Extending epidural analgesia for intrapartum cesarean section following epidural labor analgesia: a retrospective cohort study

Effect of ropivacaine, mepivacaine or the combination of ropivacaine and mepivacaine for epidural anaesthesia on the postoperative recovery in patients undergoing caesarean section: a randomized, prospective, double-blind study

BACKGROUND

Anaesthetic methods and drugs with rapid onset, rapid recovery and better postoperative analgesia are more suitable for rapid recovery in obstetric anaesthesia. We formulated the following hypothesis: a combination of mepivacaine and ropivacaine could provide a longer analgesic effect and have more advantages in terms of rapid-recovery indicators.

METHODS

A total of 180 pregnant women scheduled to undergo elective caesarean sections were randomly assigned to three surgical groups, which received 2% mepivacaine (Group M), 2% mepivacaine + 0.75% ropivacaine (Group MR) (Volume 1:1) or 0.75% ropivacaine (Group R) through an epidural catheter. The situation of postoperative analgesia and other indicators of rapid recovery were recorded.

RESULTS

One hundred and fifty patients were included in the final analysis. Their demographic data were similar. The visual analogue scale (VAS) scores of Group MR and Group R were lower than Group M at 1 and 2 h after surgery both at rest and with movement (P < 0.05), and the time to first ambulation in Group MR (17.38 ± 2.06 h) and Group M (17.20 ± 2.09 h) was shorter than that in Group R (22.18 ± 1.74 h) (P < 0.05).

CONCLUSION

Application of 2% mepivacaine combined with 0.75% ropivacaine for epidural anaesthesia can provide longer postoperative analgesia and earlier ambulation, these effect may be more suitable than that of 2% mepivacaine or 0.75% ropivacaine alone for caesarean section.

TRIAL REGISTRATION

This study was registered at Chinese Clinical Trial Registry (Registration number: ChiCTR 2300078288; date of registration: 04/12/2023).

Risk factors for failure of conversion from epidural labor analgesia to cesarean section anesthesia and general anesthesia incidence: an updated meta-analysis

OBJECTIVES

Ongoing controversies persist regarding risk factors associated with the failure of transition from epidural labor analgesia to cesarean section anesthesia, including the duration of labor analgesia, gestational age, and body mass index (BMI). This study aims to provide an updated analysis of the incidence of conversion from epidural analgesia to general anesthesia, while evaluating and analyzing potential risk factors contributing to the failure of this transition to cesarean section anesthesia.

METHODS

We conducted an extensive literature search utilizing databases such as PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WANGFANG, and the Chinese Biomedical Literature Database (CBM) up to September 30, 2022. The meta-analysis was performed using STATA 15.1 software. The quality of the included studies was assessed using the 11-item quality assessment scale recommended by the Agency for Healthcare Research and Quality (AHRQ).

RESULTS

A total of 9,926 studies were initially retrieved, and after rigorous selection, 19 studies were included in the meta-analysis. The overall incidence of conversion from epidural analgesia to general anesthesia was found to be 6% (95% confidence interval [CI]: 5-8%). Our findings indicate that, when compared to patients in the successful conversion group, those in the failure group tended to be younger (weighted mean difference [WMD] = -1.571, 95% CI: -1.116 to -0.975) and taller (WMD = 0.893, 95% CI: 0.018-1.767). Additionally, the failure group exhibited a higher incidence of incomplete block in epidural anesthesia, received a higher dosage of additional epidural administration, experienced a greater rate of emergency cesarean sections, and received anesthesia more frequently from non-obstetric anesthesiologists. However, no statistically significant differences were observed in gestational age, depth of the catheter insertion into the skin, epidural catheter specifics, duration of epidural analgesia, infusion rate of epidural analgesia, primiparity status, cervical dilatation during epidural placement, BMI, or weight.

CONCLUSION

Our study found that the incidence of conversion from epidural analgesia to cesarean section under general anesthesia was 6%. Notably, the failure group exhibited a higher rate of incomplete block in epidural anesthesia, a greater incidence of emergency cesarean sections, a more frequent provision of anesthesia by non-obstetric anesthesiologists, a higher dosage of epidural administration, and greater height when compared to the success group. Conversely, women in the failure group were younger in age compared to their counterparts in the success group.

Prolonged duration of epidural labour analgesia decreases the success rate of epidural anaesthesia for caesarean section

OBJECTIVE

To summarise the process of conversion of epidural labour analgesia to anaesthesia for caesarean delivery and explore the relationship between duration of labour analgesia and conversion.

METHODS

Parturients who underwent conversion from epidural labour analgesia to anaesthesia for caesarean delivery between May 2019 and April 2020 at the Chengdu Women's and Children's Central Hospital, Sichuan Maternal and Child Health Hospital, and Jinjiang District Maternal and Child Health Hospital were selected. If the position of the epidural catheter was correct and the effect was good, patients were converted to epidural surgical anaesthesia. If epidural labour analgesia was ineffective, spinal anaesthesia (SA) was administered immediately. For category-1 emergency caesarean sections, general anaesthesia (GA) was administered.

RESULTS

A total of 1084 parturients underwent conversion. Of these, 19 (1.9%) received GA due to the initiation of category-1 emergency caesarean section. 704 (64.9%) were converted to epidural surgical anaesthesia, 2 (0.2%) had failed conversions and were administered GA before delivery, and 357 (32.9%) were converted to SA. Logistic regression analysis showed that prolonged duration of epidural labour analgesia ([Crude odds ratio (OR)=1.065; 95% confidence interval (CI), 1.037-1.094; p < .01]; [Adjusted OR = 1.060; 95% CI, 1.031-1.091; p < .01]) was an independent risk factor for conversion failure. A receiver operating characteristic curve constructed using duration of epidural labour analgesia showed that parturients with a duration of epidural labour analgesia ≥8 h, more frequently required a change of anaesthesia technique during conversion, and the relative risk of conversion failure was 1.54 (95% CI, 1.23-1.93; p < .01).

CONCLUSION

Prolonged duration of epidural labour analgesia increases the possibility of having an invalid epidural catheter, resulting in an increased risk of conversion failure from epidural labour analgesia to epidural surgical anaesthesia. Further, this risk is higher when the time exceeds 8 h. KEY MESSAGESProlonged duration of epidural labour analgesia > 8 h is associated with conversion failure.If it is impossible to judge whether the conversion is successful immediately, spinal anaesthesia should be administered to minimise complications.