Вы находитесь на странице: 1из 7

[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.

58]

Original Article

Epidural labor analgesia: A comparison of


ropivacaine 0.125% versus 0.2% with fentanyl
Yogesh Kumar Chhetty1,2,
ABSTRACT
Udita Naithani1, Sunanda Gupta1,3,
Vikram Bedi1, Ila Agrawal4, Background: Minimum effective concentration of local anesthetics for providing optimal labor
Lalatendu Swain1 epidural analgesia and the strategies aiming to reduce their consumption are continuously
1
Departments of Anesthesia, being searched.
R.N.T. Medical College, Objectives: The objective of this study was to evaluate the efficacy of 0.125% and 0.2%
2
Department of Anesthesiology ropivacaine both mixed with fentanyl 2 mcg/ml for epidural labor analgesia.
and Critical Care, Maa Gayatri Materials and Methods: A total of 80 parturients in active labor were randomly assigned to two
Hospital, 3Geetanjali Medical College, groups of 40 each, to receive an epidural injection of 15 ml ropivacaine 0.125% with fentanyl
4
Department of Obstetrics and (2 mcg/ml) in group R1 and 15 ml of ropivacaine 0.2% with fentanyl (2 mcg/ml) in group R2 as initial
Gynecology, R.N.T. Medical College, bolus dose. Same dose regimen was used as subsequent top-up dose on patients demand for
Udaipur, Rajasthan, India pain relief. The duration and quality of analgesia, motor block, top-up doses required consumption
of ropivacaine and fentanyl and feto-maternal outcome in both groups were compared.
Results: Effective labor analgesia with no motor blockade was observed in both groups with
no failure rate. Onset of analgesia was significantly faster in group R2 (75% parturients in 0-5
min) as compared to group R1 (25% parturients in 0-5 min), P < 0.001. Duration of analgesia
after initial bolus dose was also significantly longer in group R2 (132 ± 56.81 min) than in group
R1 (72.25 ± 40.26 min), P < 0.001. Mean VAS scores were significantly less in group R2 than
in group R1 at 5, 60, and 90 min, P < 0.01. Requirement of top-up doses was significantly less
in group R2 (0.05 ± 0.22) as compared to group R1 (0.80 ± 0.65), P < 0.001. Consumption of
ropivacaine was comparable in both the groups (33.75 ± 12.16 mg in group R1 and 31.50 ±
6.62 mg in group R2 P > 0.05), but consumption of fentanyl was significantly more in group R1
(54.00 ± 19.45) as compared to group R2 (31.50 ± 6.62), P < 0.001. There were no significant changes
in hemodynamics, nor adverse effects related to neonatal or maternal outcomes in both groups.
Conclusion: We conclude that both the concentrations of ropivacaine (0.2% and 0.125%) with
Address for correspondence: fentanyl are effective in producing epidural labor analgesia. However, 0.2% concentration was
Dr. Sunanda Gupta, “aahna”, 26, found superior in terms of faster onset, prolonged duration, lesser breakthrough pain requiring
Navratna Complex, Near Mahalaxmi lesser top-ups, and hence a lesser consumption of opioids.
Apartments, Near Bedla Road,
Udaipur 313001, Rajasthan, India. Key words: Epidural labor analgesia, labor analgesia, ropivacaine 0.2% versus 0.125%,
E-mail: sunandagupta@hotmail.com fentanyl

INTRODUCTION Evidence is suggestive that labor disorders including maternal


hypertension, dystocia, meconium staining, and fetal distress
are stress related.[1,2] Hence, maternal pain relief not only
T he pains of labor result in a maternal stress response,
which is neither beneficial for the fetus nor the mother.[1] benefits the parturient, but her neonate also.

Access this article online Maternal and fetal effects of analgesia during labor remain
Quick Response Code: central to discussions among patients, anesthesiologists, and an
Website:
www.joacc.com obstetrical caregivers[3,4] with the controversies[5,6] in obstetrical
anesthesia including the effects of regional anesthesia on the
progress and outcome of labor as well as effects on the neonate.[3,4]
DOI:
10.4103/2249-4472.114284
Of all the available methods of labor analgesia, epidural
analgesia satisfies the basic requirements of labor analgesia

16 Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]

Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia

by fulfilling the objective of decreasing the pains of labor analysis resulted in a calculated sample size of a minimum of
without affecting other sensations such as a desire to push and 28 subjects per group to obtain statistical significance assuming
to allow normal walking while preserving the tone of pelvic and α error of 0.05 and power of 0.9. The study was designed
floor muscles as well as retaining the sensation of the baby’s to provide 90% power to detect a decrease in success rate from
head in the vagina; thus, allowing labor to proceed unhindered. 90% to 70% with a one-tailed test at 5% significance level.
However, since a minimum of 30 subjects are required for a
Ropivacaine, an amide local anesthetic is less cardiotoxic in clinical study to be valid and to compensate for dropouts a
animals[7] as well as it may also be more selective for sensory sample size of 40 subjects per group was chosen.
fibers when compared to other local anesthetics, producing less
motor block.[8] This allows for increased maternal ambulation Study patients (n = 80) were randomly assigned to one of
and also allows for normal progression of labor, which translates two groups of 40 each, using a computer generated table of
into fewer instrumental deliveries and more vaginal deliveries[9] random number to receive epidural injection using either,
although this is controversial.[10] These factors suggest that 15 ml of ropivacaine 0.125% with 2 μg/ml fentanyl (group R1)
ropivacaine may be superior to bupivacaine in obstetric or 15 ml of ropivacaine 0.2% with 2 μg/ml fentanyl (group R2).
analgesia.
For group R1, 15 ml of 0.125% ropivacaine was prepared
Minimum local anesthetic concentration (MLAC) studies by taking 2.5 ml of 0.75% isobaric ropivacaine (Ropin®)
by up and down sequential allocation have found both 0.2% (Neon Laboratories Ltd. 140, Damji Samji Industrial Complex,
and 0.1% ropivacaine to be effective for labor analgesia.[11] Mahakali Caves Road, Andheri East, Mumbai, Maharashtra
OPRM A118G gene has been reported to be present in a higher 400093) and diluting it with 12.5 ml of 0.9% normal saline.
number of Asians as compared to their Western counterparts, For group R2, 15 ml of ropivacaine (0.2%) was taken directly
which pre-disposes the Asian populace to a higher degree from a 20 ml ampoule (Ropin®, Neon). 30 μg of fentanyl
of pain perception.[12] Studies are lacking from the Indian (Trofentyl®, Troikaa Laboratories Ltd.) were taken by using
subcontinent, which highlight the efficacy of 0.2% versus six parts from a tuberculin syringe graduated in markings to
0.125% ropivacaine for labor analgesia, which prompted us divide 1 ml (50 mcg/ml) into 10 parts and added to 15 ml of
to undertake this study. ropivacaine in both groups to achieve a final concentration of
fentanyl (2 mcg/ml).
The objective of this study was to evaluate 0.125% versus
0.2% ropivacaine, with 2 μg/ml of fentanyl in epidural Double blindness of the study was ensured by involving,
labor analgesia, regarding their sensory and motor block three different anesthesiologists for preparing the drugs,
characteristics as well as the fetomaternal outcomes. administering them and for recording the data.

MATERIALS AND METHODS Labor analgesia technique


After informed consent patients were subjected to a thorough
After approval of the Institutional Ethical Committee, this pre-anesthetic evaluation. Before placement of the epidural
prospective randomized double-blinded study was conducted catheter, VAS score was noted with VAS 0 = no pain and
at a teaching hospital in Rajasthan on 80 term parturients of 10 = the worst imaginable pain along with baseline vitals.
American Society of Anesthesiologists (ASA) grade I and II
having uncomplicated pregnancy in a vertex presentation. After starting a 500 ml infusion of Ringers’ lactate in an 18G
peripheral intravenous canula, parturients in both groups were
Patient selection placed in the left lateral position. Following strict aseptic
Parturients in active labor, having contractions at least once techniques, and infiltrating 2% lignocaine HCl into the
every 5 min, not having any contraindication to epidural intervertebral space, epidural space was identified at L3-4 or L4-5
analgesia, and who requested epidural analgesia for pain space using a loss of resistance technique to normal saline with
relief were enrolled in this study. Exclusion criteria included an 18G Tuohy needle and an 18-gauge multi-orifice catheter
hypersensitivity to study drugs, bleeding disorders, decreased was threaded through the cephalad directed tip of the epidural
platelet counts, sepsis, and a history of drug abuse; spinal needle to a depth of 5 cm into the epidural space. If there was
column deformities and spine surgery. no blood or cerebro spinal fluid (CSF) on aspiration from the
epidural catheter, depending on the group allocated, a 3-ml
Sample size and group allocation test dose of the study medication was administered through
Expecting ropivacaine (0.2% vs. 0.125%) + fentanyl 2 μg/ml to the catheter. The presence of clinical signs of an intravascular
decrease visual analog scale (VAS) scores to <3 values, a power injection were sought, for the following 2-3 min, by asking

Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1 17
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]

Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia

the patient whether she felt dizzy, had tinnitus, or a metallic duration from injection of first initial epidural bolus dose to
taste in her mouth. If there were no signs of an intravascular attainment of VAS <3 and duration of analgesia of initial bolus
injection, the catheter was secured and the woman was placed dose was defined as time of administration of study drug until
in the supine position with left uterine displacement. Five the time of demand of top-up for the first time.
minutes after the test dose, if there were no clinical signs of
subarachnoid injection (as evidenced by the patient’s ability to Motor block assessment was carried out by BMBS, [1-6]
move her legs and the absence of hypotension), an additional Romberg’s sign, straight leg raising test, rectus abdominalis
12 ml of the study solution was administered. This dose was muscle test, and trial walk.
defined as first initial bolus dose and time was noted. On
intravascular placement of the catheter, it was removed and The time taken by the parturient to request for subsequent
resisted at another interspace while all patients with intradural top-up dose was recorded. Labor was managed according to our
placement of catheter were removed from the study. The obstetric department’s protocols and mode of delivery (normal/
adequacy of analgesia was assessed 5 min after the first initial instrumental delivery/caesarean delivery) was noted. Injection
bolus dose of study drug had been administered. Analgesia was delivery interval was defined as the time from administration of
considered adequate if pain score was <3. Onset of analgesia first initial epidural dose until the delivery. Fetal heart rate was
was defined as from time of first bolus dose to time of achieving monitored throughout the study by using a cardiotocograph,
VAS <3. If analgesia was not adequate 15 min after the first and any evidence of fetal heart rate decelerations was recorded.
initial dose, an additional 15 ml of study medication (second Neonatal assessment was performed by assessing the Apgar
initial dose) was administered, and analgesia reassessed in the score at 1 and 5 min.
same manner. If pain relief was inadequate at the peak of a
contraction, 15 min after the second initial dose of ropivacaine; Quality of maternal expulsive efforts was assessed by
the epidural anesthetic was classified as ropivacaine failure, an obstetrician as Grade 0 – Failure, 1 –Incomplete, 2 –
and patient withdrawn from the study. Presence of motor block Good, 3 – Excellent. Quality of analgesia was assessed
in the lower extremities was assessed using a Breen modified by an esthesiologist as Grade 0 – Failure, 1 – Incomplete,
Bromage scale (BMBS: Grade 1 as complete motor block to 2 – Good, 3 – Excellent, 4 – Not possible to evaluate (NPE) if
Grade 6 as no motor block). VAS and BMBS was assessed delivered by cesarean section. Side-effects including nausea,
every 15 min. All parturients were given a trial walk to assess vomiting, hypotension, hypersensitive reaction, shivering,
fever, drowsiness, pruritus, respiratory depression, retention
their ability to ambulate. An additional dose of ropivacaine
of urine, and weakness in limbs were noted.
15 ml was given as a top-up dose on patient request, with
a minimum gap of 15 min between two subsequent top-up
Statistical analysis
doses. Epidural analgesia was continued through the second
For categorical variables (presented as number [proportions]),
stage of labor.
the proportions of variances in the two groups were compared
using the Chi-squared test with calculation of the 2 statistic
At any point of time during the study period hypotension
value and P value. For quantitative variables (data presented
was defined as systolic blood pressure of <90 mmHg and
as mean ± standard deviation [SD] measurements), the groups
was treated with bolus of 6 mg ephedrine HCl. Bradycardia
were compared using Student’s t-test for independent samples.
was defined as heart rate <60 bpm and was treated with bolus
For all statistical analyses, the level of significance was
doses of 0.4 mg atropine sulfate.
P < 0.05 and the software used was Microsoft Excel 2007
Data recording and Statistical Package for the Social Sciences (SPSS) (IBM
Demographic data (age, weight, height), obstetric data Business analytics software) version 20.0.0.
(parity, dilatation of the cervix [0-10 cm], station of the vertex
of the presenting part [−3 to +3], effacement of the cervix (%),
RESULTS
membrane status) were noted prior to the initiation of labor
analgesia. Demographic data, obstetric data, and injection delivery interval
were comparable in both groups, P > 0.05 [Table 1]. Before
Pain score (VAS), sensory and motor block characteristics and initiation of analgesia mean VAS score was 9.80 ± 0.61 in
vital parameters (pulse, mean arterial pressure, respiratory group R1 and 9.90 ± 0.50 in group R2 (P > 0.05). Both the
rate) were recorded at 0 (before epidural), 5, 15 min and then concentrations of ropivacaine (0.125% in group R1 and 0.2%
every 15 min till 1 h and then every 30 min until the delivery. in group R2) produced effective analgesia (defined by VAS <3)
Sensory block height was assessed by loss of sensation to pin after single initial bolus dose in parturients of both the groups,
prick (blunt head of a pin). Onset of analgesia was defined as stating no failure rate.

18 Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]

Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia

After epidural injection majority of parturients (75%) achieved each group and was found to be significantly more in group R2
VAS <3 significantly earlier in group R2 (0-5 min), than in (132 ± 56.81 min) than in group R1 (72.25 ± 40.26 min)
group R1 (5-15 min), signifying onset of analgesia to be (P < 0.001). In group R2 only 2 (5%) patients required a single
significantly faster in group R2 as compared to group R1, top-up dose and 38 (95%) patients had adequate analgesia until
P < 0.001. After 5 min of epidural bolus injection, VAS score the delivery after initial bolus dose, whereas in group R1 only
was significantly less in group R2 (1.63 ± 2.89) than in group 13 (32.5%) parturients could achieve effective analgesia until
R1 (5.00 ± 2.89) P < 0.001. All the parturients in both the the delivery after initial bolus dose, 22 (55%) required a single
groups attained a sensory blockade level of T10 and none top-up dose and 5 (12.5) required two top-ups (P < 0.001).
of the patients in both the groups showed a sensory block Overall significantly higher number of parturients in group R1
higher than T10. Duration of analgesia of initial bolus dose, (n = 27, 67.5%) required one or more top-up doses (P < 0.001).
defined as the time until parturient requests for additional first top-up dose was required significantly earlier in group R1
analgesia (first top-up), was calculated for all 40 patients in (58.15 ± 22.65 min) than in group R2 (131.30 ± 57.11 min),
P < 0.001. Mean number of top-up doses for each patient was
significantly higher in group R1 (0.80 ± 0.65) than in group R2
Table 1: Demographic and obstetric data
(0.05 ± 0.22), P < 0.001. Total dose of ropivacaine consumed
Variable Group R1 Group R2 P value
(n=40) (%) (n=40) (%) in both groups was comparable (P > 0.05), but total dose of
Age (years) 24.13±3.46 24.15±2.76 NS fentanyl was significantly higher in group R1 (54.00 ± 19.45
Weight (kg) 54.90±5.82 55.50±5.67 NS mcg) than in group R2 (31.50 ± 6.62 mcg) P < 0.001 [Table 2].
Height (ft. in) 5.08±0.45 5.05±0.53 NS
Parity VAS scores were significantly lower in group R2 than in group
Multiparous 18 (45) 19 (47.5) NS R1 at 5 min, 60 min and 90 min of the study period, P < 0.001
Primi 22 (55) 21 (52.5) NS
[Figure 1]. Motor block characteristics in both groups were
Obstetric data
Dilation of cervix (cm) 3.43±0.64 3.33±0.73 NS
comparable. All parturients had negative Romberg’s sign and
Station of vertex 2.05±1.06 2.20±0.82 NS straight leg raising test with a positive trial walk and a BMBS of 6
Effacement of cervix (%) 85±14 86±13 NS significantly no motor blockade at all-time intervals of the study.
Presence of membrane
Absent 2 (5) 7 (17.50) NS Haemodynamic status of parturients in both groups was
Present 38 (95) 33 (82.50) NS comparable. None of the patients in any group required either
P>0.05 (NS: Not significant)
ephedrine or atropine [Table 3].

Table 2: Dose requirement, onset and block characteristics


Parameter Group R1 Group R2 P value
VAS score (mean±SD)
Before bolus dose 9.80±0.61 9.90±0.50 P>0.05 (NS)
5 min after bolus dose 5.00±2.89 1.63±2.89 P<0.001 (HS)
15 min after bolus dose 0.55±1.97 0.00±0.00
30 min after bolus dose 0.30±1.32 0.00±0.00
Patient distribution according to time of onset$
0-5 min (%) 8 (20) 30 (75) <0.001 (HS)
>5-15 min (%) 30 (75) 10 (25) <0.001 (HS)
>15-30 min (%) 2 (5) 0 <0.001 (HS)
Patient distribution according to doses required
Bolus dose only (%) 13 (32.5) 38 (95) <0.001 (HS)
Bolus dose+1 top-up (%) 22 (55) 2 (5) <0.001 (HS)
Bolus dose+2 top-up (%) 5 (12.5) 0 <0.001 (HS)
Duration of analgesia of bolus dose (min) 72.25±40.26 (n=40) 132.05±56.81 (n=40) <0.001 (HS)
Mean time to first top-up (min) 58.15±22.65 (n=27)× 131.30±57.11 (n=2)× <0.001 (HS)
Mean time to second top-up (min) 76.77±48.50 (n=5)×× NA
Mean number of top-up doses for each patient 0.80±0.65 0.05±0.22 <0.001 (HS)
Total dose of ropivacaine (mg) 33.75±12.16 31.50±6.62 >0.05 (NS)
Total dose of fentanyl (μg) 54.00±19.45 31.50±6.62 <0.001 (HS)
$
Time of bolus dose to time to achieve VAS<3, ×Number of patients requiring first top-up, ××Number of patients requiring second top-up. NS: Not significant, HS: Highly
significant, NA: Not applicable, VAS: Visual analogue scale, SD: Standard deviation

Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1 19
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]

Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia

Table 3: Hemodynamic parameters


10
Hemodynamic data Group R1 Group R2 P value
9 (mean±SD) (mean±SD)
8 Group R2
Baseline MAP (mmHg) 85.48±8.74 86.60±7.72 P>0.05 (NS)
7 Group R1
Lowest MAP (mmHg) 72.00±8.34 74.33±7.70 P>0.05 (NS)
6
% fall of MAP from 15.06 14.16 P>0.05 (NS)
VAS

5 P<0.001
baseline
4
Baseline heart rate (bpm) 73.53±6.66 72.53±8.05 P>0.05 (NS)
3
P<0.01 P<0.001 Lowest heart rate (bpm) 69±7.60 67±7.42 P>0.05 (NS)
2
% fall of heart rate from 6.16 7.62 P>0.05 (NS)
1 baseline
0
P>0.05 (NS: Not significant), MAP: Mean arterial pressure, SD: Standard
0 Min 5 Min 15 Min 30 Min 45 Min 60 Min 90 Min
deviation
Time

Figure 1: Mean visual analog scale values at various time intervals Table 4: Maternal expulsive efforts assessed by
obstetrician and quality of analgesia (as assessed
Spontaneous vaginal delivery occurred in all (100%) parturients by parturient and anesthesiologist)
in group R1 and 95% (n = 38) in group R2. 1 (2.5%) parturient Maternal expulsive Group R1 Group R2
each had forceps and cesarean delivery in group R2, P > 0.05. efforts No. % No. %
Grade 0 – Failure 0 0 1 2.5
Obstetrician’s graded maternal expulsive efforts as excellent Grade 1 – Incomplete 0 0 0 0
in most of the parturients in both groups (P > 0.05). Grade 2 – Good 9 22.5 7 17.5
Grade 3 – Excellent 31 77.5 32 80
Parturients and anesthesiologists graded acceptance rate
Parturient’s acceptance
as either excellent or “good” in both groups. However,
Grade 0 – Failure - - - -
significantly higher number of cases (97.5%) reported Grade 1 – Incomplete - - - -
acceptance rate as excellent in group R2, by both parturients Grade 2 – Good 7 17.5 - -
and anesthesiologists (P < 0.001) [Table 4]. Grade 3 – Excellent 33 82.5 39 97.5*
Grade 4 – NPE - - 1 2.5
Neonatal outcome was favorable in both the groups Anesthesiologist’s grading
(Apgar scores >7 at 1 and 5 min) with no side-effects. Grade 0 – Failure - - - -
Grade 1 – Incomplete - - - -
Grade 2 – Good 5 12.5 - -
DISCUSSION Grade 3 – Excellent 35 87.5 39 97.5*
Grade 4 – NPE - - 1 2.5
The last few years have been marked by the arrival of new 2
=8.50, df=2, *P<0.01 (S). NPE: Not possible to evaluate because of cesarean
local anesthetics; ropivacaine and levobupivacaine, with section

reduced systemic toxicity and a better preservation of motor


function.[13] Toxicity is not an issue when low concentrations found that ropivacaine 0.2% offers adequate analgesia more
of local anesthetics are used as is the case in modern neuraxial often than either 0.15% or 0.1% and the resultant motor blocks
labor analgesia.[13] It seems evident that the adequate dilution and hemodynamic effects are minimal. Addition of fentanyl
of local anesthetics and the strategies aiming to reduce their 2 mcg/ml to 0.1% ropivacaine improved analgesia to a quality
consumption are more important than the choice of the local similar to 0.2% ropivacaine.[17]
anesthetic by itself when the goal is to provide optimal
neuraxial labor analgesia. In the present study, epidural labor analgesia with ropivacaine
0.125% or 0.2% both combined with fentanyl (2 mcg/ml)
There are controversial data regarding minimum effective produced adequate labor analgesia in all the 80 parturients in
concentration of ropivacaine for initiation of epidural labor both groups showing a 100% success rate of both concentrations.
analgesia. Using up and down sequential allocation MLAC
of ropivacaine for epidural labor analgesia was reported to be However, we observed that the onset of analgesia was significantly
0.111% w/v (95% confidence interval [CI], 0.100-0.112).[14] faster when labor analgesia was initiated with 0.2% ropivacaine
In another study MLAC of ropivacaine alone was 0.13% as reported earlier that a decrease in time for onset occurs
(95% CI, 0.12-0.13) compared to 0.09% (95% CI, 0.08-0.1) with increasing concentrations of epidural bupivacaine.[18,19] In
with sufentanil, P < 0.01.[15] On the other hand, many authors[16] contrast, no difference in the onset of analgesia with increasing

20 Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]

Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia

concentration of ropivacaine had also been reported.[20] Duration nulliparous parturients, whereas we studied both nullipara and
of analgesia of initial bolus dose was also significantly more with multipara parturients and a significant correlation between
0.2% ropivacaine in our study as observed by others.[21] Addition parity and duration of labor has been found in earlier studies.[32]
of adjuvant opioids leads to further increase in duration of
analgesia.[22] Time of first top-up was also significantly more In our study, maternal expulsive effort, instrumental delivery,
in 0.2% group, which is in concordance to other studies.[20,23] and neonatal status were comparable in both groups as
Requirement of top-up doses was also significantly less frequent observed by others.[17,30,33] Authors of the Cochrane systematic
in 0.2% group, but total dose of ropivacaine was comparable review (2011)[29] opined that epidural analgesia appeared to
in two groups (31.75 mg in group R2 and 33.75 mg in group be effective in reducing pain during labor. However, women
R1) because repeated top-ups of 0.125% ropivacaine resulted who used this form of pain relief were at increased risk of
in same total dose of ropivacaine. Nevertheless repeated having an instrumental delivery. Epidural analgesia had no
top-up doses had 2 mcg/ml fentanyl and led to consumption statistically significant impact on the risk of cesarean section,
of significantly higher amount of fentanyl in group R1 maternal satisfaction with pain relief and long-term backache
(54 mcg in group R1 vs. 31.50 mcg in group R2). The recent and did not appear to have an immediate effect on neonatal
trend in practitioners of labor analgesia is to use the least possible status as determined by Apgar scores. However, they also
concentration of local anesthetic and adjuvant for the purpose stated that further research would be helpful to evaluate rare
of attaining analgesia. The main undesirable side-effects with but potentially severe adverse effects of epidural analgesia on
ropivacaine analgesia are hypotension, bradycardia, nausea, women in labor and long-term neonatal outcomes. Our study
paresthesia, and urinary retention, which are considered mild was not designed with the objective of assessing the mode of
and transient. However, the side-effects observed with opioids delivery of the parturients participating in the study. Hence,
are multivariate (nausea, pruritus, respiratory depression, appropriately powered and designed studies may help in further
lower Apgar scores in the neonate). All of these undesirable researching this aspect of labor analgesia.
effects warrant a decrease in the dosage of epidural opioids that
are used for analgesia in the laboring patient. The amount of No parturient had hypotension, hypersensitivity reaction,
ropivacaine and fentanyl that were required to attain analgesia pruritus, nausea, urinary retention, vomiting, respiratory
in our study were comparatively high. This could be attributed depression, weakness in the limbs or shivering, though
to the differences in the techniques of administering analgesia: cases of pruritus,[26] hypotension,[30] have been reported with
Intermittent boluses versus infusion by patient controlled
epidural labor analgesia. Both concentrations produced
epidural analgesia (PCEA). Studies have demonstrated that
maternal expulsive efforts, parturient and anesthesiologist
PCEA labor analgesia consumes significantly lesser amount
acceptance grades in excellent or good range similar to Beilin
of the local anesthetic opioid mixture.[24,25] Interestingly, Tan
(92% satisfaction)[21] and Lee[17] who reported a satisfaction
et al. (2009),[12] in their study concluded that the A118G single
grade of 8 on a scale of 10 for all concentrations. However,
nucleotide polymorphism of the human mu opioid receptor
in our study parturient and anesthesiologist acceptance was
(OPRM) gene influences one’s requirement of additional
significantly superior in R2 group, which could be attributable
analgesia.
to less breakthrough pain that caused significantly less number
In the present study, no motor block was observed in both of top-up requirement and VAS also remained significantly low
groups, which is in concordance to others.[17,23,26] However, higher at various time intervals.
incidence of motor block in previous studies could be attributed
The limitations of this study could be a requirement of a
to higher concentrations of ropivacaine (0.25%, 0.275%,[27]
0.5%[28]). In a Cochrane systematic review of epidural versus larger sample size which would give a wider perspective on
no analgesic in labor that included 38 studies involving 9658 maternal and neonatal side-effects. Similarly, a comparison of
women; 13 of the studies reported hypotension as an adverse intermittent boluses versus a continuous infusion technique
effect.[29] We also observed slight fall in the MAP and heart would give a better estimation of local anesthetic and opioid
rate, but none of the patients had episodes of hypotension and consumption in both groups.
bradycardia requiring treatment as was also noted earlier[20,26]
that changes in maternal pulse rate (PR) and blood pressure are CONCLUSION
not related to change in the dose of local anesthetic.
In spite of the above limitations, we have arrived at the conclusion
Injection delivery interval was comparable in both groups, that both the concentrations are effective in producing labor
but it was shorter as compared to others.[20,30,31] The reason for analgesia. Group R2 (0.2% ropivacaine) parturients; however,
this difference is probably because other studies included only had a faster onset and significantly longer duration of analgesia

Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1 21
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]

Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia

with a single dose and required lesser top-ups, resulting in a 16. Dresner M, Freeman J, Calow C, Quinn A, Bamber J. Ropivacaine 0.2%
versus bupivacaine 0.1% with fentanyl: A double blind comparison for
significantly reduced consumption of opioids. Hence, our study
analgesia during labour. Br J Anaesth 2000;85:826-9.
favors, the use of 15 ml of 0.2% ropivacaine with 2 mcg/ml 17. Lee BB, Ngan Kee WD, Lau WM, Wong AS. Epidural infusions for labor
fentanyl over 0.125% ropivacaine for labor analgesia. analgesia: A comparison of 0.2% ropivacaine, 0.1% ropivacaine, and 0.1%
ropivacaine with fentanyl. Reg Anesth Pain Med 2002;27:31-6.
It would be further interesting to evaluate the effect of varying 18. Handley G, Perkins G. The addition of pethidine to epidural bupivacaine
in labour – Effect of changing bupivacaine strength. Anaesth Intensive
the dose of administered drugs according to the stages and Care 1992;20:151-5.
intensity of labor, which could further regulate the requirement 19. Duggan J, Bowler GM, McClure JH, Wildsmith JA. Extradural block
of drugs and provide more effective analgesia. with bupivacaine: Influence of dose, volume, concentration and patient
characteristics. Br J Anaesth 1988;61:324-31.

REFERENCES 20. Lee BB, Ngan Kee WD, Wong EL, Liu JY. Dose-response study of epidural
ropivacaine for labor analgesia. Anesthesiology 2001;94:767-72.
21. Beilin Y, Galea M, Zahn J, Bodian CA. Epidural ropivacaine for the
1. Shnider SM, Abboud TK, Artal R, Henriksen EH, Stefani SJ, Levinson initiation of labor epidural analgesia: A dose finding study. Anesth
G. Maternal catecholamines decrease during labor after lumbar epidural Analg 1999;88:1340-5.
anesthesia. Am J Obstet Gynecol 1983;147:13-5. 22. Bang EC, Shin JH, Lee HS, Kang YI, Cho KS, Kim SY. The onset and
2. Pearson JF, Davies P. The effect of continuous lumbar epidural analgesia duration of 0.2% ropivacaine with a varying dose of fentanyl in epidural
upon fetal acid-base status during the first stage of labour. J Obstet labor analgesia. Anesth Pain Med 2010;5:249-54.
Gynaecol Br Commonw 1974;81:971-4. 23. Ngan Kee WD, Ng FF, Khaw KS, Lee A, Gin T. Determination and
3. Eltzschig HK, Lieberman ES, Camann WR. Regional anesthesia and comparison of graded dose-response curves for epidural bupivacaine and
analgesia for labor and delivery. N Engl J Med 2003;348:319-32. ropivacaine for analgesia in laboring nulliparous women. Anesthesiology
4. Kannan S, Jamison RN, Datta S. Maternal satisfaction and pain control in 2010;113:445-53.
women electing natural childbirth. Reg Anesth Pain Med 2001;26:468-72. 24. Boutros A, Blary S, Bronchard R, Bonnet F. Comparison of intermittent
5. Beilin Y, Leibowitz AB, Bernstein HH, Abramovitz SE. Controversies of epidural bolus, continuous epidural infusion and patient controlled-
labor epidural analgesia. Anesth Analg 1999;89:969-78. epidural analgesia during labor. Int J Obstet Anesth 1999;8:236-41.
6. Writer WD, Stienstra R, Eddleston JM, Gatt SP, Griffin R, Gutsche BB, 25. Collis RE, Plaat FS, Morgan BM. Comparison of midwife top-ups,
et al. Neonatal outcome and mode of delivery after epidural analgesia for continuous infusion and patient-controlled epidural analgesia for
labour with ropivacaine and bupivacaine: A prospective meta-analysis. maintaining mobility after a low-dose combined spinal-epidural. Br
Br J Anaesth 1998;81:713-7. J Anaesth 1999;82:233-6.
7. Nancarrow C, Rutten AJ, Runciman WB, Mather LE, Carapetis RJ, 26. Debon R, Allaouchiche B, Duflo F, Boselli E, Chassard D. The analgesic
McLean CF, et al. Myocardial and cerebral drug concentrations and effect of sufentanil combined with ropivacaine 0.2% for labor analgesia:
the mechanisms of death after fatal intravenous doses of lidocaine, A comparison of three sufentanil doses. Anesth Analg 2001;92:180-3.
bupivacaine, and ropivacaine in the sheep. Anesth Analg 1989;69:276-83. 27. Eddleston JM, Holland JJ, Griffin RP, Corbett A, Horsman EL, Reynolds F.
8. Zaric D, Nydahl PA, Philipson L, Samuelsson L, Heierson A, Axelsson A double-blind comparison of 0.25% ropivacaine and 0.25% bupivacaine
K. The effect of continuous lumbar epidural infusion of ropivacaine for extradural analgesia in labour. Br J Anaesth 1996;76:66-71.
(0.1%, 0.2%, and 0.3%) and 0.25% bupivacaine on sensory and motor 28. McCrae AF, Jozwiak H, McClure JH. Comparison of ropivacaine and
block in volunteers: A double-blind study. Reg Anesth 1996;21:14-25. bupivacaine in extradural analgesia for the relief of pain in labour. Br J
9. Comparative Obstetric Mobile Epidural Trial (COMET) Study Group Anaesth 1995;74:261-5.
UK. Effect of low-dose mobile versus traditional epidural techniques on 29. Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or
mode of delivery: A randomised controlled trial. Lancet 2001;358:19-23. no analgesia in labour. Cochrane Database Syst Rev 2011:CD000331.
10. Nageotte MP, Larson D, Rumney PJ, Sidhu M, Hollenbach K. Epidural 30. Bernard JM, Le Roux D, Frouin J. Ropivacaine and fentanyl concentrations
analgesia compared with combined spinal-epidural analgesia during in patient-controlled epidural analgesia during labor: A volume-range
labor in nulliparous women. N Engl J Med 1997;337:1715-9. study. Anesth Analg 2003;97:1800-7.
11. Aveline C, El Metaoua S, Masmoudi A, Boelle PY, Bonnet F. The effect 31. Lim Y, Ocampo CE, Supandji M, Teoh WH, Sia AT. A randomized
of clonidine on the minimum local analgesic concentration of epidural controlled trial of three patient-controlled epidural analgesia regimens
ropivacaine during labor. Anesth Analg 2002;95:735-40, table of contents. for labor. Anesth Analg 2008;107:1968-72.
12. Tan EC, Lim Y, Teo YY, Goh R, Law HY, Sia AT. Ethnic differences in 32. Ijaiya MA, Adesina KT, Raji HO, Aboyeji AP, Olatinwo AO, Adeniran
pain perception and patient-controlled analgesia usage for postoperative AS, et al. Duration of labor with spontaneous onset at the University of
pain. J Pain 2008;9:849-55. Ilorin Teaching Hospital, Ilorin, Nigeria. Ann Afr Med 2011;10:115-9.
13. Dewandre PY. The right drug and dose for neuraxial labour analgesia. 33. Lee HL, Lo LM, Chou CC, Chiang TY, Chuah EC. Timing of initiating
Acta Anaesthesiol Belg 2006;57:395-9. epidural analgesia and mode of delivery in nulliparas: A retrospective
14. Polley LS, Columb MO, Naughton NN, Wagner DS, van de Ven CJ. experience using ropivacaine. Chang Gung Med J 2008;31:395-401.
Relative analgesic potencies of ropivacaine and bupivacaine for epidural
analgesia in labor: Implications for therapeutic indexes. Anesthesiology
Conflict of Interest: Chhetty YK, Naithani U, Gupta S, Bedi V, Agrawal I,
1999;90:944-50.
Swain L. Epidural labor analgesia: A comparison of ropivacaine 0.125% versus
15. Palm S, Gertzen W, Ledowski T, Gleim M, Wulf H. Minimum local
0.2% with fentanyl. J Obstet Anaesth Crit Care 2013;3:16-22.
analgesic dose of plain ropivacaine vs. ropivacaine combined with
Source of Support: Nil, Conflict of Interest: None declared.
sufentanil during epidural analgesia for labour. Anaesthesia 2001;56:526-9.

22 Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1