Cochrane Review of Spinal vs Epidural for LSCS - Summary

Ng KW, Parsons J, Cyna AM, Middleton P. The Cochrane Library 2010, Issue 11

Outcome

No. of studies

No. of patients

Effect size (Risk ratio or Mean difference) 0.98 [0.23, 4.24] 2.37 [0.94, 5.97] Mean difference -7.9 mins [-4.23, -11.59] 0.88 [0.59, 1.32] 1.00 [0.71, 1.45] Mean difference -0.34 [-0.98, 0.30] 1.23 [1.00, 1.51] 3.00 [0.13, 70.02] 3.00 [0.14, 65.90] 1.28 [0.30, 5.45]

Failure to achieve adequate anaesthesia to 4 begin surgery Need for another anaesthetic technique 1 Time for surgery to commence 4 Need for additional pain relief during surgery 5 Women unsatisfied with anaesthetic 2 Maternal satisfaction score 2 Need for treatment for hypotension Nausea & vomiting Treatment for PDPH Neonatal intervention required 6 1 1 1

364 238 345 504 258 258 495 46 20 104

Both techniques achieved moderate degree of maternal satisfaction Maternal satisfaction = %women who preferred the same technique again when asked 24hr postoperatively Pooled scores showed no difference in visual analogue scale (VAS). Time for surgery to commence: spinal 7.91 mins less than epidural Statistically signicant heterogeneity Time for preparation and insertion of spinal vs epidural not taken into account by studies. Spinal technique required more treatment for hypotension.

Cockrane Review of CSE vs. Epidural in labour - Summary

Simmons SW, Cyna AM, Dennis AT, Hughes D. The Cochrane Library 2009, Issue 1

19 trials involving 2658 women CSE vs. traditional epidural analyses only three outcomes showed a difference. CSE was more favourable in relation to need for rescue analgesia and urinary retention, but associated with more pruritus. CSE vs low-dose epidurals, four outcomes were statistically signicant. CSE had a faster onset of effective analgesia from time of injection but was associated with more pruritus. No differences between CSE and epidural in terms of: maternal satisfaction mobilisation in labour modes of birth incidence of PDPH incidence of blood patch incidence of maternal hypotension

ere appears to be little basis for oering CSE over epidurals in labour with no dierence in overall maternal satisfaction despite a slightly faster onset with CSE and less pruritus than epidurals

e signicantly higher incidence of urinary retention and rescue interventions with traditional techniques would favour the use of low-dose epidurals

Comparative Obstetric Mobile Epidural Trial (COMET)

Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001; 358:19-23

1054 nulliparous women

traditional epidural 353

low-dose CSE infusion 351 0.2% Ropivacaine with Fentanyl 2 mcg/ml

low-dose epidural infusion 350 0.2% Ropivacaine with Fentanyl 2 mcg/ml

0.25% Bupivacaine

Rate of NVD Rate of LCSC Analgesic efcacy

35.1%

42.7%

42.9%

Less instrumental vaginal delivery in low-dose infusions (CSE or epidural) ? due to preservation of motor function during labour and delivery

PCEA vs continuous infusion for labour analgesia: a meta-analysis

Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis. van der Vyver, Halpern, Joseph. Br J Anaesth 2002; 89: 459-65

Nine studies 640 parturients Compared demand-only PCEA vs. continuous epidural infusion Signicantly fewer patients needed clinician topups in the PCEA group compared with CEI (RD, 27%; 95% CI, 18-36%; P<0.00001).

PCEA vs continuous infusion for labour analgesia: a meta-analysis

Maternal satisfaction, no consistent difference between PCEA and CEI. No difference between groups in the incidence of LSCS or instrumental vaginal delivery. No difference in the duration of either the rst or second stages of labour. PCEA is associated with less use of total local anaesthetic dose and less motor weakness.

PCEA vs continous infusion vs intermittent bolus

New Techniques for Labor Analgesia: PCEA and CSE. D'Angelo. Clin Obstet Gynecol 2003; 46(3): 623632

A review of 19 studies PCEA has several advantages over continuous infusion or intermittent boluses: Reduced pain scores Reduced motor blockade Reduced clinician workload Increased maternal satisfaction Five studies found no clear advantages with PCEA None of the studies demonstrated advantages of continous infusion or intermittent boluses over PCEA

PCEA - with or without background infusion?

Conicting results Seven studies, all RCTs, low parturients

Findings: Most had low infusion rates low < 5ml/h Maternal & Fetal outcome: no difference Maternal analgesia: no difference, except one study reported worse pain without background infusion Maternal satisfaction: no difference (not reported in one study) Motor block: no difference Clinician workload: Three studies reported less interventions in the infusion group

PCEA - Bupivacaine or Ropivacaine?

11 studies Wide range of settings, Bupivacaine 0.05% (+F) to 0.125%, Ropivacaine 0.05% to 0.2% Findings: Maternal analgesia: no difference Maternal satisfaction: no difference, reported in four studies Clinician rescue boluses: no difference, reported in six studies Motor block: Five out of ten studies reported increased incidence of motor block with Bupivacaine

PCEA - Bolus dose volume and lockout interval

Six studies, all RCTs, low-risk parturients Solutions: Bupivacaine 0.0625% - 0.125%, Ropivacaine 0.1% - 0.2% with Fentanyl or Sufentanyl Bolus volumes: 2 - 20 mL, Lockout intervals: 5 - 30 mins Most studies underpowered to show a difference in outcomes Findings: Maternal analgesia: One study (Bernard et. al) showed difference between small (4 mL) and large volume (12 mL) bolus; no difference between various lockout intervals (but may be due to differences in bolus volumes). Clinician intervention: no difference Motor block: uncommon, no difference among various PCEA settings Toxicity or side-effects: insufcient data to comment on large volume boluses

PCEA - What drug concentration to use?

Six studies, all RCTs, low-risk parturients Solutions: Bupivacaine 0.0625% - 0.25%, Ropivacaine 0.1% - 0.2%, with Fentanyl or Sufentanil Findings: Maternal analgesia: no difference Maternal satisfaction: no difference Motor block: Three out of ve studies reported more motor block with more concentrated solutions (Bupivacaine 0.25% and Ropivacaine 0.2%) Pruritus: Two studies found less pruritus without opioids Clinician intervention: no difference, reported in ve studies

Automated intermittent mandatory boluses vs continuous infusion

Intermittent vs. continuous administration of epidural ropivacaine with fentanyl for analgesia during labour. Fettes et al. Br J Anaes 2006 97(3): 359-64

47 patients recruited

7 withdrawn

Intermittent n = 20

Continuous n = 20

Ropivacaine 0.2% with Fentanyl 2 mcg/ml 10ml boluses every hour given over 5 mins

Ropivacaine 0.2% with Fentanyl 2 mcg/ml infusion 10ml/h

No difference in maternal or foetal outcomes

Automated intermittent mandatory boluses vs continuous infusion

Continuous group required three times more epidural rescue boluses compared to Intermittent group Mean total drug dose higher in Continuous group Sensory spread similar Motor block similar Cardiovascular changes uncommon, no signicant differences; only one patient needed treatment for hypotension (in Continuous group)

Duration of analgesia indicated by the time to rst rescue bolus. Signicantly longer in the intermittent mandatory group