Comparison of combined spinal-epidural and low dose epidural for labour analgesia. Adverse effects of combined spinal-epidural versus traditional epidural analgesia during labor. Comparison of epidural lidocaine and fentanyl to intrathecal sufentanil for analgesia in early labour. Combined spinal-epidural analgesia and epidural analgesia in labor: effect of intrathecal fentanyl vs. epidural bupivacaine as a bolus. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. [Obstetric analgesia: peridural analgesia versus combined spinal and peridural analgesia]. Spinal analgesia during labor with low-dose bupivacaine, sufentanil, and epinephrine. A comparison with epidural analgesia. Prospective, randomized comparison of epidural and combined spinal epidural analgesia during labor. A randomised controlled trial of epidural compared with non-epidural analgesia in labour. Transcutaneous electrical nerve stimulation does not augment combined spinal epidural labour analgesia. Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia.
To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour.
                Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n = 24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local anesthetic sodium bicarbonate 8.4% and epinephrine 1:200,000. The CSE group (n = 26) received intrathecal 25 microg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request.
                There were no differences (P>0.05) in time to perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes < three: 26/26 vs. 17/24, P+/-0.001).
                Although epidural analgesia with a low concentration of local anesthetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE. To compare two neuraxial block techniques during labor for maternal and fetal effects.
                Women in labor at term with cephalic singleton fetuses were randomized (nonblinded) to receive either labor epidural (EPI) or combined spinal-epidural (CSE) analgesia. Primary outcome was prolonged deceleration (PD) of fetal heart rate. Outcomes also included hypotension, mode of delivery, and efficacy of analgesia by visual analog pain scale (VAPS) before and after block placement.
                Randomization occurred in 127 patients: 63 received EPI, 64 received CSE. There was no difference in the rate of PD in the EPI group compared with the CSE group (3.2% vs 6.2% respectively; P=0.43, RR 2.0; 95% CI 0.4-9.3), rate of cesarean delivery, or mean epidural duration. VAPS ratings were significantly lower in the CSE group.
                There were no differences in the rate of PD or other adverse outcomes. Hypotension occurred more frequently with CSE during labor at term. The study supports both EPI and CSE during labor as safe and effective techniques for neuraxial analgesia. A randomized, double-blind study was undertaken comparing an epidural test dose of lidocaine followed by 100 microg fentanyl (E-LF, n = 19) to combined spinal epidural sufentanil 10 microg (CSE-S, n = 21) in low risk women in early labour. The primary outcome measured was the duration of analgesia; secondary outcomes included the quality of analgesia, incidence and severity of pruritus, lower limb motor blockade, and the ability to ambulate. A P < 0.05 was considered statistically significant. Baseline demographic characteristics, including parity, were similar between groups. CSE-S provided analgesia of longer duration than E-LF (126 +/- 61 min versus 83 +/- 37 min, P < 0.01). Visual analog scores (VAS) for pain were higher with E-LF throughout the study period (P < 0.05) although patients in both groups had clinically acceptable analgesia. The VAS for pruritus were higher in the CSE-S group (P < 0.05) but no patient requested treatment for pruritus. Mild motor weakness was more frequent in the E-LF group (5/19 versus 20/21, P < 0.05) and fewer patients in the E-LF group met criteria for ambulation (13/19 versus 20/21, P < 0.05). While both E-LF and CSE-S provide effective analgesia for women in early labour, the more rapid onset of analgesia, lower VAS pain scores, longer duration of action and lesser impact on ability to ambulate suggest advantages of CSE-S over E-LF. To compare the clinical effects of intrathecal fentanyl with conventional epidural bupivacaine bolus before the same continuous epidural infusion for labor analgesia.
                Fifty parturients in active labor were randomized to receive subarachnoid fentanyl 25 mcg as part of a combined spinal epidural analgesia (CSE) or bupivacaine 0.25% 10 ml incrementally into the epidural space in the epidural group. After that, 0.0625% bupivacaine with fentanyl 2 mcg/ml was infused via epidural catheter in all women at a rate of 12 ml/h. Verbal numeric pain scores (VNPS), onset time to pain relief times of additional analgesia and other side effects were recorded.
                Mean (SD) onset time to the first pain free contraction was not significantly different (7.8 +/- 4.3 min in the CSE group, 10.2 +/- 5.1 min in epidural group, p = 0.085). Most of the patients in the CSE group required additional epidural bolus dose (80% compared to 48% in the Epidural group, p = 0.038). There was no difference in motor blockage at time of delivery or mode of delivery. Significantly more women in the CSE group had pruritus (68% VS none in the epidural group, p < 0.001), all had mild degree and did not require any treatment. There was no difference in other side effects.
                Intrathecalfentanyl as part of CSE did not produce statistically a significant faster onset compared to epidural bupivacaine bolus. Most of the patients in the CSE group required epidural bolus after intrathecal fentanyl with a higher incidence of pruritus. Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique.
                Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally.
                The normal vaginal delivery rate was 35.1% in the traditional epidural group, 42.7% in the low-dose combined spinal group (odds ratio 1.38 [95% CI 1.01-1.89]; p=0.04); and 42.9% in the low-dose infusion group (1.39 [1.01-1.90]; p=0.04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group.
                The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified. To compare the analgesic efficiency, side effects and obstetrical repercussions of epidural analgesia (EP) and combined spinal-epidural analgesia (CSE).
                Prospective, randomized, double or single-blind studies as required, approved by the ethical committee of the institution.
                The study included 80 parturients, in active labour with a singleton in vertex presentation and a cervical dilatation of 3 cm or less, randomly allocated to receive either EP (n = 40) or CSE (n = 40).
                In the EP group, sufentanil (20 micrograms) and 0.25% bupivacaine (6-8 mL) were injected into the epidural space. In those of the CSE group, sufentanil (10 micrograms) was first injected into the subarachnoid space, followed by an epidural injection of the same agents at the same quantities as for the EP group. Additional analgesia was obtained in both groups by top-ups of 6-8 mL of 0.25% bupivacaine at the request of the patients. Analgesia, course of labour, obstetrical outcome, and neonatal status were assessed. Statistical analysis was performed using Anova, chi 2 analysis, Yates' correction or Fisher's exact test, with a P < 0.05 considered as significant.
                Both groups had similar demographic and obstetric data. The onset of analgesia was more rapid in CSE group (8 +/- 11 min vs. 12 +/- 7 min, P < 0.05), however the duration was similar. Technical incidents were more frequent in the CSE group (30% vs. 7%, P < 0.05). The technique of analgesia did not influence the bupivacaine amounts required for its maintenance. The incidence of adverse effects were comparable with the exception of vertigo, which was more frequent in the EP group (57% vs. 28%, P < 0.05). The first stage of labour was increased by 30% in the CSE group (281 +/- 130 min vs. 216 +/- 97 min, P < 0.05), without significant prolongation of labour length. Durations of second stage and expulsion were similar in both groups, despite the administration of a lower dose of bupivacaine in the CSE group (33 +/- 17 mg vs. 46 +/- 12 mg, P < 0.05). The rates of instrumental deliveries and Caesarien sections were comparable. The Apgar scores were satisfactory at 5 min.
                In the early phase of labour, the CSE technique using intrathecal sufentanil has no significant benefit when compared to the EP technique using bupivacaine and sufentanil. In the CSE group, technical incidents were more frequent and the length of the first stage of labour was increased. The purpose of this investigation was to evaluate the effectiveness and side effects of combined spinal-epidural (CSE) injection of a bupiv-acaine-sufentanil-epinephrine mixture during labor as compared with epidural analgesia alone.
                In a randomized trial, 63 parturients presenting for vaginal delivery received either epidural analgesia (10 mL) with 12.5 mg bupivacaine plus 10 micrograms sufentanil and 12.5 micrograms epinephrine or CSE analgesia with a single subarachnoid injection of 1 mg bupivacaine plus 5 micrograms sufentanil and 25 micrograms epinephrine (total volume, 2.5 mL). For this purpose a 29-gauge BD-Quincke spinal needle was used. All subsequent top-ups consisted of 10 mL of the mixture, as used for the patients who received epidural analgesia only.
                Thirteen patients delivered without requesting a second injection. The time required to obtain satisfactory analgesia (visual analog score < or = 2.5 and/or > 50% improvement) was significantly shorter for those who received the subarachnoid mixture than for the epidural analgesia group (4.0 +/- 0.4 vs 10.4 +/- 0.5 minutes, respectively, P < .001). The duration of analgesia was longer for the CSE group (137.4 +/- 11.5 vs 106.4 +/- 11.8 minutes, P < .05), with more patients being pain-free for longer than 150 minutes (40 vs 8%, P < .05). Less bupivacaine was consumed in the group receiving the subarachnoid mixture (21.6 +/- 2.0 vs 30.7 +/- 2.1 mg, P < .01). Pruritus was more common following subarachnoid than following epidural injection of sufentanil (53.1 vs 25.8%, P < .05). Other side effects related to the injected drugs, such as motor impairment, hypotension, or nausea or vomiting, were not observed. Although all blocks were uneventful, moderate headache compatible with postdural puncture headache occurred in two patients of the CSE group, which necessitated a blood patch after 5 days.
                The CSE mixture induced long-lasting analgesia, with fast onset and without motor block or hypotension. Pruritus and headache were the major drawbacks of this technique. The analgesic efficacy and incidence of maternal, fetal and neonatal side-effects of combined spinal epidural (CSE) and epidural (EPI) analgesia, using a mixture of bupivacaine 0.125%, epinephrine (1.25 micrograms.ml-1) and sufentanil (0.75 microgram.ml-1) for the relief of labor pain, were randomly and prospectively compared in 110 parturients. A 29 gauge Whitacre tip spinal needle was used to perforate the dura in CSE patients. Compared to EPI, CSE resulted in rapid (326 +/- 22 vs 766 +/- 79 sec, p < 0.05), excellent analgesia, using less bupivacaine (23.5 +/- 2.3 vs 33.9 +/- 2.9 mg, p < 0.05) and sufentanil (12.5 +/- 1.0 vs 16.5 +/- .7 micrograms, p < 0.05). A tendency to improved patient satisfaction in the CSE group was observed. The incidence of maternal or neonatal side effects was similar in both groups. No PDPH was observed. We conclude that CSE analgesia results in excellent pain relief during labor with immediate gratification as compared to epidural analgesia. To investigate possible short and long term side effects of epidural analgesia, compared with non-epidural analgesia for pain relief in labour.
                Randomised controlled study, with long term follow up by questionnaire. Analysis by intention-to-treat.
                Busy maternity unit within a district general hospital in England.
                Three hundred and sixty nine primigravid women in labour were included (randomised allocation: epidural n = 184, non-epidural n = 185).
                Backache at three and twelve months after delivery, instrumental delivery rates and maternal opinion of pain relief in labour.
                No significant differences were found in the reported incidence of backache between the groups at three months: middle backache [22% vs 20%, chi2 = 0.057, P = 0.81; odds ratio (95% CI) 1.4(0.9-2.3)]; low backache [35% vs 34%, chi2 = 0.009, P = 0.92; odds ratio (95% CI) 1.0(0.6-1.6)]. Nor were there significant differences at 12 months: [middle backache 16% vs 16%, chi2 = 0.013, P = 0.91; odds ratio (95% CI) 1.0(0.5-1.8)]; or low backache [35% vs 27%, chi2 = 1.91, P = 0.17; odds ratio (95% CI) 1.4(0.9-2.3)]. The incidence of instrumental delivery was somewhat higher in the epidural group [30% vs 19%, odds ratio (95% CI) 1.77(1.09-2.86)]. Maternal satisfaction was not significantly different between the groups.
                This study provided no evidence to support the suggestion of a direct association between the use of epidural anaesthesia in labour and the incidence of long term backache. Despite a significant proportion of women in each group not receiving their allocated analgesia, a significant difference in terms of instrumental delivery rates remained. Satisfaction in both groups of women was high. The spinal portion of the combined spinal epidural technique (CSE) provides dramatic but limited labour analgesia. Transcutaneous Electrical Nerve Stimulation (TENS) has been noted to modulate pain, in part by the frequency of stimulation chosen. Because nerve action potentials are blocked by local anesthetics in a frequency dependent manner, we speculated that a TENS unit could increase the quality and duration of the spinal portion of a CSE.
                Forty parturients in active spontaneous labour, with a singleton, vertex, term fetus, requesting analgesia were enrolled in a randomized, double blind fashion to receive a standardized CSE with either an active or inactive TENS unit. Prior to CSE placement, TENS intensity thresholds were determined with electrodes placed on the paraspinus muscles at T10-L1, and S2-4; TENS settings for mode, cycle, and pulse width were standardized. Data were collected at timed intervals on pain (VAS), sensory level (pinprick), motor blockade (Bromage), cervical dilatation, and duration of analgesia, and at delivery on fetal and neonatal outcome.
                The duration of the spinal portion of the CSE did not differ between groups (TENS off 91.1+/-33 [mean +/- SD] vs. TENS on 83.1+/-28 min, P = .42). Kaplan-Meier survival analysis and Mantel-Cox log rank analysis showed no difference between the two treatments (P = .28). Analgesia was comparable throughout the first hour of spinal analgesia.
                In healthy labouring parturients, the application of a TENS unit did not alter the quality or duration of labour analgesia provided by the spinal portion of CSE analgesia. Neuraxial blockade is widely used for pain relief in labour. This form of analgesia may be associated with an increase in instrumental delivery rates due to dystocia. 'Traditional' epidurals cause motor blockade and hence immobility. Using a low dose anaesthetic-opioid combination with either epidural or combined spinal-epidural, selective sensory blockade can be achieved, allowing mobility as well as pain relief. In this study, we randomised women with combined spinal-epidural analgesia either to mobilise (upright group n = 25) or to remain recumbent (n = 41) in the second stage of labour. We found women in the upright group had significantly shorter total second stage, (132 vs 109 min,P = 0.019) particularly during the pushing phase (73 vs 51 min, P = 0.011). Although there were fewer instrumental deliveries in the upright group, this was not statistically significant. Women who were randomised to the upright group, did actually mobilise. We conclude that mobilisation in the second stage of labour is possible, and may reduce the length of the second stage.
There appears to be little basis for offering CSE over epidurals in labour, with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and conversely less pruritus with low-dose epidurals. There was no difference in ability to mobilise, maternal hypotension, rate of caesarean birth or neonatal outcome. However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.