Gambling D, Berkowitz J, Farrell TR et al. A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery. Anesthesia & Analgesia 1013; 116: 636-643.
RHH Journal Club. June 6th, 2013. Dr Vinayak Kumar
No free full-text available
Does a CSE technique provide superior analgesia for the first two stages of labour compared to a standard lumbar epidural?
- Randomised Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia during first and second stages of labour and at delivery.
- Single centre – Private Practice Setting- USA (2007-09)
- 802 patients. Combined Spinal-Epidural (CSE) – 402, Epidural Analgesia -400
- Included- patients who can speak English, ASA – I to III, uncomplicated term labour, patient request for neuraxial labour pain relief.
- Excluded-Inability to speak English, ASA≥IV, gestational age <37 weeks, malpresentation , previous LSCS, multiple gestations, BMI >40kg/m2.
- Epidural vs CSE for labour analgesia
- Pain scores during first and second stages of labour and at delivery
– Epidural group -10 mL 0.125% bupivacaine with fentanyl 2 μg/mL in 2 equal divided doses via the epidural needle, followed by 5 mL through the catheter.
– CSE group – 2.5 mL of the same solution via the spinal needle before epidural catheter placement.
- Primary outcome- Assessment of pain, using a verbal rating pain scale (VRPS) of scores from 0 to 10, made at the end of the first stage of labour and shortly after delivery.
- Secondary outcome- PCEA use, number of epidural top-up doses, epidural catheter replacements, side effects, patient satisfaction and labour outcomes.
- Patients were randomised and randomisation was concealed
- Patients analysed in the similar groups to which they were randomised
- Patients and outcome assessors were blinded
- CSE group reported better analgesia during the first stage of labour -VRPS score (1.4 vs. 1.9; P < 0.001).
- Time to complete analgesia – shorter in the CSE group (21.9 vs.10.8mins:P<0.001)
- Pain scores during the second stage of labour (1.7 vs. 1.9; P = 0.17 and at delivery 2.0 vs. 2.0; P = 0.77) were not different between groups.
- Hourly pain scores were similar between groups with the exception of first hour in which better analgesia was observed in the CSE.
- No difference in secondary outcomes except the incidence of epidural top-up boluses -significantly less in the CSE group.
- The differences in pain scores demonstrated in this study are not clinically significant, even if they achieved statistically significant differences.
- NAP 3- CSE: <6% of CNB but reports of harm >13%. In Obstetrics-Harm/death-Epidural-1:166,667(opti/pessimistic) is safer than CSE (1:26,641-pessimistic, 0-optimistic))