British Journal of Anaesthesia 1998; 81: 507510

Comparison of epidural bolus administration of 0.25% bupivacaine and

0.1% bupivacaine with 0.0002% fentanyl for analgesia during labour
K. S. JAMES, E. MCGRADY, I. QUASIM AND A. PATRICK

Summary
We have compared analgesia during labour provided by two epidural drug regimens, in a double-blind, randomized, controlled study. Group A
received 10-ml bolus doses of 0.1% bupivacaine
with fentanyl 2 g ml
1 while group B received
0.25% plain bupivacaine 10 ml. Analgesia provided by both techniques was similar, but
women in group A retained motor power in their
legs and 60% chose to get out of bed. Duration of
labour and time from insertion of the epidural to
delivery was similar in both groups, but in group
A, duration of the second stage was significantly
shorter (P0.0003; 95% confidence interval (CI)

1.17,
0.27 h) and the incidence of forceps delivery was lower (P0.032). Maternal satisfaction
with epidural analgesia, as assessed by VAS, was
higher in group A (P0.04; 95% CI
0.001, 10.001).
(Br. J. Anaesth. 1998; 81: 507510).
Keywords: analgesia, obstetric; analgesic techniques, epidural;
anaesthetics local, bupivacaine; analgesics opioid, fentanyl

Despite providing excellent pain relief during labour,

epidural analgesia using local anaesthetic agents
alone produces motor block in up to 85% of
patients,1 reduces maternal satisfaction with analgesia,2 and is associated with a prolonged second stage
and increased incidence of instrumental delivery.3
Epidural opioids offer the possibility of analgesia
without motor block but when used alone do not
provide satisfactory analgesia throughout labour.4 5
Adding an opioid to local anaesthetic solutions can
provide effective analgesia with bupivacaine sparing
and a reduction in motor block.2 68 However, most
investigators have used a high concentration of local
anaesthetic (usually 0.25% bupivacaine) to initiate
analgesia, or a larger test dose, for example 1.52%
lidocaine (lignocaine) or 0.5% bupivacaine, both of
which contribute to motor block.7 9 Similarly, the use
of epidural infusions may hinder maternal mobility.
Collis and colleagues pioneered the mobile
epidural using a combined spinalepidural technique. Analgesia is established with intrathecal bupivacaine 2.5 mg and fentanyl 25 g, and maintained
with epidural top-ups of 0.1% bupivacaine and fentanyl 0.0002%10 11; almost 50% of women are able to
get out of bed at some point during labour.10
However, problems associated with this technique
include technical failure, post-dural puncture
headache10 11 and chemical meningitis.12
The aim of this study was to compare, in a doubleblind, randomized study, a mobile epidural using 0.1%

bupivacaine and 0.0002% fentanyl with a conventional

epidural using 0.25% bupivacaine throughout labour.

Patients and methods

After obtaining approval from the Hospital Ethics
Committee and written informed consent, we studied 80 women requesting epidural analgesia in
labour. Women who had been given systemic opioids
within 4 h of epidural request were excluded, as were
those with cervical dilatation greater than 4 cm.
I.v. access was secured but no i.v. fluid load was
given. An epidural catheter was sited at the second
lumbar interspace using a standard midline technique with an 18-gauge Tuohy needle. The study was
double-blind, with randomization (computer-generated numbers) and preparation of the epidural drug
solutions performed by the hospital pharmacy.
Women were allocated randomly to one of two
groups. In group A, analgesia was established with 15
ml of 0.1% bupivacaine with fentanyl 50 g and
maintained, on maternal request, with bolus doses of
10 ml of 0.1% bupivacaine with fentanyl 2 g ml
1. In
group B, analgesia was established with 15 ml of
0.25% plain bupivacaine and maintained with 10-ml
bolus doses of 0.25% plain bupivacaine.
Analgesia was measured using visual analogue scores
(VAS) on a 100-mm line and a verbal scoring system
(0no pain or pressure, 1aware of contraction but not
painful, 2aware of pressure or tolerable discomfort,
3distressing pain or pressure). Measurements were
performed every 10 min until analgesia was established
(verbal score of 1), and at 30 min and 1 h after the initial dose. Thereafter, 2 hourly VAS were recorded until
delivery.
Motor power was assessed using a modified
Bromage score 30 min after each top-up and at each
request to get out of bed (score 0no weakness, able
to straight leg raise against resistance, 1not able to
straight leg raise, able to flex knee, 2unable to flex
knee, able to flex ankle, 3unable to move lower
limb). If the mother could straight leg raise against
resistance she was allowed to get out of bed. Mode of
delivery was recorded, as were time intervals between
top-ups, duration of first and second stages of labour,
and time from insertion of the epidural until delivery.
Maternal satisfaction with analgesia was assessed
using a VAS, 24 h after delivery.
K. S. JAMES*, FFARCSI, E. MCGRADY, FRCA, I. QUASIM, FFARCSI, A.
PATRICK, FRCA, Glasgow Royal Maternity Hospital, Glasgow.
Accepted for publication: May 25, 1998.
*Address for correspondence: Directorate of Anaesthesia and
Intensive Care, Glasgow Royal Infirmary, Glasgow G4 0SF.

508

British Journal of Anaesthesia

Statistical analysis was performed using Minitab

9.2. VAS pain scores for each patient were averaged
to give one value, allowing comparison of the overall
effect of the analgesic regimens throughout labour.
Averaging eliminated differences in the length of
labour. The calculation was time-weighted to eliminate bias resulting from shorter time intervals
between VAS scores initially as analgesia was being
established. A standard time interval of 1 h was used.
All VAS were multiplied by the fraction of a 1-h time
interval they covered (e.g. 30-min time intervals were
multiplied by 0.5 and 2 h intervals by 2.0). These
derived values were totalled and divided by the
length of labour. Results were analysed using a t test
for parametric data.
Duration of labour, second stage of labour, time
interval from insertion of the epidural until delivery,
time interval between top-ups and maternal satisfaction with analgesia were analysed using the
MannWhitney U test. Chi-square test was used to
compare mode of delivery between groups.
Visual analogue scores for pain during labour,
obtained using a standard technique of on-demand
bolus administration of 0.25% plain bupivacaine
(measured from other work) have a mean of approximately 20 mm (SD approximately 9 mm). We can
assume that if VAS were increased to 30 mm (50%
increase), this would be clinically important. To compare the two groups with a power of 0.9 to detect a
difference at a significance level of less than 0.05, the
sample size required was 35 patients in each group.
We studied 40 patients in each group to allow for
withdrawals from the study during labour.

section because of failure to progress in labour. Both

women in group B required fentanyl to relieve rectal
pressure. One subsequently had a Caesarean section
because of failure to progress and the other instrumental delivery after a long second stage.
For time to first painless contraction, data from all
women were used, but for mode of delivery, length of
labour and second stage, and time between top-ups,
only patients who completed the study were assessed
(35 women in group A, 38 in group B). Patient characteristics (age, height, weight, parity and cervical
dilatation when epidural was sited) were similar in
each group.
Times to first painless contraction (verbal score1)
were similar. After injection of the initial bolus, 10
women recorded painless contractions in group A
and 11 in group B by 10 min. By 20 min, another
14 patients in group A and 20 in group B were pain
free, and all women reported pain-free contractions
by 30 min.
Total VAS for pain throughout labour were similar
in both groups (P0.31; 95% confidence interval
(CI)
2.15, 6.63) (table 1). Although the time interval between top-ups was significantly shorter in
group A (P0.0001; 95% CI 10.00, 30.00), women
in this group received significantly less bupivacaine
(table 1).
In group A, 39 of 40 women were assessed as able
to get out of bed and 24 women got out of bed during
labour. In group B, eight of 40 women were thought
to be able to get out of bed and two got out of bed
during labour, but none in group B retained the ability to walk after the first top-up.
Although satisfaction scores for labour were high
in both groups, women in group A scored higher
(table 1).
The time interval between insertion of the epidural
and delivery was similar in both groups and although
women in group A had shorter labours, this was not
significant (table 2). Duration of the second stage
of labour was significantly shorter in group A
(P0.0003; 95% CI
1.17,
0.27) (table 2) and more
women in this group had spontaneous vertex delivery
(77% compared with 58%) (table 3). There were
fewer instrumental deliveries in group A (P0.03)
(table 3). Caesarean section rates were similar.

Results
Seven women (five in group A, two in group B) were
excluded from the study despite good analgesia initially. The threshold for removal was low (women
requesting more than two top-ups within 1 h). The
length of time in the study before withdrawal for the
five women in group A was 2 h 25 min to 7 h 30 min.
The two women in group B were withdrawn at 4 h
and 4 h 25 min. All five women in group A required
0.5% plain bupivacaine to provide adequate pain
relief and all subsequently delivered by Caesarean

Table 1 Pain scores (VAS) as weighted-average (mean, SD) (t test), time interval between top-ups, total bupivacaine administered during
labour, total fentanyl administered during labour and satisfaction with analgesia in labour (VAS) (median, interquartile range)
(MannWhitney U test) in groups A and B. P values and 95% confidence intervals (CI) are also given

VAS pain (mm)

Time between top-ups (min)
Total bupivacaine (mg)
Total fentanyl (g)
Satisfaction with analgesia VAS (mm)

Group A

Group B

95 % CI

20.52 (10.16)
90 (60117.5)
45 (3550)
110 (90120)
84 (75.7589.75)

18.29 (9.43)
110 (82.5140)
87.5 (62.5112.5)

0.31
0.0001
:0.001

(
2.15, 6.63)
(10.00, 30.00)
(
57.51,
22.50)

77.5 (72.088.0)

0.04

(
0.001, 10.001)

Table 2 Duration of labour, first stage and second stage, and time from insertion of the epidural to
delivery (h) (median, interquartile range) (MannWhitney U test)

Labour
1st stage
2 stage
Epidural to delivery

Group A

Group B

95% CI

7.33 (5.699.87)
6.58 (4.968.66)
0.78 (0.330.96)
5.25 (3.56.29)

8.35 (6.611.8)
7.17 (5.429.5)
1.5 (0.832.5)
6.2 (4.729.17)

0.17
0.4
0.0003
0.057

(
3.08, 0.50)
(0.07, 3.16)
(
1.17,
0.27)
(
2.733, 0.082)

Epidural bupivacaine compared with fentanyl for analgesia in labour

Table 3 Method of delivery (number of women) (chi-square
test). SVDSpontaneous vertex delivery

SVD
Instrumental
Caesarean section

Group A
(n35)

Group B
(n38)

27
2
6

22
9
7

0.08
0.03
0.89

Discussion
We have demonstrated that with an epidural topup technique using 0.1% bupivacaine with fentanyl
2 g ml
1, analgesia was similar to that using 0.25%
plain bupivacaine, but motor power was retained
allowing women to mobilize. There also appear to be
beneficial effects on the progress of labour, with a
clinically important reduction in the length of the
second stage and instrumental delivery rate.
With this technique, 39 of 40 women retained
adequate motor power to be judged able to walk
and 60% chose to get out of bed during labour.
Reduction in motor block allowing independent
movement and awareness of contractions without
pain has been shown to be popular with mothers.10
Retention of pelvic floor sensation and motor function may allow appropriate coordinated pushing during the second stage, improving rotation and descent
of the fetal head through the pelvis. Epidural local
anaesthetic may attenuate endogenous oxytocin
production reducing uterine contractility during the
second stage.13 14 The significantly lower dose of
bupivacaine required by women in group A may
allow better uterine function and explain the shorter
second stage of labour and reduced instrumental
delivery rates observed in this study. These are
important clinical findings because both a long second stage and instrumental delivery have associated
morbidity for the mother,1517 pose a controversial
potential risk to the baby1820 and negatively influence
maternal satisfaction with the experience of labour.21
Although epidural analgesia produces excellent analgesia, this does not automatically produce maternal
satisfaction with labour, and less effective methods of
analgesia have produced higher satisfaction scores.21
We demonstrated high maternal satisfaction with
both epidural solutions, which was significantly
greater in the bupivacainefentanyl group.
Analgesia was established (verbal score1) by 30
min in all women. Establishing analgesia with an
epidural bolus is effective but takes longer than a
combined spinalepidural technique, which has been
described widely.10 However, it avoids the complications of deliberate dural puncture.11 The time difference between establishing spinal rather than epidural
analgesia should be viewed in the context of the
duration of labour and the potential complications of
the spinal component of a combined technique.
Comparing the two epidural solutions, we showed
that the duration of analgesia provided by each topup was significantly shorter in group A than in group
B (table 1). This influences the management of the
epidural with more frequent top-ups and care in recognizing block regression to avoid loss of analgesia.
However, the benefits of this solution are evident and

509

PCEA or continuous infusion may prevent this

potential problem.
In summary, we have shown that establishing
epidural analgesia in labour with 15 ml of 0.1% bupivacaine combined with fentanyl 50 g, followed by
top-ups of 10 ml of 0.1% bupivacaine with 0.0002%
fentanyl, produced similar analgesia to that obtained
from the same volume of 0.25% bupivacaine alone,
but motor block was minimized. This may influence
the progress of labour, decreasing the duration of the
second stage and incidence of instrumental delivery,
and produce high maternal satisfaction with the
experience of labour.

Acknowledgement
We thank the Robertson Centre for Biostatistics, University of
Glasgow, for statistical advice.

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