradycardia.     

Subarachnoid and intravenous PCA versus bolus administration for postoperative pain relief in orthopaedic patients

Background: Patient-controlled analgesia (PCA) with intravenous piritramide and subarachnoid bupivacaine was studied during postoperative pain management in comparison with nurse-administered bolus injections.
Methods: Following general anaesthesia (n=60) patients randomly received either 3.75–7.5 mg i. v. piritramide on demand (group P-Bolus) or via PCA (group P-PCA; initial bolus: 3.75 mg i. v. piritramide, baseline rate: 1 mg/h, demand-dose 1.5 mg, lockout time: 20 min). Following continuous spinal anaesthesia (n=60; CSA; 28-G spinal catheter) patients randomly received a subarachnoid injection of 1.5 ml bupivacaine 0.25% every 2–4 h (group B-Bolus) or a baseline infusion of 0.5 ml/h bupivacaine 0.125% plus 0.5 ml bupivacaine 0.125% on demand via PCA (group B-PCA; lockout time: 30 min). Pain ratings were assessed hourly by patients using a visual analogue scale (0=no pain, 100 mm=unbearable pain). Statistics: multivariate analysis of variance.
Results: While pain scores did not differ between group P-Bolus and P-PCA, group B-PCA showed the lowest pain ratings (18±22 mm) differing significantly from group B-Bolus (41±32 mm: P <0.001). Group P-PCA required more piritramide than group P-Bolus (46±15 mg vs. 31±13 mg, P = 0.001). In contrast group B-PCA required less bupivacaine than group B-Bolus (18±4 vs. 23±7 mg, P =0.002).
Conclusion: PCA with CSA was more effective than nurse-administered bolus-administration of bupivacaine, while the present study failed to show superiority of i. v. PCA over i. v. bolus-administration of piritramide. PCA using the subarachnoid route is a promising concept for treatment of postoperative pain in orthopaedic patients, while the PCA piritramide regime of this study warrants improvement.     

The addition of pethidine to epidural bupivacaine in labour--effect of changing bupivacaine strength.

The effects of varying the strength of bupivacaine used in epidurals for the relief of labour pain was examined. The trial randomly allocated sixty women in the first stage of labour to one of three groups. All women were of ASA status 1 or 2 and had uncomplicated pregnancies. Subjects in each group received pethidine 25 mg in 10 ml of either 0.125%, 0.1875%, or 0.25% bupivacaine. Pain scores for each patient were then assessed over the following thirty minutes. Duration of analgesia and subsequent dose requirements were examined. No difference in pain scores between groups at thirty minutes after injection of the test solutions was found. The 0.25% solution group did however have a more rapid onset of analgesia with the majority of patients in this group achieving their maximum effect between ten and twenty minutes after injection. Duration of analgesia was not prolonged by using the stronger solutions. This study suggests that when epidural pethidine 25 mg is added to local anaesthetic solutions of bupivacaine, adequate analgesia for the first stage of labour is achieved with the 0.125% bupivacaine solution. The use of stronger solutions of bupivacaine achieves no greater degree of analgesia nor longer duration of action, although the onset of analgesia may be faster with the stronger solutions. Further investigations are needed to determine if 25 mg of pethidine is the best choice of dose to use under these circumstances.     

A comparison of epidural infusions in the combined spinal/epidural technique for labor analgesia

We compared the clinical effects of three epidural infusions initiated after subarachnoid medication was administered as part of the combined spinal/epidural technique for labor analgesia. Fifteen minutes after administering subarachnoid fentanyl 25 microg and 1 mL of bupivacaine 0.25%, and 5 min after an epidural test dose of 3 mL of bupivacaine 0.25%, women were randomized to receive an epidural infusion of saline, bupivacaine 0.125%, bupivacaine 0.0625%, or bupivacaine 0.04% with epinephrine 1:600,000. All epidural infusions were started at 10 mL/h, and all except the Saline Group also received fentanyl 2 microg/mL. The end point of the study was delivery or request for additional medication for analgesia. We found that time until request for additional analgesia was longest in women who received bupivacaine 0.125% (median duration, 300 min) versus saline (median duration, 118 min) (P = 0.0001) and was intermediate for bupivacaine 0.0625% and bupivacaine 0.04% (median duration, 162 and 180 min, respectively) (P = 0.0001 versus saline). Women who received bupivacaine 0.125% had the most motor block. We conclude that all the bupivacaine-based infusions we tested maintained the analgesia from subarachnoid medication longer than saline, with the longest duration, but the most motor block, from bupivacaine 0.125%. IMPLICATIONS: In this prospective, randomized, and double-blinded study we found that initiating an epidural infusion of bupivacaine 0.125% with fentanyl 2 microg/mL at 10 mL/h 15 min after subarachnoid fentanyl 25 microg with 1 mL of bupivacaine 0.25%, followed by an epidural test dose of 3 mL of bupivacaine 0.25%, maintained the analgesia for longer but with more motor block than with either bupivacaine 0.04% or bupivacaine 0.0625%.     

Dural Puncture with a 27-Gauge Whitacre Needle as Part of a Combined Spinal-Epidural Technique Does Not Improve Labor Epidural Catheter Function

Background: This prospective, double-blind, randomized study was designed to examine whether the combined spinal-epidural technique without subarachnoid drug administration improved epidural catheter function when compared with the traditional epidural technique.

Methods: After institutional review board approval and informed consent, 251 healthy laboring parturients were randomly assigned to either group DP (combined spinal-epidural technique with 27-gauge Whitacre needle dural puncture but without subarachnoid drug administration) or group NoDP (traditional epidural technique). Patient-controlled epidural analgesia was initiated with 0.11% bupivacaine and 2 [mu]g/ml fentanyl. Top-up doses in 5-ml increments of 0.25% bupivacaine were administered if needed. Previous power analysis revealed that a sample size of 108 patients/group was needed to show a clinically useful reduction of the catheter manipulation rate from 32% to 15%.

Results: In groups DP and NoDP, 107 and 123 evaluable patients, respectively, completed the study. Demographics and outcome variables measured, including epidural catheter manipulation and replacement rate, sacral sparing, unilateral block, number of top-up doses, average hourly epidural drug usage, highest sensory blockade level, and labor analgesia quality, were not different between groups. A subgroup of 18 patients without cerebral spinal fluid return during dural puncture had a higher catheter replacement rate than those of groups DP and NoDP, but it did not reach statistical significance.     

Impact of walking epidural analgesia on obstetric outcome of nulliparous women in spontaneous labour

BACKGROUND: To explore the effects of walking epidural analgesia on obstetric and neonatal outcomes, we performed a case-control study. METHOD: Each nulliparous woman receiving walking epidural analgesia using 0.0625% bupivacaine (n = 44) was matched to two nulliparous historical controls receiving 0.125% or 0.25% bupivacaine (n = 88 each) for epidural analgesia while recumbent. RESULTS: Maternal and obstetric parameters, fetal status and presentation, and oxytocin use were comparable among groups. Those receiving walking epidural analgesia walked for a mean of 60 min (range: 20-75 min). In the control groups the mean total durations of labour were shorter (58 min in the 0.125% group and 99 min in the 0.25% group, P < 0.05). Significantly fewer walking epidural analgesia cases than controls required instrumental vaginal delivery (P < 0.05). No other differences in obstetric or fetal outcome were observed and no mother fell or stumbled while walking. CONCLUSION: Although it was associated with a prolonged first stage of labour, walking epidural analgesia appeared safe for nulliparous women and their babies.     

INFLUENCE OF THE LUMBAR INTERSPACE CHOSEN FOR INJECTION ON THE SPREAD OF HYPERBARIC 0.5% BUPIVACAINE

Forty patients undergoing elective Caesarean section were allocatedrandomly to receive hyperbaric 0.5% bupivacaine 2.5 ml at eitherthe L2–3 (n = 20) or L4–5 (n = 20) interspace. Spinalinjection was performed with a 29-gauge needle in 38 patientsand a 25-gauge needle in two. The onset time to analgesia atT10 and T6 was significantly faster and the level of analgesiaat 5 and 10 min after injection significantly higher after injectionat L2–3. Maximum height and range of analgesia, the levelof analgesia at 15 and 20 min after injection and the numberof episodes of hypotension were not significantly differentbetween the two groups. One case of post-dural puncture headachewas recorded after use of a 29-gauge needle. Overall, the choiceof lumbar interspace influenced the rate of onset of analgesia,but not the final dermatomal level (mean and range) of analgesiaachieved.