Combined Spinal-Epidural Anesthesia Bests Epidural Alone


From the annual meeting of the Society for Obstetric Anesthesia and Perinatology

Major Finding: During the first stage of labor, mean verbal analog scale pain score was significantly less in the SE group compared with EA (1.36 vs. 1.89), but the difference was not significant by the end of the second stage.

Data Source: A randomized, controlled trial of 800 women.

Disclosures: Dr. Gambling said he had no financial disclosures to report.

SAN ANTONIO — Combined spinal-epidural anesthesia was superior to traditional epidural for first-stage anesthesia but there were no differences in second stage or in delivery pain in a randomized, controlled comparison of the two methods among 800 women.

The Epidural Analgesia and Spinal Epidural Analgesia (EASE) study also showed that concerns about epidurals failing with combined spinal-epidural (SE) because of the inability to provide a test dose are unfounded, Dr. David R. Gambling reported.

Previous studies comparing the techniques have had mixed results. A Cochrane review showed that CSE had less rescue analgesia and less urinary retention but more pruritis (Cochrane Database Syst. Rev. 2007 [doi:10.1002/14651858.CD003401.pub2]). Compared with low-dose epidural anesthesia (EA), combined SE had faster-onset analgesia, more pruritis, and lower umbilical cord artery pH, but there was no mention of progress of cervical dilation, noted Dr. Gambling of the Sharp Mary Birch Hospital for Women and Newborns and the University of California, San Diego.

In EASE, 398 women received EA, consisting of 10 mL 0.125% bupivacaine with 2 mcg/mL fentanyl in two 5-mL doses via epidural needle, followed by 5 mL of the same solution via epidural catheter (total dose 15 mL). The 402 in the SE group were given 2.5 mL 0.125% isobaric bupivacaine plus 2 mcg/mL fentanyl via 26-g GM spinal needle prior to epidural catheter placement.

In both groups, medications were administered at first request for neuraxial anesthesia. Labor was managed by registered nurses and obstetricians who were blinded to group assignment.

There were no significant differences between the groups in age, height, weight, body mass index, estimated gestational age, cervical dilation at epidural insertion, or pre-epidural verbal analog scale (VAS) pain scores. However, the time to complete analgesia (from initial EA and SE injection until patient reported VAS scores of 0 or 1 was significantly less with the SE group, 11 vs. 22 minutes.

The second stage of labor was statistically significantly shorter with EA (68 vs. 78 minutes), but the difference may not be clinically significant. There were no significant differences in time from epidural induction until cervical dilation reached 10 cm, duration of pushing, or rate of cervical dilation. There were also no differences in the use of instrumentation with vaginal delivery or need for cesarean section.

During the first stage of labor, the mean VAS pain score was significantly less in the SE group. compared with EA (1.36 vs. 1.89) and also at 1 hour of labor (0.26 vs. 0.72), despite a slightly lower rate of patient-controlled analgesia use during the first stage (10 vs. 11 mL/hr). The proportion of women with mean VAS scores of zero at the end of stage 1 was significantly higher with SE (42% vs. 31% with EA), but the difference was not significant by the end of the second stage, he said.

Need for epidural top-up was greater in the EA group (26% vs. 16%), as was the need for more than one top-up (21% vs. 9%). Only a small proportion of each group (2% EA and 1.2% SE) required replacement of the epidural catheter, suggesting that there should not be concern about epidurals failing with SE because of inability to provide a test dose, he commented.

Fetal heart rate decelerations within 30 minutes of analgesic induction were more common in the SE group (8.5% vs. 4.5%), but none required emergency c-section. The proportions with Apgar scores below 7 at 1 and 5 minutes were less than 5% and less than 0.5%, respectively, in both groups.

Patient satisfaction with their mode of analgesia did not differ, at 98% for SE and 96% for EA, Dr. Gambling reported.

Patient satisfaction with their mode of analgesia did not differ between the two groups.


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