The effects of different epidural analgesia formulas on labor and mode of delivery in nulliparous women

Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis

PURPOSE

In labour, neuraxial analgesia is the standard in the provision of pain relief. However, the optimal mode of delivering epidural solution has not been determined, and some parturients may need an alternative to epidural analgesia. We sought to conduct a systematic review and network meta-analysis to compare continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, patient-controlled epidural bolus (PCEA), fentanyl patient-controlled analgesia (PCA), and remifentanil PCA, either alone or in combination.

METHODS

We searched CENTRAL, CINAHL, Ovid Embase, Ovid Medline, and Web of Science for randomized controlled trials that included nulliparous and/or multiparous parturients in spontaneous or induced labour. The maintenance epidural solution had to include a low concentration local anesthetic and an opioid. Specific subgroups in the obstetric population such as preeclampsia were excluded. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes are presented as mean differences and odds ratios, respectively, with 95% confidence intervals.

RESULTS

Overall, 73 trials were included. For the first coprimary outcome, the need for rescue analgesia, CEI was inferior to PIEB and PIEB + PCEA was superior to PCEA alone, with a low certainty of evidence given the presence of serious limitations and imprecision. The second coprimary outcome, the maternal satisfaction, was improved by PIEB + PCEA compared with CEI + PCEA and PCEA alone, with a low quality of evidence in view of the presence of serious limitations and imprecision. Fentanyl PCA increased the requirement for rescue analgesia and decreased maternal satisfaction relative to many methods of delivering epidural solution. In terms of secondary outcomes, PIEB increased analgesic efficacy compared with CEI, and PCEA reduced local anesthetic consumption at the expense of inferior analgesia relative to CEI and PIEB. PIEB + PCEA was superior to CEI + PCEA in regard to the pain score at 2 h and 4 h, consumption of local anesthetic, incidence of lower lower limb motor blockade and the rate of spontaneous vaginal delivery. Fentanyl and remifentanil PCA did not provide the same level of analgesia as all epidural methods, resulted in increasing analgesic ineffectiveness with time spent in labour, and predisposed to a higher incidence of side effects such as nausea and/or vomiting and sedation. Remifentanil PCA was superior to fentanyl PCA for analgesia at an early time point, and it increased the incidence of oxygen desaturation relative to other strategies of delivering epidural solution.

CONCLUSIONS

Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects. We interpret the findings of our systematic review and network meta-analysis as suggesting PIEB + PCEA to be the optimal delivery mode of epidural solution. Nevertheless, the potential differing importance of the various maternal, fetal, and neonatal outcomes in determining which is optimal has not, to our knowledge, been elucidated yet.

STUDY REGISTRATION

PROSPERO (CRD42021254978); registered 27 May 2021.

The Effect of Epidural Analgesia on the Maternal and Fetal Outcomes in Mothers Undergoing Induction of Labour

Introduction

Elective labour induction is associated with more pain, intrapartum interventions, cesarean deliveries, as compared with spontaneous labour, necessitating the use of labour analgesia. Epidural analgesia is one popular method for control of pain. This study was to determine the effect of epidural analgesia on the maternal and fetal outcomes in women undergoing induction of labour, as adequate data in this specific population is relatively sparse.

Materials and Methods

This was a cross-sectional study conducted over a period of 18 months which included mothers with singleton term gestation with cephalic presentation admitted for induction of labour.

Result

A sample of 238 mothers were included in the study. Among the study population, 52.7% opted for epidural analgesia. The pain score was less than 3/10 (VAS) in 81% of mothers who opted for epidural analgesia. The cesarean section rate was 20.5% and 34.3% in the epidural and non-epidural groups, respectively. After adjusting the confounding factors, there was a positive effect noted in the caesarean section rate among the epidural group, which was lesser than the non-epidural group. However, a higher instrumental delivery rate (18.8% vs. 10.5%, p-value < 0.05) was noted in the epidural group. There was no significant difference in the duration of labour and fetal outcome in the two groups.

Conclusion

Epidural analgesia providing good pain relief in the majority of the mothers was reinforced. In our study, epidural analgesia was associated with a reduction of caesarean section rate after adjusting the confounding factor. Epidural analgesia did not affect the duration of labour, cesarean section rate and fetal outcome independently, however, it was associated with increased risk of instrumental delivery. The outcomes mainly depend on the confounding factors. Therefore, mothers can be provided with an evidence-based information regarding the effect of epidural analgesia in induced labour and help those seeking epidural analgesia to make an informed choice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-022-01622-1.

Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis

BACKGROUND

Continuous epidural infusion (CEI) is commonly used for labour analgesia, but concerns over potential motor block, second-stage labour complications, and ineffective analgesia in late labour have prompted examining intermittent epidural bolus (IEB) as an alternative. However, evidence comparing these modalities is conflicting. The meta-analysis evaluates the analgesic efficacy of CEI vs IEB.

METHODS

Databases were searched for trials comparing CEI to IEB for labour analgesia. The two co-primary outcomes were risk of breakthrough pain and difference in area under the curve (AUC) for pain scores during the first 4 h post-epidural initiation. Local anaesthetic consumption, maternal outcomes (i.e. delivery mode, labour duration, and maternal satisfaction), and side-effects of epidural analgesia were also evaluated. Results were pooled using random-effects modelling. Trial sequential analysis (TSA) was used to evaluate evidence reliability.

RESULTS

Twenty-seven studies (3133 patients) were analysed. Compared with CEI, IEB decreased risk of breakthrough pain by 38% (risk ratio [95% confidence interval {CI}] of 0.62 [0.48, 0.81]; P=0.0004; I²=47%; 1164 patients) and reduced AUC of pain during the 4 h interval by 32.9% (mean difference [95% CI] of -16.7 mm h^-1 [-18.9, -14.4]; P<0.0001; 1638 patients). Intermittent epidural bolus enhanced maternal satisfaction, shortened labour duration, decreased motor block, and reduced local anaesthetic consumption. The difference between the two groups was not statistically significant for epidural side-effects or mode of delivery. The TSA indicated adequate power for reliable inferences.

CONCLUSIONS

Intermittent epidural bolus provides improved labour pain control during the first 4 h after epidural initiation with less breakthrough pain. Moderate- to high-quality evidence of intermittent epidural bolus superiority support its use as a safe and effective continuous epidural infusion alternative for labour analgesia.

Investigation of the Minimum Local Analgesic Concentration of Epidural Sufentanil Combined With Ropivacaine for Labor Analgesia

PURPOSE

Worldwide, there are only few studies focusing on labor analgesia on the MLAC (minimum local analgesic concentration) or EC50 (median effective concentration) of sufentanil and ropivacaine. Therefore, we determine the MLAC or EC50 of sufentanil and ropivacaine for epidural analgesia by using an up-down sequential allocation and survey its adverse effect in a prospective blinded randomized trial.

METHODS

Sixty nulliparous full-term parturients who required labor analgesia were recruited and randomly divided into the sufentanil and ropivacaine groups. The formulation was 25 μg sufentanil combined with 0.1% ropivacaine (added 0.9% normal saline to 75 ml). According to the response of a previous parturient, the dosage of sufentanil was increased or decreased by 5 μg in the sufetanil group; meanwhile, we also administrated an initial concentration of 0.1% ropivacaine combined with 22.5 μg sufentanil (added 0.9% normal saline to 75 ml) in the ropivacaine group. The concentration of ropivacaine was increased or decreased by 0.01% following the response of the previous parturient. The Brownlee up-down sequential allocation was used to estimate the MLAC of epidural ropivacaine and its 95% confidence intervals in labor analgesia.

FINDINGS

There were no significant changes for the two groups, including for age, height weight, active stage, second stage of labor, and gestational weeks (P = 0.769, 0.900, 0.603, 0.441, 0.577, and 0.695, respectively). The VAS scores of the parturient decreased to varying degrees (P < 0.0001) after labor analgesia compared with VAS before labor analgesia, and the most effective analgesia was reached in 60 min. The EC50 dose of epidural ropivacaine combined with 0.3 μg/mL sufentanil was 0.09687%, and the 95% CI was 0.08944%~0.1043%. Five parturients had PONV, and the incidence rate was 16.7%; one parturient had pruritus, so the incidence rate was 3.3%. The EC50 dose of epidural sulfetanil combined with 0.1% ropivacaine was 18.76 μg with a 95% confidence interval of 13.5-24.48 μg. There were no significant differences in the active stage, second stage of labor, and maternal and fetal hemodynamic data between the two groups. Notably, the Apgar scores for 1 min and 5 min were 10 scores for almost all of these patients. There were no significant differences between the two groups for maternal and fetal side effects, which had very low incidence rates.

IMPLICATIONS

The MLAC of epidural sufentanil or ropivacaine could provide satisfactory and safe analgesia for parturients while having a low incidence rate of side effects.

Comparison of ropivacaine combined with sufentanil for epidural anesthesia and spinal-epidural anesthesia in labor analgesia

BACKGROUND

To compare the application and efficacy of ropivacaine combined with sufentanil for continuous epidural anesthesia (CEA) and combined spinal-epidural anesthesia (CSEA) in labor analgesia.

METHODS

Three hundred sixty pregnant women requesting labor analgesia from October 2017 to August 2018 were selected retrospectively. According to the anesthetic method, subjects were divided into CSEA group and CEA group. Ropivacaine combined with sufentanil were used in all subjects. The labor time, visual analogue scale (VAS), Apgar score of newborn, adverse pregnancy outcomes and adverse drug reactions were observed.

RESULTS

There was no significant difference in pre-analgesia (T₀) VAS scores between the two groups (P > 0.05). VAS scores of first stage of labor (T₁), second stage of labor (T₂) and third stage of labor (T₃) in CSEA group were significantly lower than CEA group (P < 0.01). The onset time, T₁ and total labor time in CSEA group were significantly shorter than CEA group (P < 0.01). There were no significant differences between T2 and T3 (P > 0.05). There were no significant differences in adverse pregnancy outcomes and Apgar scores at 1, 5 and 10 min after birth between the two groups (P > 0.05). The incidence of adverse drug outcomes in CSEA group was significantly lower than CEA group (P < 0.01). Maternal satisfaction in CSEA group was significantly higher than CEA group (P < 0.01).

CONCLUSION

Considering ropivacaine combined with sufentanil for CSEA achieved a shorter onset time and labor period, significant analgesic effect, lower adverse drug reactions rates and higher subject satisfaction than CEA, it may be worthy of clinical promotion and application.

The Effect of Epidural Analgesia on the Delivery Outcome of Induced Labour: A Retrospective Case Series

Objective. To investigate whether the use of epidural analgesia during induced labour was a risk factor for instrumental vaginal delivery and caesarean section (CS) delivery. Study Design. This was a retrospective case series of primigravidae women being induced at term for all indications with a normal body mass index (BMI) at booking and under the age of 40 years. Results. We identified 1,046 women who fulfilled the inclusion criteria of which 31.2% had an epidural analgesia. Those with an epidural analgesia had significantly greater maternal age, higher BMI, greater percentage of oxytocin usage, and a longer first and second stage of labour. Women with an epidural analgesia had a higher instrumental delivery (37.9% versus 16.4%; p < 0.001) and CS delivery rate (26% versus 10.1%; p < 0.001). Multivariable analysis indicated that the use of an epidural was not a risk factor for a CS delivery but was a risk factor for an instrument-assisted delivery (adjusted OR = 3.63; 95% CI: 2.51–5.24; p < 0.001). Conclusion. Our study supports the literature evidence that the use of an epidural increases the instrumental delivery rates. It has also added that there is no effect on CS delivery and the observed increase is due to the presence of confounding factors.

Epidural Analgesia With Bupivacaine and Fentanyl Versus Ropivacaine and Fentanyl for Pain Relief in Labor: A Meta-Analysis

The aim of this study was to compare the efficacy and safety of the combinational use of bupivacaine and fentanyl versus ropivacaine and fentanyl in epidural analgesia for labor. Multiple electronic databases were searched by using appropriate MeSH terms, and keywords for original research papers published before October 2014. Meta-analyses were based on mean differences between the groups as well as odds ratios. Statistical heterogeneity was tested by I² index. Fifteen randomized controlled trials, recruiting 2097 parturient mothers overall, were selected for the meta-analyses. Concentrations of the preparations used (weight/volume; mean and standard deviations) were bupivacaine 0.1023% ± 0.0375%, ropivacaine 0.1095% ± 0.042%, and fentanyl 0.00021% ± 0.000089%. There were no statistically significant differences between both the combinations in the mean change in Visual Analog Score for pain during labor, incidence of instrumental or cesarean delivery, neonate Apgar score of <7, maternal satisfaction, duration of either first or second stage of labor, oxytocin use for induction, onset of analgesia, and duration of analgesia. Women who received ropivacaine and fentanyl had significantly lower incidence of motor blocks (odds ratio [95% CI] = 0.38 [0.30, 0.48] P < 0.00001, fixed effect and 0.38 [0.27, 0.54] P < 0.0001, random effects I² 30%) when compared with women who received bupivacaine and fentanyl. Incidence of side effects was similar for both the combinations. Analgesia with ropivacaine in combination with fentanyl at 0.1%:0.0002% ratio for labor pain relief is associated with lower incidence of motor blocks in comparison with analgesia with bupivacaine and fentanyl at similar ratio (0.1%: 0.0002%).