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A Prospective, Randomized Trial of Combined-Spinal Epidural, Dural-Puncture Epidural, and Standard Epidural Labor Analgesia Techniques on Maternal and Fetal Outcomes
Abstract Number: F-07
Abstract Type: Original Research
Introduction: Neuraxial techniques are the most effective form of labor analgesia. In addition to the standard epidural (EPL), combined spinal-epidural (CSE) and dural-puncture epidural (DPE) techniques have emerged in recent years. To date, a comparison of all three techniques has not been performed. We hypothesized that onset of analgesia, in the order from fastest to slowest would be CSE>DPE>EPL, and that DPE would have fewer maternal and fetal side effects compared to CSE, while offering improved sacral and bilateral sensory coverage compared to EPL.
Methods: We designed a prospective, randomized, double blind study comparing CSE, DPE and EPL techniques in 120 term parturients in early labor (≤ 5cm cervical dilation). Attending and fellow anesthesiologists performed all techniques. Initial dosing for EPL and DPE consisted of 20mL of 0.125% bupivacaine over 5 min, and for CSE, 1 of 1.5 mL premixed solution of 0.25% bupivacaine 2.5 mg and fentanyl 25 mcg. Upon block completion, an independent blinded co-investigator assessed the outcomes. The primary outcome was analgesia onset (i.e., time to visual analogue score ≤3). Secondary outcomes included time to reach T10, sacral and motor blockade, and maternal and fetal side effects. Cox proportional hazard regression was used to analyze timed outcomes. Logistic regression and Fisher’s exact test were used to analyze motor blockade, side effects and interventions.
Results: To date, 50 of 120 subjects have been recruited. CSE had the most rapid analgesia onset, T10 and sacral blockade (p<0.001); however, a higher incidence of pruritis was observed (p=0.009). The EPL and DPE groups had similar onset time, sensory blockade and maternal side effects, but EPL group had higher epidural reinforcement (p=0.04) and caesarean delivery rates (p=0.02). Significant motor blockade and fetal bradycardia occurred only in the CSE and EPL groups at similar rates.
Discussion: Labor analgesia onset was most rapid with CSE, with similar onset times between DPE and EPL. DPE may have an advantage over CSE with less maternal pruritis and fetal bradycardia; and an advantage over EPL with fewer epidural ‘top-up’ requirements and a lower cesarean delivery rate. Selection of optimal neuraxial labor analgesia technique requires consideration of anticipated maternal and fetal outcomes.
1.Osterman M. Birth, 2009
2.Cappiello E, et. al. Anesth Analg, 2008