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OBSTETRIC ANESTHESIOLOGY

A Randomized Trial of Breakthrough Pain During Combined Spinal-Epidural Versus Epidural Labor Analgesia in Parous Women

From the Department of Anesthesiology, Columbia University, New York City, New York.

Address correspondence to Stephanie R. Goodman, MD, Department of Anesthesiology, Columbia University Medical Center, 630 West 168th St., PH-5, NY, NY 10032. Address e-mail to srg24{at}columbia.edu.

Abstract

BACKGROUND: There is controversy regarding the benefits and risks of combined spinal-epidural compared with epidural analgesia (CSE, EPID) for labor analgesia. We hypothesized that CSE would result in fewer patient requests for top-up doses compared to EPID.

METHODS: One-hundred ASA physical status I or II parous women at term in early labor (<5 cm cervical dilation) requesting analgesia were randomized in double-blind fashion to the EPID group (epidural bupivacaine 2.5 mg/mL, 3 mL, followed by bupivacaine 1.25 mg/mL, 10 mL with fentanyl 50 µg) or the CSE group (intrathecal bupivacaine 2.5 mg with fentanyl 25 µg). Both groups received identical infusions of bupivacaine 0.625 mg/mL with fentanyl 2 µg/mL at 12 mL/h. The primary outcome variable was the number of top-up doses requested to treat breakthrough pain.

RESULTS: There was no significant difference between the two groups in the percentage of patients requesting top-up doses (44% CSE vs 51% EPID; 95% confidence interval of the difference –28% to +14%) nor in the need for multiple top-up doses (14% CSE vs 15% EPID). Visual analog scale scores were lower in the CSE group compared to the EPID group at 10 min after initiation of analgesia [median 0 cm (0, 0) vs 4 cm (1, 6) respectively, P < 0.001] and at 30 min [0 cm (0, 0) vs 0 cm (0, 1), respectively, P = 0.03].

CONCLUSIONS: We did not find a difference in the need for top-up doses in parous patients; however, CSE provided better analgesia in the first 30 min compared to EPID.