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Comparison of intermittent and continuous epidural analgesia on delivery and progression of labour
S. SKRABLIN1, O. GRGIC2, S. MIHALJEVIC3 & J. BLAJIC1
Department of Obstetrics and Gynecology, 1School of Medicine, 2Clinical Hospital Sestre Milosrdnice and 3 Anesthesiology, Reanimatology and Intensive Care, School of Medicine, University of Zagreb, Croatia Summary In this study, 205 nulliparous parturients were enrolled to receive either intermittent (n 101) or continuous (n 104) type of epidural analgesia in labour. The primary outcome was rate of caesarean deliveries, whereas secondary outcomes included rate of fundal pressure manoeuvres, duration of labour from application of analgesia, dose of anaesthetic and short-term maternal and neonatal outcome between two groups. Rate of caesarean deliveries was signicantly increased in the continuous group (15/104 vs 5/101, p 0.02), as well as rate of fundal pressure manoeuvres (24/104 vs 11/101, p 0.02) and dose of fentanyl (100 [100300] vs 187.5 [125450] mg, p 5 0.001 and levobupivacaine (40 [4060] vs 75 [5090] ml, p 5 0.001). Duration of labour from analgesia to delivery was not signicantly different between the two groups (414 + 101 vs 432 + 94 min, p 0.12). Keywords: Continuous, epidural analgesia, intermittent, length of labour, maternal outcome, neonatal outcome, operative delivery
Introduction
Satisfactory epidural analgesia for labour and delivery poses several challenges to the obstetrician and anaesthesiologist. The ideal analgesia has to be effective in providing adequate pain relief without unintended side-effects and negative interference with the process of labour and delivery (Eltzschig et al. 2003). Intermittent and continuous types of epidural analgesia have been commonly and widely used during labour (Fettes et al. 2006; Salim et al. 2005; Smedstad and Morison 1988; Wong et al. 2006). Continuous infusion is associated with more consistent analgesia without excessive uctuations in the level of anaesthetic, improved patient satisfaction but it may be related with either insufcient analgesia or excessive blockade (Fettes et al. 2006; Halpern et al. 2005; Salim et al. 2005; Smedstad and Morison 1988; Vallejo et al. 2007). In the presence of excessive sensory blockade, a parturient may not appreciate a strong urge to push upon reaching the second stage of labour, and this stage could be prolonged (Lamont et al. 1989). Additionally, the majority of previous studies found that the continuous type was associated with a higher total dose of anaesthetic (Boutros et al. 1999; Eddleston et al. 1992; Fettes et al. 2006; Quinn et al. 1993; Smedstad and Morison 1988; Wong et al. 2006). On the other hand, with the intermittent technique, a delay in bolus administration may cause incomplete or suboptimal analgesia with higher uctuations in anaesthetic level (Lamont et al. 1989; Salim et al. 2005). Moreover, in a retrospective study, an intermittent in comparison with the continuous type was associated with higher incidence of caesarean deliveries (CD) (Driver et al. 1996). Therefore, in this prospective trial, our objective was to determine the effect of intermittent and continuous type of
epidural analgesia on the CD rate, rate of fundal pressure (FP) manoeuvre, progression and duration of labour, dose of anaesthetic in labour and short-term maternal and neonatal outcome in a nulliparous population.
Correspondence: O. Grgic, Department of Obstetrics and Gynecology, Vinogradska 29, 10000 Zagreb, Croatia. E-mail: ozren.grgic@gmail.com
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200 ml of Ringers acetate solution was administered. If the systolic pressure decreased to 80 mmHg or 30% from baseline, ephedrine 5 mg was administered. Data were collected for each parturient and included demographic characteristics, labour data and method of delivery. The primary outcome was: 1. The incidence of CD between two groups. The secondary outcomes were: 1. Incidence of FP manoeuvres 2. Dose of anaesthetic and oxytocin per parturient 3. Duration of labour from beginning of epidural anesthesia to delivery between the two groups 4. Neonatal status: neonatal weight, Apgar score at 1 and 5 min, umbilical pH
Table I. Demographic characteristics. Continuous (n 104) Maternal age (years) (mean) IQR Range Gestational age at delivery (cw) (mean) IQR Range Onset of labour Spontaneous ROM Induction Cervical effacement at time of randomisation Partial Full Cervical dilatation (cm) at time of randomisation (mean) IQR Range Amniotic uid Normal Meconium Contractions per 10 min at time of randomisation (mean) IQR Range VAS before randomisation (cm) IQR Range 28 2630 1840 40 Intermittent (n 101) 28 2533 1842 40 p value 0.48*
0.33*
3840 3742 50 28 26
49 55 4
50 51 4
0.42{ 0.53{
45 35 82 22 2
45 35 87 14 2 0.09{ 0.34{
12 13 6.2
12 13 6.5
0.33*
5.38.2 3.110
5.38.2 2.29.9
M, median; IQR, interquartile range; cw, completed weeks; ROM, rupture of membranes; BMI, body mass index; VAS, visual analogue scale. *MannWhitney test. {w2-test. {Cochran MantelHaenszel test.
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Table II. Primary and secondary outcomes. Statistical analysis Continuous (n 104) Intermittent (n 101) 5 11 2 23 14 40 4060 2080 100 100300 100600 414 + 101 140720 7.1 + 0.3 0.318 3,545 + 482 2,1304,600 5 3 3 23 1 5.4 1.731.2 33 78 4 3 1 p value 0.03* 0.02*,jj NA
,jj
RR 2.91 2.12 NA
Caesarean delivery Fundal pressure No. of doses (mean) IQR Range Dose of Levobupivacaine (ml) IQR Range Dose of Fentanyl (mg) IQR Range Length of labour from epidural to delivery (min) (AM + SD) Range Dose of Oxytocin (IU) Range Neonatal status Weight (g) AM + SD Range Apgar 7 at 1 min Apgar 7 at 5 min pH 57.1 Maternal status Intrapartum fever Motor blockade AUVAS Range Hypotension Episiotomy Perineal tears 3rd/4th degree Retained placenta Postpartum haemorrhage
15 24
75 5090 40180 187.5 125450 1251,350 432 + 94 145735 7.3 + 0.3 0.318.5 3,510 + 459 2,3404550 4 2 2 21 11 4.3 1.324.5 22 80 4 4 2
50.001{,jj
NA
50.001{,jj
NA
0.12{
NA
0.34{
NA
0.36{ 0.48* 0.48* 0.48* 0.38x 0.01*,jj 0.36{ 0.56x 0.54x 0.62* 0.51* 0.51*
NA 1.28 1.54 1.54 1.12 10.68 NA 1.53 1.01 1.03 0.77 0.51 0.354.65 0.269.06 0.269.06 0.671.91 1.4081.24
AM, arithmetic mean; SD, standard deviation; NA, not applicable; M, median; IQR, interquartile range; IU, international unit; AUVAS, area under visual analogue score curve from start of epidural infusion to delivery. *Fishers exact test. {Wilcoxon signed ranks test. {Mann Whitney test. x 2 w -test. jjStatistically signicant.
5. Maternal status: intrapartum fever (temperature 438.58C); motor blockade (modied Bromage score 40); hypotension in labour (systolic pressure 520% from baseline); episiotomy; perineal tears 3rd/4th degree; retained placenta; postpartum bleeding (bleeding 4500 ml); intrapartal VAS score.
Statistics
As a part of the study design, a sample size calculation was performed (Sample size calculator, MaCorr Inc., Toronto, Ontario, Canada). The calculation was designed to detect at least 20% difference in the rate of CD between the groups. Condence interval was determined using the condence level (CL) of 95%. The programme calculated that the condence interval is 7.8%. Using the CL of 95% and condence interval of 7.8%, the programme calculated that for our population, the sample size needed to be 158 participants. Data were analysed using SPSS version 15.0 (SPSS Inc., Chicago IL, USA). We analysed the data based on intention to treat analysis. The w2 and Fisher exact tests were used to evaluate categorical data where appropriate. Additionally, for comparison of the categorical data between the two groups, we calculated a risk ratio (RR) with 95% condence interval.
A MannWhitney test was used to evaluate continuous variables where appropriate and normality of distribution was assessed using the KolmogorovSmirnov test. Comparison between the groups for cervical dilatation and number of contractions in 10 min before enrolment was made by CochranMantelHaenszel test. Comparison for total dose of anaesthetic between the groups was made by with Wilcoxon signed ranks test. Two-tailed p values are reported throughout and statistical signicance was dened as p 0.05.
Results
Totally, 266 nulliparous parturients between 3742 weeks of pregnancy with fetus in cephalic presentation and cervical dilatation of 25 cm consented to participate in the study between May 2009 and February 2010. Of the parturients, 61 were excluded (18 due to failure to achieve adequate analgesia; 11 because of chronic systemic disease; 11 due to the feto-pelvic disproportion; eight because of different contraindications to neuraxial blockade; seven because of breech presentation; four parturients refused to participate; and nally two had other malpresentations). Therefore, the nal results were based on 205 parturients.
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Discussion
The results of our study showed that continuous compared with intermittent epidural analgesia in labour is associated with a higher dose of anaesthetic, higher rate of CDs and increased rate of FP manoeuvre, as well as higher incidence of motor blockade during labour, without any difference in duration of labour. Several changes have occurred in the past few decades regarding the drugs, methods, and strategies used to provide epidural analgesia for labour. Improvements in parturients satisfaction and safety have contributed to the increasing use of epidural analgesia during labour but, as almost all medical treatments, it has been associated with a number of unintended effects (Eltzschig et al. 2003). In a previously reported trial in nulliparous population, Fettes et al. (2006) randomised 40 parturients to receive continuous or intermittent doses but the duration of rst (467 + 273 vs 587 + 267 min) and second stage (99 + 66 vs 103 + 62 min) of labour was equal in both groups (Fettes et al. 2006). Additionally, Salim and colleagues randomised 130 parturients and did not nd signicant differences in duration of the rst (4.4 + 2.1 vs 4.6 + 2.5 h) and second stage (1.6 + 0.9 vs 1.4 + 0.9 h) of labour between these two groups (Salim et al. 2005). Our study in comparison to the previously reported trials showed similar results regarding the duration of labour. Results of study of Boutros et al. (1999) showed that the total dose of anaesthetic in the primiparous population was not different between the two groups (58.5 + 18.1 vs 49.5 + 26.6 mg) but the hourly dose of local anaesthetic was signicantly higher in the continuous group (13.8 + 3.7. vs 10.2 + 2.1 mg/h). Fettes et al. (2006) showed that the total dose of non-opioid anaesthetic was increased in the continuous group (124.2 + 17.9 mg vs 104.7 + 29.2 mg, p 0.02). In a recent study published by Wong and co-workers (2006), a total dose of opioid as well as non-opioid anaesthetic was statistically signicantly higher in a continuous group. Our study, as all previous trials regarding the total and hourly dose of anaesthetic between the two types of anaesthesia, conrmed that continuous infusion is associated with a signicantly increased dose of anaesthetic. Because of the higher dose of anaesthetic in the continuous group, the rate of motor blockade was statistically signicantly higher.
According to the method of delivery, parturients in the continuous group had almost a three times higher relative risk for CD. Our nding is different from the results of a retrospective study by Driver and co-workers published 15 years ago (Driver et al. 1996). They showed that parturients who received a continuous epidural analgesia were signicantly less likely to have an emergency CD (p 0.002). The difference could be because in the continuous group, parturients may not have a strong urge to push, and this could lead to signicant prolongation of the second stage of labour. Some other new trials that compared these two types of epidural analgesia have not found higher rates of CD or operative vaginal deliveries in either group (Eddleston et al. 1992; Fettes et al. 2006; Quinn et al. 1993; Salim et al. 2005; Smedstad and Morison 1988; Wong et al. 2006). In the continuous group, the incidence of FP to achieve delivery was signicantly higher. Results of a recent study showed that there were no data available to determine whether or not FP was of benet, but this manoeuvre did not appear to increase the rate of spontaneous vaginal births in women with epidural analgesia (Torvaldsen et al. 2004). A major limitation in our study was that it was not completely blind, which could have led to observer bias. Participation in the study did not change the standard obstetric procedure. The decision for delivery induction, cervical examination, indications for CD or for FP was made by the senior consultant and not by any of the investigators. In conclusion, our results show that continuous type of epidural anaesthesia might be associated with a higher rate of CD, a higher dose of anaesthetic and increased rate of FP manoeuvres, without any difference in the duration of labour. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.
References
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