Hepner et al.: LABOUR ANALGESIA
233
PIDURAL analgesia has been used exten-
threaded five centimeters into the epidural space.
Catheters of both groups were initially not dosed to
avoid introducing the variability of catheter function. If,
at 20 min, analgesia was inadequate in any parturient of
either group (Visual Analogue Pain Score>3), 13 ml
BFSE were injected in incremental doses through the
epidural catheter. When additional analgesia was
requested, both groups received 13 ml BFSE in incre-
mental doses (first 3 ml as a test dose) and an infusion
of BF with epinephrine 1:400, 000 was started at 10
sively to provide pain relief in labour and is
the standard by which other methods of
labour analgesia are compared. Recently,
E
the combined spinal-epidural (CSE) technique has
gained popularity as an approach to labour analge-
1,2
sia.
The technique was reviewed extensively by
Norris et al., who showed a similar safety profile
3
between the two techniques. Side effects of CSE
include pruritus, postdural puncture headache,
hypotension, nausea and vomiting and fetal bradycar-
dia. The incidence of pruritus, nausea and vomiting
are greater than with the epidural technique alone.
Some anesthesiologists at our institution argue that
the CSE technique takes longer to perform and more
effort to manage (less time efficient). The suggested
advantages of CSE are its rapid onset of analgesia and
relative lack of motor blockade. Epidural analgesia tra-
ditionally has been associated with motor blockade.
However, no studies have compared a very low dose
local anesthetic and opioid mixture in the epidural
space with the CSE technique, both of which produce
minimal motor block. In addition, no studies have
compared the time involved in performing and man-
aging these two techniques. We hypothesized that the
time to perform the technique, the amount of motor
blockade and the number of physician interventions
are not different between these two techniques.
–1
ml·hr . Another anesthesiologist, blinded to the tech-
nique, was in charge of collecting the data. Maternal
blood pressure, heart rate, oxyhemoglobin saturation,
fetal heart rate and uterine activity were monitored
throughout labour and delivery. Parturients were laying
on their right side throughout labor so as to avoid aor-
tocaval compression. Visual Analogue Pain Score
(VAPS) on a scale of 0-10 (0=no pain and 10=worst
possible pain) was obtained at 0, 5, 10 and 15 min after
the first injection, every 15 min thereafter until 60 min
and then every 30 min until delivery. Parturient satis-
faction on a scale of 1-4 (1-very satisfied to 4-not satis-
fied) were obtained at the time of complete analgesia, at
delivery and on post-partum day 1 (PP #1). Maternal
Bromage scores were obtained at 15 and 30 min to
assess motor block: 1= unable to move feet or knees
(complete motor block), 2=able to move feet only
(almost complete), 3=just able to move knees (partial),
and 4=full flexion of feet and knees (none).4
Measurements included times from skin infiltration 1)
to taping of the epidural catheter, 2) to initial sensation
of analgesia (a decrease in VAPS) and 3) to request for
additional analgesia. Parturient interventions were
defined as supplemental analgesia and treatment of pru-
ritus, hypotension (systolic blood pressure <100
mmHg, >30% decrease from baseline), nausea, vomit-
ing or nonreassuring fetal heart rate changes. Maternal
parameters obtained included height, weight, gravity
and cervical dilatation. Newborn parameters obtained
included umbilical artery pH, umbilical vein pH,
weight and Apgar scores at one and five minutes. Data
are presented as mean ± standard deviation (SD).
Parametric data were analyzed using unpaired t tests.
Nonparametric data were analyzed using chi-square. A
value of P < 0.05 was considered significant.
Materials and methods
Following institutional review board approval, written
informed consent was obtained from 50 healthy term
parturients who requested labor analgesia. They were
randomized to either the epidural technique alone or to
the combined spinal-epidural technique. Parturients
with preeclampsia, diabetes, preterm labour, bleeding
problems, scoliosis, in advanced labor (>5 cm cervical
dilatation) or who received previous intravenous opioid
were excluded. The epidural technique was performed
in the sitting position by a third year anesthesia resident.
The epidural space was entered using a midline
approach at the L2-3 or L3-4 interspace with an 18 gauge
Tuohy-Weiss epidural needle with a loss of resistance to
air technique. The epidural group received 16 ml bupi-
vacaine 0.0625% (B)-fentanyl 0.0002% (F) with 0.05
ml in 10 ml local anesthetic sodium bicarbonate 8.4%
(S) and epinephrine 1:200, 000 (E) in divided doses
Results
over three minutes through the epidural needle. In the
CSE group, the intrathecal space was entered with a 26-
gauge 127 mm Gertie Marx needle through the epidur-
al needle, and 1 ml bupivacaine 0.25% plus 25 µg
fentanyl (0.5 ml) were injected through the spinal nee-
dle. In both groups, a multiport epidural catheter was
There were no differences in maternal or neonatal
demographics (Tables I, II.). It did not take longer to
perform the CSE nor did it take more of the physi-
cian’s time to manage the CSE technique compared
with the epidural technique. In addition, the time
from injection of the solution to maternal request for