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EVALUATION AND COMPARISION OF LABOUR ANALGESIA USING ROPIVACAINE 0.2% IN COMBINATION WITH FENTANYL 2g/ml AND BUPIVACAINE 0.

1% IN COMBINATION WITH FENTANYL 2g/ml USING PATIENT CONTROLLED EPIDURAL Saba Ahad , B.N.Seth , S. Dam , V. Kalla , Prabhakar Amar Kumar ANALGESIA (PCEA) TECHNIQUE
Department Of Anaesthesiology , Sant Parmanand Hospital , New Delhi , India

Introduction
P value = 0.565 Epidural and spinal analgesia are the most effective methods of intrapartum pain relief in current practice Effective epidural analgesia has been found to reduce maternal plasma concentrations of catecholamines which results in improved utero-placental perfusion and more effective uterine activity. PCEA (patient controlled Epidural Analgesia) for labour has been proved safer and effective and is replacing CEI (Continuous Epidural infusion). Ideal local anaesthetic would provide a rapid onset of effective analgesia with minimal motor blockade, minimal risk of maternal toxicity and negligible effect on uterine activity and utero-placental perfusion. Bupivacaine and Ropivacaine are both amide local anaesthetic with similarity in structure, potency and Pharmacodynamics. An association between the use of epidural bupivacaine during labour and fetal heart rate decelerations has been reported. Ropivacaine is less cardiodepressant and arrythmogenic and blocks fewer motor fibres than bupivacaine. By combining an opioid with less concentrated solution of local anaesthetic, adequate analgesia can be provided throughout labour, with less motor block, nausea and pruritis with no neonatal depression. P value = 0.026 P value 0.05 is significant Level of Sensory Block Fig 4 : Duration of Labor
no. of patients

Fig 3 : Level of Sensory Block P value 0.05 is significant

Objectives
To evaluate and compare effects of epidural ropivacaine 0.2% and bupivacaine 0.1% in combination with fentanyl 2g/ml using patient controlled epidural analgesia technique with regards to : Quality and duration of analgesia Degree of motor block Mode of delivery and duration of labour Perinatal outcome Maternal satisfaction

Materials and Methods


Ethics committee approval Written Informed consent Study Design - Randomized double blind study Sample size - 100 Primigravida , ASA I / II , 18 - 30 yrs age Exclusion criteria : ASA physical status 3 or more Age less then 18yrs or more than 30 yrs Parenteral analgesics administration before epidural injection Patients with local infection Bleeding disorders Multiple gestation Inability to understand how to use PCEA pump
no. of patients

P value = 0.481

Fig 5 : Mode Of Delivery P value 0.05 is significant ID - Instrumental delivery LSCS - Lower section Caesarean section NVD - Normal vaginal Delivery

Mode of delivery
Volume of drug used

Group I 50 primigravida with established labour and with cervical dilatation of 3-5 cm Epidural ropivacaine 0.2% in combination with fentanyl 2g/ml Group II 50 primigravida with established labour and with cervical dilatation of 3-5 cm Epidural bupivacaine 0.1% in combination with fentanyl 2g/ml Technique of Epidural Block : Left lateral position , thighs flexed up and neck flexed forwards Back examined for any abnormality Under aseptic conditions and local anaesthesia , 16 guage Tuohy needle inserted inepidural space with 16 guage epidural catheter passed through the lumen of tuohy needle leaving approximately 3 cm of the catheter inside the epidural space. Monitoring : Baseline parameters of parturient were noted before and after the procedure viz heart rate, non invasive blood pressure, oxygen saturation, Fetal heart rate using cardiotocography Pain assessment : By Visual Analouge Scale 0 being no pain and 10 defined as worst pain Assessed at 2 min interval for first 10 min, 5 min interval until 30 mins, every 15 min till 2 hrs and every 2 hrs till delivery. Sensory assessment : By pin prick at bilateral midclavicular line after 30 mins of bolus dose Motor assessment : By MBS (Modified Bromage Scale) From 0 to 3 Assessedafter 30 mins of bolus dose Side effects : Nausea, pruritis and Respiratory depression Assessed at 5 mins, 60 min, and 2 hrly intervals. Fetal outcome : By Apgar score Assessed at 0, 5 and 10 mins No. of cases Maternal satisfaction : Noted at the end of the delivery Graded as excellent, fair, satisfactory or unsatisfactory. Total volume of the test drug solution : During the whole duration of labour analgesia Self administered top up doses included

P value = 0.085 Fig 6 : Total Volume of Drug Distribution P value 0.05 is significant

Statistical Values P value at 30 min= 0.045 Fig 7 : Fetal Heart Rate (FHR) Variation P value 0.05 is significant

Mean FHR

Time interval

P value = 0.241 Fig 8 : APGAR Score Distribution P value 0.05 is significant

APGAR Score

Results
Demographic profile : Table 1.

Fig 9 : Mother Satisfaction

Group 1 Age(Yrs) Wt(Kg) Height(cm) 26.742.59 69.18.897

Group 2 26.42.416 67.49.934

P value
Group 1 : Epidural ropivacaine 0.2% in combination with fentanyl 2g/ml

P value = 0.594 P value 0.05 is significant

0.370 0.084

157.644.91 159.55.926 0.910

Group 2 : Epidural bupivacaine 0.1% in combination with fentanyl 2g/ml P value 0.05 is significant

Gestational age (wks) 38.982.025 39.72.092


Visual Analogue Scale

P value for all time intervals for both groups > 0.05

Discussion
Fig 1 : Visual Analogue Scale distribution (VAS) P value 0.05 is significant Both bupivacaine and ropivacaine provide effective labour analgesia with little or no difference in maternal satisfaction, mode of delivery, or other labour characteristics. Ropivacaine seems to cause less motor block, particularly in long labours, but this finding may be attributable to differences in drug potency between drugs. Although the use of ropivacaine resulted in an increase in the duration of the first stage of labour in parturient who delivered vaginally, there were no differences in other outcomes. Time interval It is possible that ropivacaine is less cardiotoxic than bupivacaine when high dose are used, but this is clinically unimportant in the usual dose range used for labour analgesia.

Conclusion
P value = 0.196
no. of patients

From a clinical and safety perspective, either drug is a reasonable choice for labour analgesia. Fig 2 : Modified Bromage Scale (MBS). P value 0.05 is significant

References
1. Howell CJ, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anesth 1992 Jan;1(2):93-110. 2. Shnider SM, Abboud TK, Artal R, HHenriksen EH, Stefani SJ, Levinson G. Maternal catecholamines decrease during labor after lumbar epidural anesthesia. Am J ObstetGynecol 1983 Sep1;147(1):13-5 3. America Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for the obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007 Apr; 106(4):843-63. 4. Eisenach JC, Grice SC, Dewan DM. Epinephrine enhances analgesia produced by epidural bupivacaine during labor. Anesth Analg 1987 May;66(5):447-51