Spinal-epidural Labor Analgesia Research Articles

Real-time analgesic efficacy and factors determining drug requirements of combined spinal-epidural analgesia for labor: a prospective cohort study

PurposeCombined spinal-epidural analgesia (CSEA) is effective but not sufficient for labor pain. This study was conducted to assess the real-time analgesic efficacy, side effects of anesthetic drug dosage, and maternal satisfaction in labor to provide reference for the optimization of labor analgesia.MethodsThis was a prospective, cohort, single-center study that included 3020 women who received CSEA for labor analgesia. The visual analogue scale (VAS) for labor pain, real-time anesthetic drug dosage, side effects, adverse labor outcomes, factors influencing average drug dosage, and maternal satisfaction with CSEA were assessed.ResultsOverall, the VAS labor pain score was lowest at the first hour after the anesthesia was given. After 4 h for primiparas and 3 h for multiparas, the VAS score was greater than 3 but the anesthetic drug dosage did not reach the maximum allowed dosage at the same time. The average anesthetic drug dosage was positively correlated with fever, urinary retention, uterine atony, prolonged active phase, prolonged second stage, assisted vaginal delivery, and postpartum hemorrhage. The average anesthetic drug dosage was the highest in women ≤ 20 years old, those with a body mass index (BMI) ≥ 24.9 kg/m2, and those with a primary or secondary education level.ConclusionAppropriate age guidance and emphasis on education of labor analgesia, weight management during pregnancy, and real-time anesthetic dosage adjustment during labor based on VAS pain score may have positive effects on the satisfaction of labor analgesia.Clinical trial number and registryClinicaltrials.gov (ChiCTR2100051809).

Association between breakthrough labor pain, patient-controlled epidural analgesia use, and numeracy: A pilot observational study

ObjectiveLabor analgesia can be maintained with a continuous epidural infusion, supplemented by patient-controlled epidural boluses. patient-controlled epidural boluses use and timing require numeric understanding, as patients need to understand when they can administer supplemental boluses, lockout intervals, and total doses. We hypothesized that women with lower numeric literacy have a higher rate of provider-administered supplemental boluses for breakthrough pain because they do not understand the concept behind patient-controlled epidural boluses. DesignPilot observational study SettingLabor and Delivery Suite ParticipantsNulliparous, English-speaking patients with singleton, vertex pregnancies admitted for postdates (gestational age ≥ 41 weeks) induction of labor requesting neuraxial labor analgesia. InterventionsCombined spinal-epidural labor analgesia was initiated with intrathecal fentanyl and epidural analgesia was maintained using continuous epidural infusion with patient-controlled epidural boluses. Measurements and findingsNumeric literacy was assessed using the Lipkus 7-item expanded numeracy test. Patients were stratified by whether or not they required supplemental provider-administered analgesia and patient-controlled epidural boluses use patterns were evaluated. A total of 89 patients completed the study. There were no demographic differences between patients who required supplemental analgesia compared with those who did not. Patients that required supplemental analgesia were more likely to request and receive patient-controlled epidural boluses (P<0.001). Hourly bupivacaine requirement was higher in women with breakthrough pain. There were no differences in numeric literacy between the two groups. Key conclusionsPatients who required treatment of breakthrough pain had higher patient-controlled epidural boluses demands-to-delivery ratio. Numeric literacy was not correlated with the need for provider-administered supplemental boluses. Implications for practiceEasy to understand scripts on how to use patient-controlled epidural boluses allows for understanding of patient-controlled epidural boluses use.

Maternal heart rate variability patterns associated with maternal hypotension and non-reassuring fetal heart rate patterns following initiation of combined spinal-epidural labor analgesia: a prospective observational trial

BackgroundWe evaluated whether baseline maternal heart rate variability (HRV), including the Analgesia Nociception Index (ANI), is associated with maternal hypotension and fetal heart rate (FHR) abnormalities following combined spinal-epidural (CSE) labor analgesia. MethodsLaboring women were enrolled in this prospective observational study. The primary endpoint was maternal hypotension. The secondary endpoint was FHR abnormalities within 30 min following CSE analgesia initiated with intrathecal plain bupivacaine 1.0 mg and fentanyl 20 µg. The maternal ANI, electrocardiogram, blood pressure, heart rate, oxygen saturation, and FHR tracings were recorded 15 min before and 30 min after CSE. Parturients were grouped based on presence of hypotension and FHR abnormalities. Patient demographics and HRV metrics were compared. Receiver operating characteristics (ROC) curves were constructed for the prediction of hypotension and FHR abnormalities. ResultsNo significant intergroup differences were detected in patient characteristics. Several baseline HRV metrics and ANI differed significantly between the normotensive (n = 50) and hypotensive (n = 31) groups and between parturients showing FHR abnormalities (n = 19) and those showing reassuring FHR traces (n = 62). The area under the ROC curve (AUC) for predicting hypotension of the baseline low-frequency (LF)/high-frequency (HF) ratio was 0.677 (95% CI 0.55 to 0.80), and that of the ANI was 0.858 (95% CI 0.78 to 0.94). For predicting non-reassuring FHR patterns, the AUC of the LF/HF ratio was 0.77 (95% CI 0.65 to 0.89), and that of the ANI was 0.833 (95% CI 0.72 to 0.94). ConclusionsThe ANI can predict the propensity for maternal hypotension and non-reassuring FHR patterns following CSE.

Effect of Epidural Bolus Levobupivacaine and Lignocaine in Late Second Stage of Parturition in Combined Spinal Epidural Labor Analgesia

Background: Use of minimum local analgesic concentration in the epidural component of combined spinal epidural (CSE) effectively maintains analgesia in the first stage of labor. However, local anesthetic concentration needs to increase to achieve effective analgesia in the second stage as there are more recruitment of A-δ fiber occurs. This study compared the effect of epidural bolus of Levobupivacaine and Lignocaine in the late second stage of parturition in combined spinal epidural labor analgesia.Methods: This multicenterd, open-label, randomized controlled trial was conducted under supervision of Department of Anesthesia, Analgesia, and Intensive Care Medicine of Bangabandhu Sheikh Mujib Medical University from July 2019 to June 2020 including 80 parturients of 18-35 years old, ASA status I and II, full-term, primiparous, who were randomized into two groups to receive either 10ml bolus of 0.0625% levobupivacaine with fentanyl 2μg/ml or 10ml bolus of 0.5% lignocaine with fentanyl 2μg/ml after CSE analgesia at first stage of labor. Level of analgesia, duration of second stage of labor, quality of pain relief, maternal satisfaction, mode of delivery and APGAR score of neonate were evaluated.Results: During delivery, levobupivacaine group had a lower intensity of pain compared to lignocaine group (VAS score 1.89±0.67 vs 2.64±0.92, p = 0.001). Duration of second stage of labor in levobupivacaine group was significantly shorter compared to lignocaine group (48.4±16 minutes vs 63.5±28.4, p-value 0.007). Besides, quality of pain relief and maternal satisfaction were better in levobupivacaine group compared to lignocaine group. Moreover, instrumental delivery rate was high in lignocaine group. Fetal outcome measured as APGAR score was similar in both groups.Conclusion: Epidural bolus of levobupivacaine-fentanyl produces more adequate analgesia than lignocaine-fentanyl in late second stage of labor and does not increase instrumental delivery rate with similar fetal outcome.

Acupoint Injection Decreases Anesthetic Cosumption during Combined Spinal-Epidural and Patient-Controlled Epidural Labor Analgesia.

To explore if acupoint injection can improve analgesic effects or delivery outcomes in parturients who received combined spinal-epidural analgesia (CSEA) and patient-controlled epidural analgesia (PCEA) for labor analgesia. A total of 307 participants were prospectively collected from July 2017 to December 2019. The participants were randomized into the combined acupoint injection with CSEA plus PCEA group (AICP group, n=168) and CSEA plus PCEA group (CP group, n=139) for labor analgesia using a random number table. Both groups received CSEA plus PCEA at cervical dilation 3 cm during labor process, and parturients of the AICP group were implemented acupoint injection for which bilateral acupoint of Zusanli (ST 36) and Sanyinjiao (SP 6) were selected in addition. The primary outcome was Visual Analogue Scale (VAS) score, and the secondary outcomes were obstetric outcomes and requirement of anesthetics doses. Safety evaluations were performed after intervention. The VAS scores were significantly lower in the AICP group than in the CP group at 10, 30, 60, and 120 min after labor analgesia (all P<0.05). The latent phase of the AICP group was shorter than that of the CP group (P<0.05). There were less additional anesthetics consumption, lower incidences of uterine atony, fever, pruritus and urinary retention in the AICP group than those in the CP group (all P<0.05). Acupoint injection combined CSEA plus PCEA for labor analgesia can decrease the anesthetic consumption, improve analgesic quality, and reduce adverse reactions in the parturients. (Registration No. ChiMCTR-2000003120).

Intrathecal dexmedetomidine improves epidural labor analgesia effects: a randomized controlled trial.

Objectiveα2‑agonists and opioids have been used as intrathecal adjuvants to local anesthetics for several years, but the effect of intrathecal dexmedetomidine (Dex) or sufentanil combined with epidural ropivacaine in labor analgesia is not fully understood.MethodsA total of 108 parturient women receiving combined spinal-epidural labor analgesia were randomly divided into three groups. Group C received l mL saline (0.9%) intrathecally, Group D received 5 µg Dex intrathecally, and Group S received 5 µg sufentanil intrathecally. All parturient women then received 0.1% epidural ropivacaine and 0.2 µg/mL sufentanil for patient-controlled epidural analgesia with standard settings. The visual analog scale score, onset time, duration of intrathecal injection, local anesthetic requirements, and side effects were recorded.ResultsThe labor analgesia effects in Groups D and S were better than those in Group C. Groups D and S displayed significantly shorter onset times, longer durations of intrathecal injection, and reduced local anesthetic requirements compared with Group C. The incidence of shivering and pruritus in Group D was lower than that in Group S.ConclusionIntrathecal administration of 5 µg Dex could improve epidural labor analgesia effects.This randomized controlled clinical trial was registered with the Chinese Clinical Registry Center (ChiCTR-1800014943, http://www.chictr.org.cn/).

Progress of labor and obstetric outcome in parturients with combined spinal-epidural analgesia for labor: A comparative study.

Background:Alleviation of labour pain is known to improve maternal and fetal outcome. Combined Spinal-Epidural (CSE) analgesia is an excellent method.Aim and objectives:In view of reports of its concerns on labour, this study was conducted to evaluate the progress of labour, obstetric outcome in cases with and without CSE analgesia, the maternal pain relief and fetomaternal adverse effects.Materials and methods:In this comparative study, 60 parturients were allocated into case and control groups of 30 each. CSE analgesia was administered utilizing 0.5 ml of 0.125% Levobupivacaine / 0.2% Ropivacaine with 2 mcg/ml fentanyl. Progress of labour was recorded in partogram including duration of labour, mode of delivery, pain relief - Visual Analogue Scale (VAS) score, development of motor block, maternal satisfaction and Apgar score. Data was analyzed by Descriptive and Inferential statistics.Results:Mean duration of first and second stage of labour among cases was 530±44.1 minutes, 61.5±12.7 minutes respectively and that of control was 526.6±64.9 minutes, 60±10.8 minutes respectively with no prolongation of labour P > 0.05. CSE analgesia did not alter the mode of delivery P=0.145 with rapid onset of pain relief. Apgar score was normal in both groups. Total 29 (97%) parturients experienced effective labour analgesia following CSE analgesia with VAS score 0. Maternal adverse effects included pruritus, transient initial motor blockade and post spinal headache.Conclusion:CSE analgesia did not affect the duration of labour, mode of delivery with minimal fetomaternal adverse effects and provides rapid onset of pain relief. CSE analgesia can be considered for safe and effective labour analgesia.

Lower, Variable Intrathecal Opioid Doses, and the Incidence of Prolonged Fetal Heart Rate Decelerations After Combined Spinal Epidural Analgesia for Labor: A Quality Improvement Analysis.

BackgroundCombined spinal-epidurals with low-dose intrathecal opioids and local anesthetics are commonly used to initiate labor analgesia due to the fast onset of analgesia and good patient satisfaction. Intrathecal fentanyl has been associated with fetal bradycardia, and the rate may be higher at doses of 25 mcg and above. As such, our institution limits intrathecal fentanyl doses to less than 15 mcg for labor. Prompted by a few incidents of prolonged fetal bradycardia at even these low doses, we sought to audit the side effects associated with varying low doses of intrathecal fentanyl.MethodsAfter IRB approval, a retrospective review was performed on 555 labor records from May–December, 2016. All the patients received combined spinal epidurals for labor analgesia. Intrathecal medication consisted of 1 mL of 0.25% bupivacaine, and varying fentanyl doses: 2.5, 5, 10, and 15 mcg. The incidences of prolonged fetal heart rate decelerations, emergent cesarean delivery, magnitude of pain reduction, pruritus requiring treatment, and hypotension were compared.ResultsDemographic variables were equivalent between the groups. There were no differences in the rates of prolonged fetal decelerations (in order of increasing fentanyl dose: 4.4%, 2.3%, 7.6%, 3.0%, p-value = 0.11), emergent cesarean delivery, magnitude of pain reduction, pruritus, or maternal hypotension.ConclusionsIn conclusion, the rates of prolonged fetal heart rate decelerations after combined spinal epidural with intrathecal bupivacaine and fentanyl does not differ for fentanyl doses of 15 mcg and below.

Adverse Side Effects and Route of Administration of Opioids in Combined Spinal-epidural Analgesia for Labour: A Meta-analysis of Randomized Trials

(Int J Obstet Anesth. 2020;41:83–103) Both epidural (EP) and combined spinal-epidural (CSE) techniques are used to establish effective labor analgesia. Over time, the latter has gained popularity due to faster onset of pain relief and superior sacral nerve coverage. The addition of opioids in neuraxial labor analgesia allows for lower concentrations of local anesthetic and a longer duration of the analgesic effect. However, opioids also impart risk for additional side effects including pruritus, sedation, nausea, vomiting, hypotension, and fetal heart rate pattern disturbances. This study was designed to analyze how individual and combined routes of neuraxial opioid administration impact the incidence of maternal and fetal side effects.

Comparison of the labor curves with and without combined spinal-epidural analgesia in nulliparous women- a retrospective study

BackgroundNeuraxial labor analgesia is known to increase the rate of instrumental delivery and prolong the second stage of labor; however, there is no standard method to evaluate the progress of labor under analgesia. Friedman curve is considered the gold standard for evaluating the progress of labor. However, it included not only neuraxial labor analgesia but also labor without analgesia. Thus we compared the labor curves of primiparous women undergoing labor with and without neuraxial labor analgesia, to understand the progress of labor in both groups and to arrive at a standard curve to monitor the progress of labor under neuraxial analgesia.MethodsPrimiparous women with cephalic singleton pregnancies who delivered at term from 2016 to 2017 were included. Two hundred patients who opted for combined spinal-epidural (CSE) labor analgesia were included in the CSE group and 200 patients who did not undergo CSE were included in the non-CSE group. In all, 400 cases were examined retrospectively. The evaluation parameters were cervical dilation and fetal station, and we calculated the average value per hour to plot the labor curves.ResultsThe labor curve of the non-CSE group was significantly different from the Friedman curve. In the CSE group, the time from 4 cm dilation of the cervix to full dilation was 15 h; in addition, the speed of cervical dilation was different from that in the non-CSE group. The progress of labor in the CSE group was faster than that in the non-CSE group during the latent phase; however, the progress in the CSE group was slower than that in the non-CSE group during the active phase.ConclusionsNeuraxial labor analgesia results in early cervical dilation and descent of the fetal head; thus, appropriate advance planning to manage the delivery may be essential.

Модификация комбинированной спинально-эпидуральной аналгезии родов

Модификация комбинированной спинально-эпидуральной аналгезии родов

Pain, stress, analgesia and postpartum depression: Revisiting the controversy with a randomized controlled trial.

Background:Pain and depression are associated, but it is uncertain if effective pain relief during labor by labor analgesia reduces the incidence of postpartum depression (PPD). This randomized, controlled study assessed whether combined spinal-epidural (CSE) labor analgesia is associated with a decreased risk of PPD. Other reported risk factors for PPD were also assessed.Materials and Methods:Parturients were randomly assigned to either CSE labor analgesia or normal vaginal delivery (n = 65 each). CSE parturients received 0.5 ml of 0.5% hyperbaric bupivacaine intrathecally and PCEA with continuous infusion of 0.1% levobupivacaine and 2 μg/ml fentanyl @5 ml/h along with patient-controlled boluses with a lockout interval of 15 min. Parturients of both the groups were assessed using Edinburgh Postnatal Depression Scale (EPDS) for depressive symptoms at day 3 and PPD at 6 weeks (primary outcome; defined as EPDS score ≥10 at 6 weeks postpartum). Secondary outcomes included pain scores, maternal satisfaction, and Apgar scores at 1 and 5 min. Parturients were also screened for several risk factors for PPD.Results:Incidence of PPD was 22.3%. The difference in incidence of PPD between the CSE group vs. control group was not significant (27.7% vs. 16.9%; Fisher's exact P = 0.103). Of all the risk factors analyzed in logistic regression model, perceived stress during pregnancy was the only significant predictor of the development of PPD (adjusted Odds Ratio 11.17, 95% Confidence interval 2.86–43.55; P = 0.001).Conclusion:CSE analgesia in laboring parturients does not reduce PPD at 6 weeks. Instead, perceived high stress during pregnancy appears to be the most important factor.

A prospective randomised comparative study of epidural bupivacaine and levobupivacaine after single dose of intrathecal fentanyl for combined spinal epidural labour analgesia

A prospective randomised comparative study of epidural bupivacaine and levobupivacaine after single dose of intrathecal fentanyl for combined spinal epidural labour analgesia

Assessment of blood-brain barrier integrity and neuroinflammation in preeclampsia

Although blood-brain barrier integrity is intact under normal pregnancy conditions, animal studies suggest that blood-brain barrier impairment occurs in preeclampsia. Yet, human data are limited, and the integrity of the blood-brain barrier has not been assessed in women with preeclampsia. We sought to test the hypothesis that the integrity of the blood-brain barrier is impaired and that neuroinflammation is increased in women with preeclampsia. We performed an observational case-control study in pregnant women >24 weeks gestation who underwent spinal anesthesia for elective cesarean delivery or combined spinal epidural analgesia for labor. Cases were women with preeclampsia, and control subjects were women with either healthy pregnancy, chronic hypertension, or gestational hypertension. Paired samples of blood, urine, and cerebrospinal fluid were collected from each subject before delivery. We measured albumin, C5a, C5b-9, tumor necrosis factor-α, and interleukin-6 concentrations in plasma and cerebrospinal fluid, and albumin, C5a, and C5b-9 concentrations in urine, using colorimetric or enzyme-linked immunosorbent assays. The ratio of albumin in cerebrospinal fluid to plasma (Qalb) was used as a surrogate for maternal blood-brain barrier integrity. Cerebrospinal fluid concentrations of C5a, C5b-9, tumor necrosis factor-α, and interleukin-6 were used as surrogate markers of neuroinflammation. Differences in Qalb and cerebrospinal fluid protein concentrations between groups were assessed by nonparametric test of medians. Forty-eight subjects were enrolled, which included 16 cases with preeclampsia, 16 control subjects with healthy pregnancy, and 16 control subjects with either chronic or gestational hypertension. Qalb values were not increased in preeclampsia cases compared with healthy or hypertensive control subjects (Qalb median, 3.5 [interquartile range, 2.9-5.1] vs 3.9 [interquartile range, 3.0-4.8] vs 3.9 [interquartile range, 3.0-4.8]; P=.78]. Moreover, Qalb values were not increased in the subset of women with preeclampsia with severe features (n=8) compared with those without severe features (n=8; Qalb median, 3.5 [interquartile range, 3.3-4.9] vs 3.7 [interquartile range, 2.3-5.5]; P=.62]. Cerebrospinal fluid concentrations of C5a, C5b-9, tumor necrosis factor-α and interleukin-6 were not increased in cases of preeclampsia, compared with control subjects with either healthy pregnancy, chronic hypertension, or gestational hypertension (P>.05, all comparisons). In contrast to the negative findings in cerebrospinal fluid, plasma concentrations of both C5b-9 and interleukin-6 and urine concentrations of C5a and C5b-9 were increased in cases of preeclampsia. Through measurements of albumin, complement proteins, and cytokines in paired samples of blood and cerebrospinal fluid at the time of delivery, we found no evidence of blood-brain barrier impairment or neuroinflammation in preeclampsia. Larger studies that will investigate a wider range of proteins are suggested to validate our findings.

A prospective study of comparison of analgesia and foetal outcome in term parturients with and without low dose combined spinal epidural labour analgesia

A prospective study of comparison of analgesia and foetal outcome in term parturients with and without low dose combined spinal epidural labour analgesia

A Study on Combined Spinal Epidural Labour Analgesia a Comparison between 0.125% Bupivacaine with Fentanyl Versus 0.1% Ropivacaine with Fentanyl

A Study on Combined Spinal Epidural Labour Analgesia a Comparison between 0.125% Bupivacaine with Fentanyl Versus 0.1% Ropivacaine with Fentanyl

Pneumocephalus and Seizures Following Combined Spinal-epidural for Labor

(J Clin Anesth. 2018;44:123–124) In this correspondence, the authors described a patient who presented with simultaneous pneumocephalus and cavernoma after receiving combined spinal-epidural analgesia for labor. However, unlike most cases of combined spinal-epidural analgesia for labor, which use loss of resistance to air to identify the epidural space, the authors used loss of resistance to saline. To the author’s knowledge, there are no published reports of the use of loss of resistance to saline for this purpose. Identification of the epidural space was successful upon the fourth attempt with the patient in a sitting position. Upon injection of local anesthetic, the patient immediately complained of a severe headache, that was unremitting with postural changes and continued into the postpartum period. On postpartum day 2, the patient presented with a tonic-clonic seizure. Magnetic resonance imaging showed intraventricular pneumocephalus and cavernoma in the right frontal region, and electroencephalogram showed abundant epileptic activity. Oxygen was added to the patient’s therapy with clinical improvement; complete reabsorption of air on radiologic examination was seen on the sixth day and the asymptomatic patient was discharged.

Combined Spinal Epidural in a Parturient With Tinea Versicolor

(J Clin Anesth. 2017;43:63–64) In this correspondence, the authors discussed the case of a 33-year-old parturient who presented for labor analgesia (combined spinal epidural technique) with a history of recurrent lumbar tinea versicolor, as well as a maculopapular rash from the cervical to the sacral area on physical examination. Tinea versicolor is a benign condition in which Malassezia globosa, a yeast found in normal flora, becomes pathogenic following exposure to heat and humidity in immunosuppressed individuals. Following informed consent, combined spinal epidural labor analgesia was administered with a 27-G Pencan spinal needle following sterile skin preparation and using a needle-through-needle technique. The epidural catheter remained in situ for 13 hours. The authors reported an uneventful delivery and postoperative course.

Effects of combined spinal epidural labor analgesia on episiotomy: a retrospective cohort study

BackgroundAccording to some published studies, neuraxial analgesia may be associated with prolonged labor and an increased risk for instrumental vaginal delivery. However, its effects on episiotomy are unknown. This study aimed to examine the incidence of episiotomy with and without combined spinal–epidural analgesia (CSEA) during labor.MethodsThis was a retrospective cohort study, in which the computerized medical records of nulliparous women with singleton, cephalic and live births were reviewed and women with and without CSEA were matched based on their propensity scores. Univariate and multivariate analyses were used to examine the association between CSEA and the incidence of episiotomy during vaginal delivery.ResultsIn the cohort study with 11,994 vaginal deliveries, 5748 received CSEA and 6246 did not receive CSEA. 4116 CSEA women were successfully matched with 4116 Non-CSEA women. In the univariate analysis, the incidence of episiotomy was 47.4% in the CSEA group and 44.7% in the Non-CSEA group. However, after a multivariable logistic regression analysis, CSEA did not increase the risk of episiotomy (adjusted OR, 1.080; 95% confidence interval [CI], 0.988–1.180).ConclusionsThe use of CSEA during labor and vaginal delivery did not increase the risk of episiotomy.

Epidural Volume Extension During Combined Spinal-Epidural Labor Analgesia Does Not Increase Sensory Block

Epidural Volume Extension During Combined Spinal-Epidural Labor Analgesia Does Not Increase Sensory Block