oleh : Nor Fatehah bt Hamdan 030.08.

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Labour pain is excruciating and a significant contributor of stress and anxiety

Painful uterine contractions cause maternal hyperventilation and increased cathecholamine concentration resulting in maternal and foetal hypoxemia

Combined spinal epidural (CSE) analgesia is increasingly used to provide pain relief during labour

Dose adjustments and frequency of administration of the drug according to parturient;s requirementis satisfaction

It combines the advantage of rapid onset of spinal analgesia and the flexibility of the epidural catheter

 Demographic data were analysed using analysis of variance Unpaired t-test and chi-square tests were used where

appropriate Sample size of 60 with 30 parturients in each group was determined with power of study of 80% Data were expressed as mean SD. Standard tests of significance were applied to determine the P value P < 0.05 was considered significant

Addition of opioids to local anaesthetics reduces its requirement by synergistic effect of opioids receptors in the spinal cord

This reduces the chances of motor blockade and the hemodynamic perturbation

Studies comparing CSE technique employing sufentanil and fentanyl are very few and give conflicting results

Hence, we decided to compare the efficacy, quality and duration of analgesia and maternal and foetal effects of adding the two highly lipid-soluble opioids, sufentanil and fentanyl to low-concentration bupivacaine for CSE labour analgesia

 60 parturients 6 months

ASA grade I & II with singleton, term pregnancy in

spontaneous labour with cervical dilation of less than 4 cm, with normal foetal heart tracing requesting labour analgesia Excluded : medical disorders, obstetric complications, malpresentation of foetus, contraindication for regional analgesia

Parturients were administered with 1000 ml RL and monitor were connected

Patients placed in left lateral position, under aseptic precautions. CSE analgesia (L2-L3 or L3-L4 level)

Lumbar epidural space : 18G Touhy needle Spinal analgesia : 25G Whitacre needle (one space below)

Injected intrathecally The parturient turn supine immediately Group S : 0.5 ml 0.5% bupivacaine heavy (2.5mg) and 0.5 ml sufentanil (5 mcg) Group F : 0.5 ml 0.5% bupivacaine heavy (2.5 mg) and 0.5 ml fentanyl (25 mcg)

monitoring BP,HR,RR, SPO2 ( 0,5,15,30 min)

SE : pruritus, hypotension, motor blockade, shivering, sedation, bradycardia

Motor block and sensory blocked were recorded

Foetal heart rate (FHR) monitored

Assessing pain using VAS If VAS score 5 : administered eoidural topup

 APGAR scores at 1 and 5 min

Foetal
Monitored for 2 hrs following delivery and the epidural cathether was removed Questioned after 24hrs about the procedure and satisfaction

Parturient

Characteristics Mean age (years)

Groups S ( n=30 ) 23.46

Group F ( n= 30) 22.02

Mean weight (kg)

Mean height (cm) Primipara multipara

58.18
154.48 63.33 36.66

57.60
154.24 66.66 33.33

Mode of delivery FTND LSCS

Group S (n=30) 22 6

Group F (n=30) 22 5

Instrumental delivery

FTND : Full-term normal delivery LSCS : Lower segment caesarean section

Parameter Time of inset intrathecal analgesia (min) Duration of intrathecal analgesia (min) Mean duration between epidural top-ups (min)

Group S 2.48 (0.28) 109.70 (6.37) 90.51 (15.87)

Group F 2.55 (0.77) 73.63 (15.70) 83.54 (24.0)

VAS scores 0-1 1-4 4-7 7-10

Group S 28(93.33%) 2(6.66%) 0 0

Group F 27(90%) 3(10%) 0 0

Significance Not significant Not significant -

Side effects Pruritus Nausea and vomiting Bradycardia Hypotension Sedation

Group S 6 3 2 1 4

Group F 9 2 3 2 5

Highly lipid-soluble synthetic opioids such as sufentanil & fentanyl are being increasingly used along with very low concentration of local anaesthetics such as bupivacaine to provide excellent releif of pain during labour.

Addition of bupivacaine to intrathecal opioid prolongs duration of labour analgesia compared with either drug used alone

Duration of analgesia provided intrathecally: - sufentanil and bupivacaine was 109.706.37 min - Fentanyl and bupivacaine was 73.6315.76

10 mcg sufentanil : severe hypotension 2.5 mcg : produce analgesia of shorter duration and slower onset 5 mcg : moderate effect

CSE : produce immediate and predictable onset of analgesia enhancing the parturients cooperation

Higher concentration of bupivacaine (0.25%) : - Motor block causing pelvic musle relaxation Foetal malposition Maternal inability to push Higher incidence of instrumental delivery

VAS scoring were comparable between two groups

Use of sufentanil & fentanyl found to be safe among neonates

The incidence of side effect was comparable between two groups

Continuous infusion of dilute mixture of local anaesthethic and opioids produce stable analgesia and increased maternal hemodynamic stability

conclusion

CSE using sufentanil and fentanyl achieved high patient satisfaction and excellent labour analgesia without serious maternal and neonatal side-effects Sufentanil provided significantly longer duration of labour analgesia compared with fentanyl