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OBSTETRIC ANESTHESIA

A Multicenter Randomized Controlled Trial Comparing Patient-Controlled Epidural with Intravenous Analgesia for Pain Relief in Labor

Stephen H. Halpern, MD MSc, FRCPC^*, Holly Muir, MD FRCPC, Terrance W. Breen, MD FRCPC, David C. Campbell, MD MSc, FRCPC, Jon Barrett, MBBch MD, MRCOG, FRCSC, Robert Liston, MB ChB, FRCSC^||, and J. Wade Blanchard, MSc^¶

*Department of Anaesthesia, Sunnybrook and Women’s College Health Sciences Centre, and the University of Toronto, Toronto, Ontario, Canada; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Department of Anesthesia, Royal University Hospital, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, and College of Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada; Department of Obstetrics and Gynaecology, University of Toronto, and Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada; ||Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia Women’s Hospital, Vancouver, British Columbia, Canada; and ¶Department of Mathematics & Statistics, Statistical Consulting Service, Dalhousie University, Halifax, Nova Scotia, Canada

Address correspondence and reprint requests to Stephen H. Halpern, MD, MSc, Department of Anesthesia, Sunnybrook and Women’s College Health Sciences Centre, 76 Grenville St., Toronto, Ontario, M5S 1B2, Canada. Address e-mail to stephen.halpern{at}sw.ca

In this multicenter, randomized, controlled trial, we sought to determine whether patient-controlled epidural analgesia (PCEA) for labor affected the incidence of cesarean delivery when compared with patient-controlled IV opioid analgesia (PCIA). Healthy, term nulliparous patients in 4 Canadian institutions were randomly assigned to receive PCIA with fentanyl (n = 118) or PCEA with 0.08% bupivacaine and fentanyl 1.6 µg/mL (n = 124). There was no difference in the incidence of cesarean delivery—10.2% (12 of 118) versus 9.7% (12 of 124)—or instrumental vaginal delivery—21.2% (25 of 118) versus 29% (36 of 124)—between groups. The duration of the second stage of labor was increased in the PCEA group by a median of 23 min (P = 0.02). Fifty-one patients (43%) in the PCIA group received epidural analgesia: 39 (33%) because of inadequate pain relief and 12 (10%) to facilitate operative delivery. Patients in the PCIA group required more antiemetic therapy (17% versus 6.4%; P = 0.01) and had more sedation (39% versus 5%; P < 0.001). Maternal mean pain and satisfaction with analgesia scores were better in the PCEA group (P < 0.001 and P = 0.02, respectively). More neonates in the PCIA group required active resuscitation (52% versus 31%; P = 0.001) and naloxone (17% versus 3%; P < 0.001). These observations support the hypothesis that PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA. PCEA provides superior analgesia and less maternal and neonatal sedation compared with PCIA.

IMPLICATIONS: Two-hundred forty-two healthy, term, nulliparous patients in spontaneous labor were randomized to receive either patient-controlled IV or patient-controlled epidural labor analgesia. No difference in the incidence of cesarean delivery was observed between groups. The data support the hypothesis that epidural analgesia does not increase the incidence of cesarean delivery compared with IV analgesia.