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A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women.

ABSTRACT: There is controversy regarding the benefits and risks of combined spinal-epidural compared with epidural analgesia (CSE, EPID) for labor analgesia. We hypothesized that CSE would result in fewer patient requests for top-up doses compared to EPID.One-hundred ASA physical status I or II parous women at term in early labor (<5 cm cervical dilation) requesting analgesia were randomized in double-blind fashion to the EPID group (epidural bupivacaine 2.5 mg/mL, 3 mL, followed by bupivacaine 1.25 mg/mL, 10 mL with fentanyl 50 microg) or the CSE group (intrathecal bupivacaine 2.5 mg with fentanyl 25 microg). Both groups received identical infusions of bupivacaine 0.625 mg/mL with fentanyl 2 microg/mL at 12 mL/h. The primary outcome variable was the number of top-up doses requested to treat breakthrough pain.There was no significant difference between the two groups in the percentage of patients requesting top-up doses (44% CSE vs 51% EPID; 95% confidence interval of the difference -28% to +14%) nor in the need for multiple top-up doses (14% CSE vs 15% EPID). Visual analog scale scores were lower in the CSE group compared to the EPID group at 10 min after initiation of analgesia [median 0 cm (0, 0) vs 4 cm (1, 6) respectively, P < 0.001] and at 30 min [0 cm (0, 0) vs 0 cm (0, 1), respectively, P = 0.03].We did not find a difference in the need for top-up doses in parous patients; however, CSE provided better analgesia in the first 30 min compared to EPID.

SUBMITTER: Goodman SR

PROVIDER: S-EPMC2670780 | biostudies-literature | 2009 Jan

REPOSITORIES: biostudies-literature

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A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women.

Goodman Stephanie R SR Smiley Richard M RM Negron Maria A MA Freedman Paula A PA Landau Ruth R

Anesthesia and analgesia 20090101 1

<h4>Background</h4>There is controversy regarding the benefits and risks of combined spinal-epidural compared with epidural analgesia (CSE, EPID) for labor analgesia. We hypothesized that CSE would result in fewer patient requests for top-up doses compared to EPID.<h4>Methods</h4>One-hundred ASA physical status I or II parous women at term in early labor (<5 cm cervical dilation) requesting analgesia were randomized in double-blind fashion to the EPID group (epidural bupivacaine 2.5 mg/mL, 3 mL, ...[more]

PMID: 19095858

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Project description:Key Points Question Is the use of epidural analgesia during labor associated with adverse neonatal and childhood outcomes? Findings In this population-based cohort study of 435 281 mother-offspring pairs, the use of epidural analgesia in labor was not associated with adverse neonatal outcomes after adjustment for confounders and mediation by mode of delivery. Epidural analgesia was, however, associated with a small reduction in some adverse developmental outcomes at 2 years. Meaning In this study, epidural analgesia in labor was not associated with adverse immediate or longer-term offspring outcomes. This cohort study uses data on mother-infant pairs from the Scottish National Health Service to investigate the association of epidural anesthesia use during labor with neonatal and childhood outcomes. Importance Although use of epidural analgesia during labor is safe, detailed information about its association with neonatal and child outcomes is limited. Objective To investigate the association of labor epidural analgesia with neonatal outcomes and childhood development during the first 1000 days of life. Design, Setting, and Participants This population-based cohort study used Scottish National Health Service hospital administrative data of all 435 281 singleton live births in Scotland between January 1, 2007, and December 31, 2016, with follow-up over the first 1000 days of life. All 435 281 mother-infant pairs delivering between 24 weeks 0 days and 43 weeks 6 days’ gestation who were in active labor with cephalic presentation and who delivered vaginally or via unplanned cesarean delivery were included. Stillbirths and infants with known congenital anomalies were excluded. Data were analyzed between August 1, 2020, and July 23, 2021. Exposures Epidural analgesia in labor. Main Outcomes and Measures Neonatal outcomes included resuscitation, Apgar score less than 7 at 5 minutes, and neonatal unit admission. Childhood development measures (gross and fine motor function, communication, and social functioning) were obtained from standardized national childhood surveillance assessments performed at 2 years. Results This study included a total of 435 281 live births with cephalic presentation in labor (median gestational age at delivery, 40 weeks [IQR, 39-41 weeks]; 221 153 male infants [50.8%]), of which 94 323 (21.7%) had labor epidural. Epidural analgesia was associated with a reduction in spontaneous vaginal deliveries (confounder-adjusted [Cadj] relative risk [RR], 0.46; 95% CI, 0.42-0.50), an increased risk of neonatal resuscitation (Cadj RR, 1.07; 95% CI, 1.03-1.11), and an increased risk of neonatal unit admission (Cadj RR, 1.14; 95% CI, 1.11-1.17). With additional analysis for mediation by mode of delivery (CMadj), these associations were reversed (CMadj RR, 0.83; 95% CI, 0.79-0.86 for neonatal resuscitation and CMadj RR, 0.94; 95% CI, 0.91-0.97 for neonatal unit admission). Epidural analgesia was associated with a reduced risk of an Apgar score less than 7 at 5 minutes in both confounder and confounder/mediation analyses. Epidural analgesia was associated with a reduced risk of having developmental concern in any domain at 2 years in confounder and confounder/mediation analyses (CMadj RR, 0.96; 95% CI, 0.93-0.98), with specifically fewer concerns regarding communication (CMadj RR, 0.96; 95% CI, 0.93-0.99) and fine motor skills (CMadj RR, 0.89; 95% CI, 0.82-0.97). Conclusions and Relevance The results of this cohort study suggest that labor epidural analgesia is not independently associated with adverse neonatal or childhood development outcomes. Associations with neonatal resuscitation and admission were likely mediated by mode of delivery.

Project description:BackgroundIf conversion of labor epidural analgesia to cesarean delivery anesthesia fails, the anesthesiologist can be confronted with a challenging clinical dilemma. Optimal management of a failed epidural top up continues to be debated in the absence of best practice guidelines.MethodAll members of the Obstetric Anaesthetists' Association in the United Kingdom were emailed an online survey in May 2017. It obtained information on factors influencing the decision to utilize an existing labor epidural for cesarean section and, if epidural top up resulted in no objective sensory block, bilateral T10 sensory block, or unilateral T6 sensory block, factors influencing the management and selection of anesthetic technique. Differences in management options between respondents were compared using the chi-squared test.ResultsWe received 710 survey questionnaires with an overall response rate of 41%. Most respondents (89%) would consider topping up an existing labor epidural for a category-one cesarean section. In evaluating whether or not to top up an existing labor epidural, the factors influencing decision-making were how effective the epidural had been for labor pain (99%), category of cesarean section (73%), and dermatomal level of blockade (61%). In the setting of a failed epidural top up, the most influential factors determining further anesthetic management were the category of cesarean section (92%), dermatomal level of blockade (78%), and the assessment of maternal airway. Spinal anesthesia was commonly preferred if an epidural top up resulted in no objective sensory block (74%), bilateral T10 sensory block (57%), or unilateral T6 sensory block (45%). If the sensory block level was higher or unilateral, then a lower dose of intrathecal local anesthetic was selected and alternative options such as combined-spinal epidural and general anesthesia were increasingly favored.DiscussionOur survey revealed variations in the clinical management of a failed epidural top up for cesarean delivery, suggesting guidelines to aid decision-making are needed.

Dataset Information

A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women.

Publications

A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women.

Similar Datasets

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