Effect of Continuous Epidural Analgesia on the Progress of Labor / 대한마취과학회지

BACKGROUND: The effect of epidural analgesia on the progress of labor is controversial. The objective of this study is to determine the effect of analgesia on the outcomes of labor, especially the cesarean delivery rate in the epidural and non-epidural (intramuscular nalbuphine) groups, prospectively. METHODS: All the nulliparous women were divided into two groups, group 1 (epidural group, n = 35) and group 2 (non-epidural group, intramuscular nalbuphine, n = 43) randomly. Epidural analgesia was maintained with a continuous epidural injection of 0.0625% bupivacaine with 0.2 microgram/ml fentanyl in group 1 and nalbuphine 10 mg was intramuscularly injected in group 2 when the cervix was dilated to at least 3-5 cm. The duration of the first and second stages of labor, cesarean delivery rate, Apgar score and body weight of infant were recorded and the pain score of parturient was recorded by 0-100 mm visual analogue scale. RESULTS: The duration of first and second stage were prolonged in the group 1 (epidural group). But there were no significant differences in the duration of first and second stage, Apgar score and body weight of infant between the two groups. Cesarean delivery rate was 16% (n = 7/35) in group 1 and 17% (n = 6/43) in group 2, so there was no significant difference between the two groups. Pain score was significantly lower in group 1 than in group 2. CONCLUSIONS: Epidural analgesia was not associated with increased cesarean delivery rate and provided safe and effective intrapartum pain control. Maternal-fetal factors and obstetric management, not epidural analgesia, are the most important determinants of the cesarean delivery rate.

The Clinical Study of Labor Analgesia by Intrathecal Injection of Morphine, Fentanyl, and Bupivacaine / 대한마취과학회지

BACKGROUND: Intrathecal fentanyl has been known to have rapid analgesic effect for the first stage of labor, but pruritus usually occurs, and respiratory depression can happen. The addition of bupivacaine during intrathecal analgesia has been known to have synergistic action with intrathecal opioids. We observed the efficacy of the intrathecal injection of morphine, fentanyl, and bupivacaine on labor parturients. METHODS: 20 laboring patients were studied. Each patients received morphine 0.2 mg, bupivacaine 2.5 mg, and fentanyl 10 microgram intrathecally. Analgesia was assessed using visual analogue scale (VAS) score as the time elapsed from the drug administration to the delivery. Side effects such as nausea, vomiting, pruritus, urinary retention, respiratory depression, and hypotension were evaluated. RESULTS: The onset of analgesia was rapid (within 5 minutes) and VAS scores were significantly lower than pre-treatment value for 5 hours. The incidence of nausea or vomiting was 55% (11/20). Pruritus occurred 50% (10/20). The occurrence of urinary retention was 35% (7/20). Hypotension occurred 10% (2/20). No patient developed post dural-puncture headache, respiratory depression, fetal bradycardia, or motor weakness. More than 90% of the patients in this study said that they were satisfied with this analgesic procedure. CONCLUSIONS: Intrathecal injection of morphine 0.2 mg, fentanyl 10 microgram, and bupivacaine 2.5 mg provided rapid and effective analgesia in labor patients.

The Effect of Intrathecal Bupivacaine Mixed with Sufentanil for Labor Analgesia / 대한마취과학회지

BACKGROUND: The combination of a local anesthetic and an opioid has been shown to produce effective epidural labor analgesia. It was reported that the combination of intrathecal opioid and bupivacaine could produce labor analgesia with longer duration and less side effects. This study was done to evaluate the effect of intrathecal bupivacaine mixed with sufentanil for labor analgesia. METHODS: Eighty women requesting labor analgesia were randomly assigned to receive intrathecal 10 mcg of sufentanil (S group, n = 40) or 2.5 mg of bupivacaine plus 10 microgram of sufentanil (SB group, n = 40) diluted in a total volume of 2.2 ml with normal saline. The analgesia was performed using combined spinal-epidural technique in the lateral position. Visual analogue scales (VAS) for pain, sensory changes to cold, duration of analgesia, motor block, hypotension, fetal heart rate, pruritus, and other side effects were assessed for 30 minutes after intrathecal drug injection. RESULTS: There were no significant differences in the VAS pain scores and sensory levels at 5 minutes after intrathecal drug injection between groups. However, VAS pain scores were significantly lower and sensory levels higher in the SB group at 15 minutes and 30 minutes after intrathecal drug injection. The duration of analgesia provided by intrathecal sufentanil (n = 31) was 103.4 41.1 min, by intrathecal sufentanil plus bupivacaine (n = 29) 113.0 32.1 min (P = 0.30). Motor block assessed by a modified Bromage scale was significantly frequent in the SB group (P< 0.001). Not only adverse effects such as hypotension, fetal bradycardia, pruritus, and nausea, but also satisfaction scores were similar in both groups. CONCLUSIONS: The addition of bupivacaine to intrathecal sufentanil produced more frequent motor block and extensive sensory block, but better analgesia. However, duration of analgesia, side effects and satisfaction score did not change.

Conventional Intermittent "Top-up" Injections of 0.25% Bupivacaine/Fentanyl vs 0.125% Bupivacaine/Fentanyl during Labor / 대한마취과학회지

BACKGROUND: Conventional intermittent "Top-up" injections (CIT) of fentanyl added to bupivacaine reduces the total amount of local anesthetic required, resulting in less motor blockade, reducing incidence of instrumental deliveries, and improving the quality of analgesia during labor. The purpose of this study was to compare the analgesic efficacy of two different solutions and side effects of them. METHODS: Fifty healthy parturients were divided into two groups: intermittent epidural injections of 0.25% bupivacaine with 0.0005% fentanyl (Group I) and 0.125% bupivacaine with 0.0005% fentanyl (5 microgram/ml) (Group II). We injected 5 ml of each solution to block T10 sensory level of the request of the parturients. Assessments included interval of epidural injection, duration of first and second stage of labor, total dose of bupivacaine, maternal blood pressure, satisfaction, fetal heart rate, and Apgar scores. RESULTS: The interval of epidural injection was 75.7+/-50.6 min in Group I, compare with 57.8+/-27.5 min in Group II (p<0.05). The total dose of bupivacaine was 45.5+/-15.3 mg in Group I, compared with 23.5+/-10.4 mg in Group II (p<0.05). There was no significant difference between the two groups in terms of duration of labor, maternal blood pressure, maternal satisfaction, fetal heart abnormality, or Apgar scores of neonates. No serious side effects were encountered in either group, although two patients in Group I experienced urinary retention. Only one patient in each group experienced nausea and vomiting. CONCLUSIONS: The injection of 0.125% bupivacaine plus fentanyl provides good analgesia during labor. We concluded that lower concentration of bupivacaine was better in consideration of adverse effects of it on fetus and mother.

A Scalding Burn Resulting from Sitz Bath Long Enough after Epidural Block for Vaginal Delivery: A case report / 대한마취과학회지

Epidural block is one of the most effective methods of intrapartum pain relief in current practice. This is a case of a scalding burn resulting from a sitz bath long enough after epidural block for vaginal delivery. The patient received 7 ml of 0.25% bupivacaine mixed with 1 : 300,000 epinephrine and fentanyl 50 microgram for epidural block. Following delivery, the patient started complaining of voiding difficulty without any motor weakness 6 hours after the epidural block occured. At that time, the patient did not feel any hot or pain sensations during the 15 minutes of unintentional hot water application for sitz bath. Consequently, an approximately 5~10% superficial second degree burn developed on her perineal and inner thigh region.

Incidence of Cesarean Section Following a Continuous Lumbar Epidural Analgesia for Labor Pain / 대한마취과학회지

BACKGROUND: This retrospective study was subjected to evaluate a causal relation in the incidences of Cesarean section with or without epidural analgesia during labor. METHODS: All of the subjects was divided into two groups which consisted of 394 cases wanted epidural analgesia as Epidural group and 2938 cases unwanted it as Non-epidural group. Continuous lumbar epidural analgesia was performed at L3-4 interspace with catheter advancing 3 cm cephalad when cervix was dilated to at least 3~5 cm and then patient was placed lateral decubitus or sitting posture. 0.125% bupivacaine 10 ml was injected initially via the epidural catheter and then followed by a mixture (10 ml) of bupivacaine 16.7 mg and fentanyl 16.7 microgram hourly to be infused continuously. The data were analysed using Pearson's x2 test with p<0.05 taken as a significant difference. RESULTS: The incidence of normal spontaneous vaginal delivery and Cesarean section, the cause of alteration to Cesarean section, and gestational frequency followed by Cesarean section rate showed no significant difference between two groups. The occurrence of neonate below 7 points of Apgar score at one and five minute after Cesarean section was rather more in Non-epidural group (p<0.05) than that in Epidural group. CONCLUSION: It is concluded that the continuous lumbar epidural analgesia with the dose of bupivacaine and fentanyl as mentioned above does not affect to Cesarean section rate during labor, which provides safe and effective for labor pain control.

Hemodynamic Changes Associated with Uterine Contraction under Obstetric Analgesia / 대한마취과학회지

BACKGROUND: Continuous epidural analgesia is the most widely used technique in obstetric analgesia today. Hemodynamic changes during pregnancy were most remarkable during the uterine contractions of the first stage of labor. The aim of this study was to compare the difference in hemodynamics between two groups with and without obstetric analgesia. METHODS: Twenty healthy parturients were divided into two groups as follows: Group 1; 10 parturients under epidural analgesia, Group 2; 10 parturients without epidural analgesia,and hemodynamic changes were monitored throughout labor. For the purpose of analysis, the course of labor was divided into three categories according to the degree of dilation of the cervix: 4 cm, 4~7 cm and above 7cm. Hemodynamic parameters were obtained during and in-between contractions over the course of labor through transcutaneous impedence cardiography and a noninvasive automatic blood pressure monitor. RESULTS: Heart rate (HR) in Group 2 were more increased than that in Group 1 during uterine contraction. In Group 1, the end-diastolic volume index (EDVI) and stroke volume index (SVI) at 4 cm dilation and SVI at above 7 cm dilation of the cervix were increased during the contraction. In Group 2, HR increased throughout the first stage of delivery and systolic blood pressure (SBP), EDVI at 4~7 cm and above 7 cm dilation and SVI at above 7 cm dilation were increased during contractions. CONCLUSIONS: Our study showed more stability in hemodynamic parameters in parturients under epidural analgesia as compared to those without analgesia. From these results, we conclude that continuous epidural analgesia is very safe to the fetus as well as mother since the technique dose not cause significant hemodynamic change during uterine contractions.