Neuraxial Analgesia for Labour: Standard Techniques versus Novel Approach

Neuraxial Analgesia for Labour: Standard Techniques versus Novel Approach

  • Issue 71

Selin Erel
selinerel@yahoo.com

Note from the Editor: Dr Erel was awarded the ESA 2017 Young Teaching Recognition Award

Pain relief methods for labour are classified as non-pharmacological and pharmacological. Non-pharmacological approaches are emotional support, touch and massage, therapeutic use of heat and cold, hydrotherapy, vertical position or upright posture, transcutaneous electrical nerve stimulation, acupuncture, aromatherapy, and sterile intradermal water blocks.[1],[2] Pharmacologic methods consist of inhalation and systemic analgesia, and neuraxial blocks. Neuraxial analgesia is the most effective method providing complete analgesia without maternal or foetal sedation. Regardless of the technique, the primary goal is to provide adequate maternal analgesia without foetal and neonatal adverse effects using local anaesthetics (bupivacaine, ropivacaine, or levobupivacaine) and/or lipid soluble opioids (fentanyl or sufentanil).[4] Standard neuraxial labour analgesia techniques (epidural and combined spinal epidural: CSE) and comparison of these techniques with a novel approach (dural puncture epidural: DPE) are overviewed.

ACOG and ASA stated that maternal request is a sufficient indication for pain relief during labour in the absence of a medical contraindication.[4-6] After preanaesthetic evaluation,7 optimal timing of neuraxial analgesia is the active phase of 1st stage of labour.[7] Lately, it has been suggested that labouring women should receive labour analgesia when they request it instead of delaying until the cervix dilates at least 4–5 cm.[8]

Management of neuraxial analgesia

Epidural analgesia is commonly induced by 15–20 mL of bupivacaine (0.0625–0.125%), or ropivacaine (0.08–0.2%) with fentanyl (2 µg/mL), or sufentanil (0.2–0.33 µg/mL) after test dose (3 mL of lidocaine 1.5%).[3]
CSE analgesia is induced with intrathecal fentanyl or sufentanil alone or combined with bupivacaine or ropivacaine. Bupivacaine 1.7 mg (ED95: 1.66 mg) combined with fentanyl 15 µg/mL (ED50) has been mostly preferred.[9]
CSE analgesia with intrathecal fentanyl 20 µg alone followed by patient-controlled epidural analgesia (PCEA) provided adequately satisfactory analgesia similar to conventional epidural analgesia.10 Favourable PCEA protocols using bupivacaine 0.125–0.0625 including fentanyl 2 µg/mL with basal infusion rates (8–15 mL/h), bolus dose of 5–10 mL, and lock-out intervals of 10–20 min have been described.[3],[4]

Neuraxial analgesia techniques are not limited to epidural and CSE blocks. A novel method called DPE, a modification of CSE, was described in 1996.11 After performing CSE via needle-through-needle technique, the spinal needle is withdrawn without any subarachnoid drug administration. Then, an epidural catheter is placed to administer drug solutions via catheter. Suzuki et al.[11]have demonstrated the increased caudal spread of analgesia after DPE using 26 G Whitacre spinal needle for orthopaedics surgery for the first time. The mechanism seems to be due to the translocation of epidural medications through a dural puncture. Then, further studies with DPE in labouring women using 27 G and 25 G Whitacre spinal needles were published.[12],[13] Although Thomas et al.[12] did not show improved epidural labour analgesia quality or reduction in catheter manipulation with 27 G spinal needle, Cappiello et al.[13] proved that DPE with 25 G Whitacre spinal needle was responsible for improved sacral analgesia. Recently, improved block quality with DPE over epidural and fewer maternal and foetal side effects with DPE over CSE have been reported.[14]

Comparison of standard epidural or CSE versus DPE technique is listed below and summarized (Table 1):

  • Onset of analgesia, which is assessed as time elapsed to reach numeric pain rating scale ≤1 is significantly earlier with CSE than either epidural or DPE as anticipated (p<0.0001). However, onset of analgesia with DPE is markedly shorter than with standard epidural.
  • Significantly more parturients have sacral analgesia (bilateral block at S2) 10, 20, and 30 minutes after DPE than epidural (p<0.001, p<0.001, and p=0.034, respectively). DPE and CSE have almost similar sacral analgesia at 20 and 30 minutes.
  • Need for epidural catheter adjustment is markedly less with DPE.
  • Time to first physician top up requirement is markedly longer with DPE.
  • Rates of pruritus and hypotension are almost the same with DPE and epidural, which are markedly less with than CSE. No post-dural puncture headache is observed after DPE.
  • Frequency of foetal heart rate decelerations with DPE and epidural are similarly less than that of
  • Rate of caesarean and instrumental delivery are greater with CSE and DPE.
  • Significantly fewer new borns have Apgar score ≤7 at 1 minute after DPE.

Table 1. Comparison of standard neuraxial analgesia techniques versus DPE.

In conclusion, DPE appears to offer favourable risk benefit ratio for labour analgesia.

Acknowledgement

I would like to thank my mentor Prof Berrin Gunaydin for her help and support.


2017 Young Teaching Recognition Award Winners: Dr Selin Erel (second from right) – Dr Igor Vaskovic (far left)
Panel: Dan Longrois, Vojislava Neskovic, Benedikt Preckel, Andreas Sandner-Keisling

REFERENCES
1. Camann W, Alexander KJ. Easy Labor. New York: Ballantine Books, 2006.
2. Gunaydin B. Obstetric pain and its management in the perinatal period: What do we need to know? In Kuczkowski CK, Drobnik L. International Textbook of Obstetric Anaesthesia and Perinatal Medicine. Wydawca: Med-Media, 2010.
3. Wong CA. Advances in labor analgesia. Int J Women’s Health 2009;1:139.
4. Chestnut’s Obstetric Anesthesia: Principles and Practice. 5th ed. Philadelphia: Elsevier Saunders, 2014.
5. ACOG Committee on Obstetric Practice. Opinion No: 269. Obstet Gynecol 2002;777(1):67.
6. http://asahq.org/publicationsAndservices/standards/47.pdf
7. Practice Guidelines for Obstetric Anesthesia. Anesthesiology 2016;124(2):270-300.
8. Wong CA, Scavone BM, Peaceman AM, et al. New Eng J Med 2005;352(7):655-65.
9. Whitty R, Goldszmidt E, Parkes RK, et al. Determination of the ED95 for intrathecal plain bupivacaine combined with fentanyl in active labor. IJOA 2007;16(4):341-5
10. Sezer OA, Gunaydin B. Efficacy of patient-controlled epidural analgesia after initiation with epidural or combined spinal epidural analgesia. IJOA 2007;16(3):226-30.
11. Suzuki N, Koganemaru M. Onizuka, et al. Anesth Analg 1996;82(5):1040-2.
12. Thomas JA, Pan PH, Harris LC, et al. Dural puncture with a 27-gauge Whitacre needle. Anesthesiology 2005;103(5):1046-51.
13. Cappiello E, O’rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique.
Anesth Analg 2008;107(5):1646-51.
14. Chau A, Bibbo C, Huang CC, et al. Dural Puncture Epidural Technique Improves Labor Analgesia Quality. Anesth Analg 2017;124(2):560-9.