|Year : 2017 | Volume
| Issue : 1 | Page : 43-46
Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia
Geetha C Rajappa1, Tejesh C Anandaswamy1, Thejaswini J Pattadi2, Asha Swarup3
1 Department of Anaesthesiology, MS Ramaiah Medical College, Bangalore, Karnataka, India
2 Department of Obstetrics and Gynaecology, Narayana Hrudhayalaya Multispeciality Hospital, Bangalore, Karnataka, India
3 Department of Obstetrics and Gynaecology, MS Ramaiah Medical College, Bangalore, Karnataka, India
|Date of Web Publication||1-Jun-2017|
Geetha C Rajappa
Department of Anaesthesiology, MS Ramaiah Medical College and Hospitals, Bengaluru - 560 054, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Both epidural analgesia and combined spinal epidural analgesia (CSEA) are employed for pain relief during labor because they provide reliable analgesia compared to other modalities. Studies are equivocal with respect to their effect on the rate of cervical dilatation, duration of labor, and labor outcome. The primary outcome of the present study was to compare the effect of epidural analgesia alone with CSEA with respect to the rate of cervical dilatation. Materials and Methods: One hundred and twenty parturients with an initial cervical dilatation of <4 cm were randomized to receive CSEA or epidural analgesia alone for pain relief during labor. The rate of cervical dilatation, onset of effective analgesia, number of epidural top-ups requested, labor outcome, and the quality of analgesia was assessed in both the study groups. Statistical Analysis: Mann–Whitney and Chi-square tests were performed where applicable to compare the data between the two groups. Results: The results of the study showed that the rate of cervical dilatation was rapid with CSEA compared to epidural analgesia alone [median (interquartile range) 2 (1.2,3) v/s 1.16 (1,2)]. The onset of analgesia was earlier with combined spinal epidural (CSE v/s EA, 3.7 ± 1.3 min v/s 23.8 ± 5.8 min). Labor outcome and quality of analgesia was similar between the two groups. The incidence of pruritus was higher with CSEA than with epidural analgesia alone. Conclusion: CSEA is associated with more rapid cervical dilatation and shorter duration of first stage of labor when compared with epidural analgesia alone.
Keywords: Cervical dilatation, combined spinal epidural analgesia, epidural analgesia
|How to cite this article:|
Rajappa GC, Anandaswamy TC, Pattadi TJ, Swarup A. Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia. J Obstet Anaesth Crit Care 2017;7:43-6
|How to cite this URL:|
Rajappa GC, Anandaswamy TC, Pattadi TJ, Swarup A. Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2019 Dec 11];7:43-6. Available from: http://www.joacc.com/text.asp?2017/7/1/43/194300
| Introduction|| |
Neuraxial analgesic techniques are the most popular and most effective method of pain relief during labor. Neuraxial analgesia is known to improve maternal cardiovascular and pulmonary physiology, as well as fetal acid-base status., In view of the superior analgesia and maternal–fetal benefits, neuraxial analgesia is being increasingly accepted as the technique of choice for pain relief during labor. In spite of the perceived benefits and increased use, debate exists regarding its impact on the progress of labor and mode of delivery. Evidence suggests that neuraxial analgesia does not increase caesarean delivery; however, its use prolongs the second stage of labor with an increased rate of instrumental vaginal delivery.
The combined spinal epidural (CSE) technique is a popular alternative to conventional epidural analgesia (EA) because of its rapid onset of analgesia. Studies are equivocal with respect to the superiority of pain relief, maternal satisfaction, rate of cervical dilatation, and labor outcome when CSE is compared to EA for pain relief during labor.,,,, The primary outcome of the present study was to assess the cervical dilatation rate. The secondary outcomes were pain relief, onset of analgesia, number of epidural top-up doses, labor outcome, and side effects. We hypothesized that CSE would result in more rapid cervical dilatation compared to EA.
| Materials and Methods|| |
The study was approved by the institutional ethics committee, and was conducted after obtaining written informed consent from all the participants. All healthy nulliparous and multiparous women with term, singleton pregnancies who presented in spontaneous or induced labor with cervical dilatation of ≤4 cm, who desired neuraxial analgesia, were eligible to participate. Women with nonvertex presentation, contraindication for neuraxial analgesia, multiple pregnancies, high risk cases (such as pregnancy-induced hypertension, cardiac disease, and gestational diabetes) and cervical dilatation of >4 cm were excluded from the study. Parturient satisfying the inclusion criteria was randomly assigned to receive either epidural analgesia alone (EA group) or combined spinal epidural analgesia (CSE group) for pain relief during labor with a computer generated random table.
In the EA group, the epidural space was cited in the L2-3 or L3-4 interspace with a 18G Tuhoy needle and a 20G epidural catheter threaded 3–4 cm into the epidural space. After confirming the correct position with an epidural test dose, 10 mL of 0.125% bupivacaine with 25 mcg fentanyl was administered. In the CSE group, subarachnoid block was initiated with 25 mcg fentanyl administered with a 25G Quinke needle in the L3-4 interspace. Epidural was cited in L2-3 interspace with 18G Tuhoy needle and a 20G epidural catheter threaded 3–4 cm into the epidural space. Position of the catheter was confirmed with epidural test dose. Epidural injection of 8 mL of 0.125% bupivacaine in aliquots of 4 mL were administered whenever patient demanded analgesia in both the groups. However, epidural injection was withheld once full dilatation of cervix was achieved.
Per vaginal examination was done just before the initiation of labor analgesia and later at the discretion of the obstetrician to note the progress of the labor and dilatation of the cervix. The onset of analgesia, number of epidural injections requested, the mode of delivery, and the need for instrumentation were noted. The cervical dilatation rate was derived from the cervical examinations at analgesia initiation and full dilatation [Cervical dilatation rate = (10 cm − cervical dilatation at initiation of analgesia in cm)/time between examinations]. Analgesia was assessed using a 0–10 visual analog scale (VAS) initially at 5 min, 10 min, 30 min, 60 min, and later every 60 min till full cervical dilatation. Any maternal or neonatal complications such as pruritus, post-dural-puncture headache (PDPH), or neonatal asphyxia were also noted and managed appropriately, as per institutional protocol.
The sample size was derived by nMaster software and obtained based on the results of the study by Tsen et al. Considering the results of mean cervical dilatation rate of CSE and EA, to achieve 80% power 95% confidence level with effect size of 0.6, the minimum sample size required was 57 participants in each group. We decided to recruit 65 participants to overcome any loss during the study period. Data was analyzed using the Statistical Package for the Social Sciences version 18.0 (SPSS, IBM Corp. USA, 2010). The cervical dilatation rate was summarized in terms of median and interquartile range (IQR). Mann–Whitney and Chi-square tests were performed where applicable to compare the data between the two groups. P value of <0.05 was considered to be statistically significant.
| Results|| |
One hundred and twenty parturients completed the study among the 130 recruited participants. Six parturients in the EA group and 4 in the CSE group had to be taken up for caesarean section due to fetal distress before the full cervical dilatation was achieved, and hence were excluded from the study. Maternal demographics, cervical dilatation at initiation of analgesia, and labor outcome were comparable between the two groups [Table 1] and [Table 2]. The number of nulliparous and mulitparous parturients were similar between the two groups. Labor management was based on a standard protocol followed in our institution. Both techniques were comparable in providing effective analgesia; effective analgesia was defined as VAS <4 at 30 min. Analgesia, as assessed by VAS, was comparable between the two groups at all time intervals after the first 30 min [Figure 1].
The cervical dilatation rate was more rapid in the CSE group compared to the EA group [Table 2]. Most of the parturients in the CSE group had a cervical dilatation between 1.2–3 cm/h, with a median rate of 2 cm/h. In the EA group, the cervical dilatation rate was 1–2 cm/h, with a median of 1.16 cm/h. The P value when calculated by Mann–Whitney test was <0.001 (highly significant), i.e. the rate of cervical dilatation with CSE was significantly rapid than that with EA. The onset of analgesia was significantly rapid in the CSE group compared to EA group (3.7 ± 1.3 min vs. 23.8 ± 5.8 min, P < 0.001). The number of epidural top-ups received by parturients in the CSE group was less than those in the EA group (1.6 ± 1.0 v/s 2.6 ± 1.2, P < 0.001).}
The incidence of pruritus and PDPH was more in parturients receiving CSE analgesia compared to EA alone. However, statistical inference could not be drawn as the study was not powered to look for these side effects. In the CSE group, 3 newborns had APGAR 7 at 1 min, which improved to 9 at 5 min following oxygen supplementation. In the EA group, 5 newborns had APGAR 7 at 1 min, which improved to 9 at 5 min among 4 of them with oxygen supplementation. One newborn had to be shifted to neonatal ICU care, which improved subsequently. None of the babies required oxygen inhalation, endotracheal intubation, mask ventilation, or naloxone.
| Discussion|| |
Neuraxial techniques are considered as the technique of choice for pain relief in labor because they provide the most effective and reliable analgesia compared to the other techniques. Both epidural and combined spinal epidural techniques are used according to individual or institutional preferences to provide analgesia during labor. The CSE technique has gained popularity because it provides rapid analgesia and minimal motor blockade. Despite the popularity and advantages, neuraxial techniques are perceived by many obstetricians to reduce the rate of progress of labor and increase the rate of caesarean delivery and instrumental vaginal delivery. However, large clinical trials and Cochrane reviews have found no difference in the labor outcome or duration of labor.,,,,,,
The results of our study is similar to the study by Tsen et al. and Bhagwat et al. In our study despite similar cervical dilatation at the time of initiation of analgesia, parturients in the CSE group had rapid rate of cervical dilatation and shorter duration of active stage of first stage of labor. They required less number of epidural top-ups compared to the EA group.
The mechanism for the rapid rate of cervical dilatation with CSE technique is not clearly known; however, various possibilities have been hypothesized in previous studies. The use of CSE technique decreases the local anesthetic exposure in the parturients., Exposure of uterine muscle strips to local anesthetic is shown to decrease the rate and strength of muscle contractions. Epinephrine and norepinephrine levels increase due to painful labor, and rapid analgesia as provided by CSE decreases the fluctuation in the levels of catecholamines. Decreased levels of epinephrine, a tocolytic, may minimize its inhibitory effect on uterine contractility. In our study, parturients in the CSE group required less epidural top-ups than the EA group, and thus had relatively less exposure to the local anesthetic. Provision of effective analgesia during labor may accelerate labor by reducing maternal catecholamines.
The onset of effective analgesia was faster with CSE than with EA alone. This is expected as it is well known that intrathecal opioids produce a rapid analgesia, whereas epidural analgesia requires relatively more time to become established.
Parturients in the CSE group had better analgesia compared to the EA group during the initial 30 min. This was due to the rapid onset of analgesia in the CSE group compared to the EA group (3.7 min v/s 23.8 min). Once the analgesia was well established, the VAS scores were similar in the two groups. The most common side effect noted in both groups was pruritus, which occurred with greater frequency in patients receiving CSE compared to EA (86% vs. 65%). This was transient, tolerable, and required no treatment other than maternal reassurance. Other studies have noted pruritus to be a common side effect with neuraxial analgesia.,
The potential limitations of the study are the uncertainties regarding the exact timing of full cervical dilatation because this was unavoidable as the interval between per vaginal examinations was at the discretion of the attending obstetrician, with no definite time interval between two examinations. The study groups were heterogeneous in terms of parity, including both nulliparous and multiparous parturients. It is well-known that the duration of labor is shorter in multiparous than nulliparous. However, both groups had a similar distribution of parity and may not have confounded the results.
| Conclusion|| |
In conclusion, our study confirmed that CSEA is associated with more rapid cervical dilatation and shorter duration of first stage of labor when compared with epidural analgesia alone.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]