SummarySevmt~-lhree women who requested epidural analgesia during labour were randomly allocated in a prospective study to receive eithrr u continuous epidural infusion of 0.075% bupivacaine at a rate of 12-18 mllhour (38 mothers) There has been considerable interest recently in the use of continuous epidural infusions for pain relief in labour. Most previous studies have used continuous epidural infusions of either 0.125% or 0.25% bupivacaine, although recently Ewen el ul.l0 showed 0.08% bupivacaine to be superior to infusions of 0.25% bupivacaine. No study has compared the quality of analgesia provided by a continuous infusion of low, concentration bupivacaine with that provided by a standard regimen of intermittent top-ups. We therefore conducted a prospective randomised trial that compared a continuous epidural infusion of 0.075% bupivacaine with intermittent top-ups of 0.5% bupivacaine.
MethodsSeventy-three women aged between 16 and 35 years who requested epidural analgesia during labour were included in the study, which was approved by the local ethical committee. The nature and risks of the procedure were explained to the patient and written consent obtained. Patients were randomly allocated to one of two groups; the top-up group received intermittent top-ups of 0.5% bupivacaine, and the infusion group a continuous epidural infusion of 0.075% bupivacaine. No other analgesic or sedative drugs were given. The following groups were not eligible for inclusion in the trial: gestational age less than 36 weeks, multiple pregnancy, breech presentation, probable cephalopelvic disproportion, trial of scar, the presence of moderate or severe hypertension or pre-eclampsia, cervical dilatation greater than 8 cm, coagulation defect or local sepsis.The mother's circulation was preloaded with 500 ml Hartmann's prior to insertion of the epidural and the arterial blood pressure recorded. The mother was asked to score her pain using a 10-cm linear scale. This was a horizontal line labelled 'no pain' at one extreme and 'worst pain imaginable' at the other. The epidural space was located with the mother in the left lateral position, a t either the L2!3 or L3!4 interspace with a 16-gauge Tuohy needle using loss of resistance to either saline or air. An epidural cathether was advanced through the Tuohy needle and 3 cm left in the epidural space. The cpidural was resited in a different interspace if a bloody tap occurred, and the mother continued in the study. A test dose of 2 ml bupivacaine 0.5% was given after a negative aspiration test for cerebrospinal fluid and blood. A furthcr 4-6 ml bupivacaine 0.5% was given if there were no untoward sequelae 5 minutes after the test dose. The paticnt was then turned onto her right side and the arterial pressure recorded every 5 minutes for 20 minutes.The epidural in the top-up group was topped up by the midwife with 6-8 ml bupivacaine 0.5% on maternal request.
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