The effectiveness of two epidural analgesic regimens on the ability to ambulate was compared in women in labor by a prospective, randomized, double-blind design. One group of patients received epidural fentanyl, a 75-micrograms bolus and an infusion of fentanyl 2.5 micrograms/mL at 15 mL/h (FENT, n = 53). A second group received ultra low-dose bupivacaine (0.04%), epinephrine (1.7 micrograms/mL), and fentanyl (1.7 micrograms/mL) (BEF, n = 77), a 15-mL bolus followed by an infusion at 15 mL/h. Adequate analgesia was rapidly obtained in 90.6% of patients in the FENT group and 92.2% of patients in the BEF group (P = 0.89). Seventy percent of patients in the FENT group ambulated versus 68% in the other group. The BEF mixture provided analgesia of longer duration (287 +/- 171 min versus 156 +/- 72 min, P = 0.0001). The number of patients delivering during administration of only their study drug (without needing higher doses of local anesthetics) was 52% for BEF and 21% for FENT (P = 0.0005). Hip flexion weakness precluding ambulation occurred in 17% (P = 0.002) of BEF patients and orthostatic hypotension in 9% (P = 0.08). Neither problem occurred in FENT patients. Neonatal outcome was similar in both groups. Approximately 70% of women receiving epidural analgesia with fentanyl or ultra low-dose bupivacaine, epinephrine, and fentanyl may ambulate safely during labor.

No abstract

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 microg/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.

Purpose: To test the hypothesis that O. I mg intrathecal morphine plus NSAIDs provides satisfactory analgesia post-Cesarean section with fewer side effects than 0.25 mg intrathecal morphine. Methods: Sixty women, scheduled for elective Cesarean section under spinal anesthesia, were randomized to receive either 0. I mg or 0.25 mg intrathecal morphine combined with hyperbaric bupivacaine 0.75% and 20/lg fentanyl. All patients received a I O0 mg indomethacin suppository at the end of surgery and 500 mg naproxen po b.i.d, was started the evening of surgery and continued until discharge. A blinded researcher recorded the pain, pruritus, and nausea scores, the time to first request for additional analgesics, a visual analogue scale (VAS) satisfaction score, and the use of additional opioids, antipruritics, and/or antiemetics. Results: Of the 60 patients enrolled, two were not included in the data analysis because of protocol violations leaving 30 patients in the 0. I mg group and 28 in the 0.25 mg group. There were no differences in the VAS pain scores or the number of women requesting an opioid other than codeine between the two groups. The VAS pruritus scores in the 0. I mg group were lower throughout the 24 hr (P < 0.001 ). Fewer women in the 0. I mg group (4/30 vs 12/28) requested nalbuphine'to treat itching (P = 0.018). Nausea scores were lower in the 0. I mg group (P < 0.00 I). Conclusion: The use of 0. I mg intrathecal morphine plus NSAIDs provides analgesia of similar quality to 0.25 mg but with fewer undesirable side effects following Cesarean section.Objectis : V&ifier I'hypoth~se qui veut que O, I mg de morphine intrath6cale combin~e ~ des AINS foumissent une analg&ie satisfaisante ~ la suite d'une c&arienne et moins d'effets secondaires que 0,25 mg de morphine intrath&ale. M~thode 9 Soixante femmes, admises pour une c&arienne planiti& sous rachianesth&ie et r~parties au hasard ont regu 0, I. mg ou 0,25 mg de morphine intrath&ale combin& ~ de la bupivacaine hyperbare 0,75 % et ~ 20 /~g de fentanyl. Toutes ont regu un suppositoire de 100 mg d'indom6thacine ~ la fin de I'op&ation et 500 mg de naproxEne po b.i.d. ~ partir du premier soir jusqu'au jour du d~part. Un anesth6.siologiste impartial a enregistr~ les scores de douleurs, de prurit et de naus~es, le temps avant la premiere demande d'analg&iques suppl~men-taires, le degrE de satisfaction ~ I'&helle visuelle analogue (EVA) et I'usage d'opidides, d'antiprurigineux et/ou d'anti6m&iques additionnels. l~.sultats : Des 60 patientes recrut&s, deux front pu participer ~ la cueillette de donn~es ~ cause de violations au protocole de recherche; il est restE 30 patientes clans le groupe de 0, I mg et 28 dans celui de 0,25 mg. II n'y a pas eu de diff&ence intergroupe pour les scores ~ I'EVA ou le nombre de femmes qui ant demand~ un opio'l'de autre que la cod6ine. Le degr6 de prurit fourni par I'EVA a 6t~ plus bas dans le groupe de 0, I mg pendant 24 h (P < 0,001). Moins de femmes du groupe de O, I mg (4/30 vs 12/28) ont demand6 de la nalbuphine contre le prurit (P ...

No abstract

There was no difference in the incidence of operative delivery or neonatal outcome among nulliparous patients who received low concentrations of bupivacaine or ropivacaine for labor analgesia.

In <25 years, intrathecal administration of opioids (i.e. spinal analgesia) has evolved from an experimental model into an important therapy for obstetric analgesia and anaesthesia. A small dose of opioid delivered into the CSF provides almost immediate relief from labour pain with minimal risks to the mother and fetus. Careful attention, and prompt treatment when needed, can ameliorate the adverse effects of fetal bradycardia, respiratory depression and pruritus. The major limitation of intrathecal opioids for labour analgesia is the short duration of effect: 90-180 minutes under ideal circumstances. To address this problem, and to increase flexibility for anaesthesia as well as analgesia, the combined spinal-epidural (CSE) technique was developed. The CSE technique involves injection of drugs into the CSF and placement of an epidural catheter. An intrathecally administered opioid provides a rapid onset of labour analgesia without motor block or significant haemodynamic perturbation. The epidural catheter allows ongoing administration of medications to maintain labour analgesia and provides a means of delivering anaesthesia for operative delivery. This review will focus on intrathecally administered opioids as used as part of CSE analgesia. Considerable research has focused on the optimum dose of opioids when delivered intrathecally, with or without adjuncts, in the CSE technique. Fentanyl and sufentanil, two of the lipophilic synthetic opioids, have emerged as the most useful. Bupivacaine, a long-acting local anaesthetic, is often added to prolong the duration of analgesia, although this tends to increase the likelihood of motor blockade of the lower extremities. Comparisons of the CSE technique with standard epidural practices have shown that both are effective means of providing analgesia during labour. Controversy revolves around the incidence of fetal bradycardia following CSE and whether this phenomenon increases the rate of operative deliveries. The rapid onset of analgesia with intrathecally administered opioids must be balanced against the added risks of dural puncture and considered in the context of the whole duration of labour. Ultimately, the decision to choose a CSE technique depends on the experience of the anaesthesia provider and the local availability of drugs, equipment and monitoring capabilities.

Prevalence of coagulation abnormalities associated with intrauterine fetal deathPurpose: The purpose of this study was to determine factors associated with abnormal coagulation in the setting of intrauterine fetal death (IUFD) IUFDs (3.2%) and that this number rises in the presence of abruption or uterine perforation.