Quality of Labor Analgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study

Abstract

Background The dural puncture epidural technique may improve analgesia quality by confirming midline placement and increasing intrathecal translocation of epidural medications. This would be advantageous in obese parturients with increased risk of block failure. This study hypothesizes that quality of labor analgesia will be improved with dural puncture epidural compared to standard epidural technique in obese parturients. Methods Term parturients with body mass index greater than or equal to 35 kg · m–2, cervical dilation of 2 to 7 cm, and pain score of greater than 4 (where 0 indicates no pain and 10 indicates the worst pain imaginable) were randomized to dural puncture epidural (using 25-gauge Whitacre needle) or standard epidural techniques. Analgesia was initiated with 15 ml of 0.1% ropivacaine with 2 µg · ml–1 fentanyl, followed by programed intermittent boluses (6 ml every 45 min), with patient-controlled epidural analgesia. Parturients were blinded to group allocation. The data were collected by blinded investigators every 3 min for 30 min and then every 2 h until delivery. The primary outcome was a composite of (1) asymmetrical block, (2) epidural top-ups, (3) catheter adjustments, (4) catheter replacement, and (5) failed conversion to regional anesthesia for cesarean delivery. Secondary outcomes included time to a pain score of 1 or less, sensory levels at 30 min, motor block, maximum pain score, patient-controlled epidural analgesia use, epidural medication consumption, duration of second stage of labor, delivery mode, fetal heart tones changes, Apgar scores, maternal adverse events, and satisfaction with analgesia. Results Of 141 parturients randomized, 66 per group were included in the analysis. There were no statistically or clinically significant differences between the dural puncture epidural and standard epidural groups in the primary composite outcome (34 of 66, 52% vs. 32 of 66, 49%; odds ratio, 1.1 [0.5 to 2.4]; P = 0.766), its individual components, or any of the secondary outcomes. Conclusions A lack of differences in quality of labor analgesia between the two techniques in this study does not support routine use of the dural puncture epidural technique in obese parturients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Image Segmentation-Based Cervical Spine MRI Images to Evaluate the Treatment of Patients with Chronic Pain

“…In equation (12), A represented the standard manual segmentation result and B meant the segmentation results 3 Computational and Mathematical Methods in Medicine of GVF-Snake or cervical spine MRI-based ISA. Dice obtained by solution was the ratio of the accurate segmentation part.…”

“…Cervical epidural puncture is an effective way to diagnose and treat acute and chronic pain diseases [ 12 ]. Compared with other sites, the tissue layer thickness of cervical epidural puncture site is increased, and the segment is relatively high, so the risk and difficulty of puncture during the actual operation is relatively high [ 13 ].…”

Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement over Conventional Labor Epidural Analgesia?

“…Despite this study design, Tan et al 2 found no advantage of the dural puncture epidural technique. They acknowledged that use of a very dilute epidural solution might have lessened the effect of transdural drug passage.…”

“…In the general parturient population, the overall effect seems to be quite modest at best. In the higher-risk population studied by Tan et al , 2 there were no significant advantages. It may still be possible to identify patients who could benefit (for example, those in whom equivocal loss of resistance is encountered).…”

“…The study by Tan et al 2 features a design well poised to help detect a difference between techniques. Obese women are often thought to present more difficult anatomy for identification of the epidural space and would thus potentially benefit more from the observation of CSF during dural puncture epidural, which would help the operator confirm midline placement of the epidural needle and reject a false loss of resistance.…”