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A Prospective, Randomized Trial of Standard Epidural, Dural-Puncture Epidural, and Combined-Spinal Epidural Labor Analgesia Techniques on Maternal and Fetal Outcomes
Abstract Number: GM-03
Abstract Type: Original Research
Introduction: The dural puncture epidural technique (DPE) is a modification of the combined spinal epidural technique (CSE), where a dural hole is created but intrathecal medication administration is withheld. DPE has labor analgesia advantages compared with a standard epidural technique (EPL). To date, all three techniques have not been compared; we hypothesized that DPE would result in faster onset of pain relief compared to EPL, with fewer maternal and fetal side effects compared to CSE.
Methods: Upon patient consent, we prospectively randomized 120 parturients in early labor (≤ 5cm cervical dilation) to EPL, DPE or CSE. Attending and fellow anesthesiologists performed all placements. Initial dosing for EPL and DPE consisted of 20 mL of 0.125% bupivacaine + fentanyl 2 mcg/mL 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. Two blinded obstetricians independently interpreted uterine contractions and fetal heart rate tracings one hour before and after neuraxial placement. The primary outcome was time to achieving numeric pain rating scale (NPRS) ≤1. Secondary outcomes included maternal and fetal side effects. Cox proportional hazard regression was used to analyze timed outcomes. Fisher’s exact test was used to analyze secondary outcomes.
Results: The time to achieving NPRS ≤1 was similar between EPL and DPE. However, the incidence of T10 and S2 sensory blockade at 10 min with DPE was greater than EPL (p=0.03; <0.001) and comparable to CSE (p=0.49; 0.09). DPE had fewer requests for top-ups (p=0.02) compared to CSE and EPL. DPE and CSE had less asymmetric (2 dermatome difference) blockade after 30 min (p<0.001) and less motor block (p=0.04;0.003) compared to EPL. CSE had significantly higher incidence of pruritus (p<0.001) and uterine hypertonus (p=0.001) compared to DPE and EPL.
Discussion: DPE, when compared to EPL, has greater incidence of T10 and sacral coverage at 10 min, and lower incidence of asymmetric and motor blockade. DPE, when compared to CSE, has fewer requests for epidural top-ups and a lower incidence of pruritus and uterine hypertonus. For parturients requesting early labor analgesia, the DPE technique offers greater maternal and fetal advantages when compared with EPL and CSE techniques.
1.Cappiello E, et al. Anesth Analg, 2008