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OBSTETRIC ANESTHESIOLOGY

A Randomized Trial of Dural Puncture Epidural Technique Compared with the Standard Epidural Technique for Labor Analgesia

From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Address correspondence and reprint requests to Lawrence C. Tsen, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75, Francis St., CWN-L1 Harvard Medical School, Boston, MA 02115. Address e-mail to ltsen{at}zeus.bwh.harvard.edu.

Abstract

BACKGROUND: We designed this prospective, double-blind, randomized study to examine whether a dural puncture without intrathecal drug administration immediately before epidural drug administration would improve labor analgesia when compared to a traditional epidural technique without prior dural puncture.

METHODS: Eighty nulliparous parturients with cervical dilation less than 5 cm were randomly assigned to receive a standardized epidural technique, with or without a single dural puncture with a 25-gauge (G) Whitacre spinal needle. After successful placement of the needle(s) and the epidural catheter, 12 mL of bupivacaine 2.5 mg/mL was administered through the epidural catheter and a patient-controlled epidural infusion of bupivacaine 1.25 mg/mL + fentanyl 2 µg/mL was initiated. The presence of sacral analgesia (S1) and pain scores were compared between groups.

RESULTS: In demographically similar groups, parturients with prior dural puncture had more frequent blockade of the S1 dermatome (absolute risk difference [95% confidence interval] 22% [6–39]), more frequent visual analog scale scores <10/100 at 20 min (absolute risk difference 20% [1–38]), and reduced one-sided analgesia (absolute risk difference [95% CI] 17% [2–330]). The highest median sensory level (T10) was no different between groups.

CONCLUSIONS: Dural puncture with a 25-G spinal needle immediately before the initiation of epidural analgesia improves the sacral spread, onset, and bilateral pain relief produced by analgesic concentrations of bupivacaine with fentanyl in laboring nulliparous patients.