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Variable intrathecal opioid dose and incidence of prolonged decelerations after CSE analgesia for labor
Abstract Number: SAT-33
Abstract Type: Original Research
Combined-spinal epidurals (CSE) for labor analgesia provide rapid onset and superior pain relief compared to lumbar epidurals. Prolonged decelerations (>2 minutes) may occur after CSE initiation, with a reported incidence between 4 and 21%(1,2) despite no significant changes in blood pressure(3) These abnormalities in fetal heart rate can require intrauterine resuscitation; and operative delivery may be warranted if they persist. We sought to quantify the incidence of prolonged decelerations after CSE in our institution and the need for emergent cesarean delivery.
Using a de-identified dataset, we conducted a retrospective chart review of labor CSEs placed between May and December 2016. We gathered demographic, obstetric (use of oxytocin, prolonged decelerations within 20 minutes of CSE placement, number of these incidents which led to immediate cesarean delivery) and anesthetic (pain scores, dose of intrathecal (IT) fentanyl, blood pressure before and after CSE, use of rescue medication for decelerations) data. Patients were grouped and analyzed by IT dose of fentanyl used in the CSE. Our standard CSE includes isobaric bupivacaine 2.5mg and 2.5-15mcg IT fentanyl per provider preference.
A total of 585 records were reviewed. The overall incidence of prolonged deceleration after CSE was 4.3% (n=25), with a mean time to deceleration of 13 (±5) min. There was no association of incidence of fetal decelerations with varying opioid doses (p=0.11). Demographic data, use of oxytocin and incidence hypotension was similar between groups. Lower pain scores were observed in the 15mcg group compared to all other groups (p<0.05). Two cases of emergent cesarean delivery were recorded in the 10mcg dose range. See table 1.
The incidence of prolonged decelerations after CSE (4.3%) was comparable to published data and was independent of the IT fentanyl dose. CSE analgesia, introduced to our institution 8 years ago, has been widely accepted despite initial concerns about increased incidence of emergent cesarean delivery. The close multidisciplinary management (OB, anesthesiology and nursing) of prolonged decelerations has contributed to its success, and our findings support its safety.
1. Carvalho B. JCA. 2007.
2. Palmer C. A&A. 1999.
3. Van de Velde M. A&A 2004.