Epidural infusions for nulliparous women in labour. A randomised double-blind comparison of fentanyl/bupivacaine and sufentanil/bupivacaine

Bupivacaine in combination with fentanyl or sufentanil in epidural/intrathecal analgesia for labor: a meta-analysis

This study is to compare the effectiveness of combinational use of bupivacaine with fentanyl (BUPI-FEN) and sufentanil (BUPI-SUF) in epidural/intrathecal analgesia for labor. Electronic databases were searched for relevant research papers published between 1985 and 2014. Meta-analyses of mean differences or odds ratios were performed and statistical heterogeneity between the studies tested by I(2) index. Ten studies recruiting a total of 728 women in labor were selected. Concentrations of the anesthetics used as mean ± sd were bupivacaine 0.115 ± 0.056%, fentanyl 0.0007 ± 0.001%, and sufentanil 0.00017 ± 0.00022%. Duration of analgesia was not significantly different between BUPI-SUF and BUPI-FEN administered mothers (mean difference [95%CI] of -33.55 [-74.94, 7.83] minutes; P = .11) under random effects. The onset of analgesia was also not significantly different between both groups (mean difference [95%CI] of -0.61 [-1.38, 0.16] minutes; P = .12). The number of neonates with Apgar score < 7 was significantly lower in BUPI-FEN group (odd ratio [95%CI] of 0.31 [0.10, 0.95]; P < .05). Pruritus incidence was similar. In conclusion, BUPI-FEN combination exhibits significantly better tolerability at an approximate ratio of 6 FEN:1 SUF, albeit, both fentanyl and sufentanil in combination with bupivacaine provide similar analgesic properties via the epidural or intrathecal routes for labor pain relief.

Comparison of efficacy of bupivacaine and fentanyl with bupivacaine and sufentanil for epidural labor analgesia

OBJECTIVES

A study to compare the efficacy between fentanyl and sufentanil combined with low concentration (0.0625%) of bupivacaine for epidural labor analgesia in laboring women

MATERIALS AND METHODS

Fifty full term parturients received an initial bolus dose of a 10 ml solution containing 0.125% bupivacaine. The patients were randomly divided into two: group F received 0.0625% bupivacaine with 2.5 mcg/ml fentanyl and group S received 0.0625% bupivacaine with 0.25 mcg/ml sufentanil. Verbal analogue pain scores, need of supplementary/rescue boluses dose of bupivacaine consumed, mode of delivery, maternal satisfaction, and neonatal Apgar scores were recorded. No significant difference was observed between both groups.

RESULTS

Both the groups provided equivalent labor analgesia and maternal satisfaction. The chances of cesarean delivery were also not increased in any group. No difference in the cephalad extent of sensory analgesia, motor block or neonatal Apgar score were observed. Although mean pain scores throughout the labor and delivery were similar in both groups, more patients in fentanyl group required supplementary boluses though not statistically significant.

CONCLUSION

We conclude that both 0.0625% bupivacaine-fentanyl (2.5 μg/ml) and 0.0625% bupivacaine-sufentanil (0.25 μg/ml) were equally effective by continuous epidural infusion in providing labor analgesia with hemodynamic stability achieving equivalent maternal satisfaction without serious maternal or fetal side effects. We found that sufentanil was 10 times more potent than fentanyl as an analgesic for continuous epidural labor analgesia.

A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction

BACKGROUND

The effect of epidural local anesthetic concentration on analgesic action is still the subject of debate. This study compared the effect of a four-fold change in concentration of bupivacaine for epidural analgesia in labor.

METHODS

Nulliparous women in early active labor were recruited. All women received analgesic drugs via a lumbar epidural catheter, and all received fentanyl 1 microg/kg with the epidural induction dose and no further opioids throughout the study. Patients were randomized to receive either a 5-mL bolus followed by a 5-mL/h infusion of concentrated (0.25%) bupivacaine or a 20-mL bolus followed by a 20-mL/h infusion of dilute (0.0625%) bupivacaine. Patient-controlled epidural analgesia of the study solution was then used to assess additional analgesia requirements. Analgesic requirement, maternal satisfaction and obstetric outcome were compared.

RESULTS

For subjects receiving 0.25% bupivacaine, the median total dose of drug administered was greater (117 vs. 90 mg, P=0.0008), and the mean maternal satisfaction score was less (82 vs. 93, P=0.04) than with the 0.0625% solution.

CONCLUSIONS

Larger volumes of more dilute solutions may result in dose sparing and provide more effective labor analgesia. This study supports the continued trend towards dilute local anesthetic mixtures for labor epidural analgesia.

Epidural analgesia for childbirth: effects of newer techniques on neonatal outcome

New low-dose, local anesthetic-opioid combinations, combined spinal epidural analgesia, and new anesthetic drugs, such as ropivacaine and levobupivacaine, have modified the anesthetic practice in obstetric labor analgesia. These new analgesic techniques have less or no neonatal effects when compared with traditional epidural labor analgesia. They also have less effect on mode of delivery, which may in turn affect neonatal outcome. The use of very diluted or low concentrations of local anesthetic solutions may reduce their placental passage and thus the possible subtle neonatal effects. Small doses of epidural or spinal opioids alone or combined with low doses of local anesthetics does not affect the well-being of the neonate at birth. When considering the neonatal outcome, combined spinal epidural analgesia is as well tolerated as low-dose epidural analgesia. Transient fetal heart rate changes have been described immediately after the administration of intrathecal or epidural opioids. Maternal hypotension may also occur at the onset of epidural analgesia. Whether the occurrence of transient fetal heart rate changes or maternal hypotension immediately after the epidural block may influence the neonatal outcome at birth needs verification.

Factors related to childbirth satisfaction

BACKGROUND

A woman's satisfaction with the childbirth experience may have immediate and long-term effects on her health and her relationship with her infant, but there is a lack of current research in this area.

AIM

This paper reports a study to examine multiple factors for their association with components of childbirth satisfaction and with the total childbirth experience.

METHOD

A correlational descriptive study was conducted with 60 low-risk postpartum women, aged 18-46 years, with uneventful vaginal deliveries of healthy full-term infants at two medical centres in the south-eastern United States. The Labor Agentry Scale, McGill Pain Questionnaire and Mackey Childbirth Satisfaction Rating Scale and a background questionnaire were completed by women. Obstetrical data were collected from the medical record.

FINDINGS

Personal control was a statistically significant predictor of total childbirth satisfaction (P = 0.0045) and with the subscale components of satisfaction (self, partner, baby, nurse, physician and overall). In addition, having expectations for labour and delivery met was a significant predictor of satisfaction with own performance during childbirth.

CONCLUSIONS

Personal control during childbirth was an important factor related to the women's satisfaction with the childbirth experience. Helping women to increase their personal control during labour and birth may increase the women's childbirth satisfaction.

Does the use of low dose bupivacaine/opioid epidural infusion increase the normal delivery rate?

To investigate whether using low dose epidural infusion improves the normal delivery rate, outcome of labour was studied in women with singleton vertex presentations randomised to receive either 0.0625% bupivacaine opioid, or plain bupivacaine 0.125% for labour. The infusion rate was titrated to maintain analgesia and a sensory level to T10. Data were analysed using the unpaired t test, Mann-Whitney U test and for categorical variables chi2 test. Adjusted odds ratios for factors significantly associated with non-normal delivery were calculated using stepwise logistic regression. There were 291 women in the low dose and 296 in the plain bupivacaine group. There were no significant differences between groups in parity, race, induction of labour, use of augmentation, cervical dilatation at epidural insertion, duration of any stage of labour or duration or volume of infusion. Total dose of bupivacaine (126 +/- 47 mg versus 91 +/- 32 mg) and the proportion of women with motor block at the end of labour (45% versus 27%) were significantly greater in the plain bupivacaine than in the low dose group (P < 0.0001). The adjusted odds ratios (95% CI) for factors significantly associated with non-normal delivery were primiparity: 4.68 (2.78-7.88), older maternal age: 1.1 (1.05-1.14), longer active second stage of labour: 1.01 (1.005-1.017), total bupivacaine dose: 1.01 (1.005-1.016) and greater cervical dilatation at epidural insertion 1.22 (1.08-1.37). Treatment group and motor block at the end of labour had no significant effect. We found no increase in normal delivery rate with low dose infusions.

Neuraxial opioids in labour

Neuraxial opioids were first used for labour analgesia in 1980 following the description of spinal cord opioid receptors in 1979. Via these receptors in the dorsal horn, opioids modulate both the visceral and the somatic pain of labour. The onset and duration of action of the individual opioid are determined primarily by its relative lipid solubility. Neuraxial opioids have a local anaesthetic sparing effect, allowing the use of lower concentrations of both agents while maintaining analgesia. As a sole agent, intrathecal opioids can be used to provide analgesia during the first stage of labour, especially in the high-risk parturient. They also have a role in the management of perineal pain and the provision of rapid-onset analgesia. Unfortunately maternal and neonatal side-effects can occur, the most important being respiratory depression.

Long term backache after childbirth: prospective search for causative factors

OBJECTIVES

To assess in a prospective randomised study the association between motor block resulting from high and low dose epidural infusions of bupivacaine in labour and the incidence of long term backache after childbirth, and to compare the incidence of backache in women not receiving epidural analgesia.

DESIGN

Women requesting epidural analgesia in labour between October 1991 and March 1994 were randomised to receive infusions of either bupivacaine alone or low dose bupivacaine with opioid. Data were collected during labour and the immediate postpartum period from these women and from women recruited at random over the same time from those who had laboured without epidural analgesia. A postal questionnaire about symptoms was sent three months after childbirth to all women. Further data were collected one year after childbirth from those who had reported new backache at three months.

SETTING

St Thomas's Hospital, London.

SUBJECTS

599 women were recruited, of whom 450 (75%) replied to a follow up questionnaire.

RESULTS

152 women (33.8% of responders) reported backache lasting three months after delivery and, of these, 33 (7.3%) had not previously suffered with backache. There were no significant differences between the treatment groups in the incidence of postnatal backache overall or of new backache or any symptoms after childbirth. Among all demographic, obstetric, and epidural variables examined the only factors significantly associated with backache after childbirth were backache before and during pregnancy.

CONCLUSIONS

The incidence of new long term backache was not significantly increased in women who received epidural analgesia in labour. Motor block resulting from epidural local anaesthetic administration was not a significant factor in the development of backache.

Epidural analgesia for labour and delivery: fentanyl or sufentanil?

PURPOSE

The highly lipid soluble opioids, fentanyl and sufentanil, are used in combination with local anaesthetics with/without epinephrine to provide epidural analgesia during labour and delivery. Our aim was to determine whether wither opioid was superior when used with low dose local anaesthetic.

METHODS

In a double-blind study patients were randomized to two epidural infusion groups: Group I (n = 50) fentanyl 2 micrograms.ml-1 with bupivacaine 0.015% and epinephrine 2 micrograms.ml-1, Group II(n = 50) sufentanil 1 microgram.ml-1 with bupivacaine 0.015% and epinephrine 2 micrograms.ml-1. Following a 20 ml bolus of the study solution an infusion was started at 10 ml.h-1. To achieve analgesia patients could receive two boluses of 5 ml of the study solution and if analgesia was still inadequate, a further 5 ml bupivacaine 0.25% was used. Pain and overall satisfaction were assessed with a 10-point visual scale. Plasma samples obtained from the mother at the time the infusion was discontinued and from the umbilical cord vein at delivery were assayed to determine opioid concentration.

RESULTS

Pain scores were greater for Group I than for Group II patients throughout the first and second stages of labour (P = 0.002). More patients in Group I (42%) requested a dose of bupivacaine 0.25% than in Group II (6%) (P < 0.001) and the total dose of bupivacaine given to Group I patients was greater than that of Group II, 26.0 +/- 22.0 mg vs. 13.4 +/- 12.6 mg, P = 0.005. There were no differences with respect to first or second stage duration, incidence of side effects, infusion duration, outcome of labour or neonatal Apgar scores. There was no opioid accumulation in either maternal or foetal blood.

CONCLUSION

Epidural opioid infusion with very low dose bupivacaine (0.015%) achieved an overall high level of patient satisfaction in both groups without serious maternal or neonatal side effects. At the fentanyl-to-sufentanil ratio used here patients receiving sufentanil had lower pain scores and substantially fewer patients required bupivacaine rescue.

Epidural infusion of low-dose bupivacaine and opioid in labour. Does reducing motor block increase the spontaneous delivery rate?

Labouring women were randomly allocated to receive epidural infusions during labour of either 0.125% plain bupivacaine (n = 200) or a combination of 0.0625% bupivacaine with either 2.5 micrograms.ml-1 fentanyl or 0.25 micrograms.ml-1 sufentanil (n = 199) each starting at 12 ml.h-1 and adjusted as necessary to maintain analgesia. The dose of bupivacaine, both hourly (p < 0.001) and total (p < 0.001), was significantly lower in the group receiving the combination. Motor block was significantly less common and less severe in the combination group (p < 0.001). These reductions did not result in a significant increase in spontaneous deliveries. Maternal satisfaction with first (p < 0.001) and second stage analgesia (p < 0.001) was significantly increased in the combination group. The addition of opioid to the epidural infusion did not reduce the incidence of perineal pain. There were no significant differences between the groups in neonatal outcome or the incidence of early postnatal symptoms.

Epidural clonidine-fentanyl combination for labour analgesia: a comparison with bupivacaine-fentanyl

This open study of 20 women compared epidural clonidine (300 microg)/fentanyl (100 microg) with bupivacaine (25 mg)/fentanyl (100 microg) in the provision of pain relief in labour. Sensory tests in the clonidine group revealed slight alterations in the appreciation of pin prick and temperature but motor power was unchanged. Analgesia after the first dose was similar in the two groups, but thereafter the analgesia provided by clonidine/fentanyl was less than that from bupivacaine/fentanyl. Despite the incomplete pain relief provided by clonidine/fentanyl, mothers appreciated their essentially normal sensations and muscle power. Midwives also commented favourably on the normal mobility of these labouring mothers. There was no difference between the two groups in the duration of labour or the condition of the infants.