British Journal of Anaesthesia 1992; 68: 580-584
CONTINUOUS EXTRADURAL ANALGESIA: COMPARISON OF
MIDWIFE TOP-UPS, CONTINUOUS INFUSIONS AND PATIENT
CONTROLLED ADMINISTRATION
J. PURDIE, J. REID, J. THORBURN AND A. J. ASBURY
SUMMARY
We have compared three techniques used to
provide extradural analgesia during the first stage of
labour: 0.25% plain bupivacaine 10ml demand
top-ups delivered by the midwife; continuous
infusion of 0.125% plain bupivacaine Wmlh'1;
and patient-controlled extradural analgesia (PCEA)
delivering 3-mlboluses of 0.25%bupivacaine. Each
technique produced comparable analgesia achiev-
ing equivalent maternal satisfaction, with no dif-
ference in mode of delivery and no complications.
This regimen for PCEA proved a viable alternative
for continuous extradural analgesia and was popu-
lar with the mothers, midwives and anaesthetists.
KEY WORDS
Anaesthesia, extradural: patient-controlled. Anaesthesia:
obstetric. Anaesthetics, local: bupivacaine.
Continuous extradural analgesia is accepted as the
most effective method of providing good pain relief
in labour. In addition to conventional top-up
regimens, extradural analgesia may be provided by
continuous infusions; the advantages and disadvan-
tages of these two techniques are well recognized.
Several recent studies have demonstrated the
efficacy of patient-controlled extradural analgesia
(PCEA) in labour [1-3]. To achieve adequate
analgesia, top-ups are required more frequently, but
the timing of these is under the patient's own
control.
The aim of this study was to compare the analgesia
provided by three methods of continuous extradural
analgesia, including PCEA, in a labour suite where
midwife administration of top-ups of 0.25 % bupiv-
acaine has been practised routinely for many years.
PATIENTS AND METHODS
After hospital Ethics Committee approval and
informed consent, we studied 300 women requiring
extradural analgesia in labour. An extradural block
was established at L2-3 or L3-4 with 0.25%
bupivacaine 10 ml. When pain free contractions
were experienced, the extent of the sensory block
was assessed. Patients were then allocated randomly
to receive continuous analgesia by one of three
methods:
Midwife top-ups (MWT). Top-up injections of
0.25 % bupivacaine 3 ml initially followed, 5 min
later, by 7 ml, administered by the sister midwife.
This technique has been routine practice in our unit
for many years.
Infusion group. Continuous infusion of 0.125%
bupivacaine 10 ml h"1.
PCEA group. Graseby patient-controlled analgesia
pump from which they were allowed to demand an
hourly maximum of four 3-ml boluses with a 5-min
lockout interval.
The attending midwife monitored maternal heart
rate and systolic arterial pressure at 5-min intervals
after top-ups and thereafter every 30 min. The level
of T7 was marked by adhesive tape on the anterior
abdominal wall and the extent of the sensory loss was
assessed every 1 h, using ice. The anaesthetist was
informed if sensory loss extended above T7, and in
the case of the infusion group the rate was reduced or
stopped accordingly. If analgesia was inadequate,
the anaesthetist was called and supplementary extra-
dural injections, partial withdrawal of catheter in the
extradural space or resiting of the extradural catheter
were defined as anaesthetist interventions.
The obstetric management of each group was
uniform until full cervical dilatation was achieved.
Consequently, analysis of analgesia is confined
principally to the first stage of labour. Pain was
assessed as follows.
Quality of analgesia was assessed by the attending
midwife: 0 = no pain, pressure or tightening; 1 =
aware of tightening or pressure, but not painful; 2 =
slight pain or pressure, but not distressing; 3 =
distressing pain or pressure. These assessments were
performed at 1-h intervals. The number of record-
ings of each score was summed from all women in
J. PURDIE*, F.C.ANAES.; J . REID, F.C.ANAES. J J. THORBURN,
F.CANAES. ; Department of Anaesthesia, Queen Mother's Hospital,
Yorkhill, Glasgow G2 8SJ. A. J ASBURY, F.CANAES., PH.D.,
University Department of Anaesthesia, Western Infirmary,
Dumbarton Road, Glasgow G i l 6NT. Accepted for Pub-
lication: December 18, 1991.
* Present address: Department of Anaesthesia, Victoria
Infirmary, Langside, Glasgow.
PATIENT-CONTROLLED EXTRADURAL ANALGESIA 581
TABLE I. Patient characteristics (mean (range or SD)), type (No. (%)) and duration (mean (SD)) of labour, and mode of
delivery (No. (%)). MWT = Midwife top-up; PCEA = patient-controlled extradural analgesia; Infusion = continuous
infusion; SVD = spontaneous vertex delivery; LCFD = low cavity forcep delivery; MCFD = mid cavity forcep
delivery; KRFD = Kiellands rotation forcep delivery; Vent. = ventouse extraction delivery; MR/FD = manual rotation
plus forcep delivery ; EmL USCS, Ext. = emergency lotver uterine segment Caesarean section under extradural anaesthesia ;
EmL USCS, GA = emergency lower uterine segment Caesarean section under general anaesthesia
MWT PCEA Infusion P

Number 78 75 84
Age (yr) 25.07(16-37) 25.28(16-34) 25.83 (17^10) ns
Weight (kg) 68.66(13.59) 71.51 (13.36) 70.63 (14.76) ns
Height (m) 1.62(0.01) 1.62(0.05) 1.63(0.01) ns
Labour
Spontaneous 22(28.2%) 11(14.7%) 14(16.7%) ns
Induced 26(33.3%) 26(34.7%) 33(39.3%) ns
Accelerated 30(38.5%) 38(50.7%) 37(44%) ns
Duration of 2nd 96.98 (58.8) 94.15(50.90) 98.73(61.14) ns
stage (min) (n = 59) (n = 60) (n = 62)
Delivery
SVD 15(19.2) 24 (32) 25 (29.8)
LCFD 4' 4-j 2'
2
MCFD
KRFD
23
5 (57.7)
§[(46.7) 18
4 (46.4)
Vent.
MR/FD
13
0. sJ 14
1-
EmLUSCSJExt.
EmLUSCS.GA
12
5} (21.8) i } (21.3) " } (23-8)
Assisted breech 1 0 0

each study group to produce a total for each of the

four pain scores, which was then expressed as a
percentage of the total number of hourly assessments
for each technique studied.
Maternal satisfaction was assessed as a retro-
spective measurement of the degree of pain relief
experienced by the mother in the previous 1 h, thus
taking into account any painful periods occurring
during that time which would not necessarily be
present at the time of assessment of the quality of
analgesia. Satisfaction was scored as: 1 = satisfied;
2 = dissatisfied; 3 = very unhappy.
All women were interviewed within 24 h of
delivery by an anaesthetist who was unaware of the
technique used when pain relief was assessed again.
The woman was asked to complete a linear analogue
pain score representing her opinion of the overall
efficacy of her analgesia^and to assess her analgesia
as complete, good, acceptable or unacceptable for all,
most or some of the time during the first stage and
for delivery. The mode of delivery was also recorded.
Statistical analysis was carried out using Minitab
(Version 7) running on an Amstrad 1640 PC.
Analysis of variance, Kruskal-Wallis and chi square
tests were applied where appropriate. P < 0.05 was
considered significant. For clarity, a proportion of
the results are expressed as a percentage, but
statistical calculations were performed on actual
numbers.
RESULTS
Patient characteristics are shown in table I. There
were no significant differences between the three
groups. Only primigravidae are included in the
analyses (n = 237); there were insufficient numbers
of multiparous patients.
Extradural data
Table II shows the extradural data from each of
the three study groups. Mean duration of extradural
block was similar in each group. Women in the
infusion group received significantly greater doses of
bupivacaine, the mean dose administered being 144.2
(SD 70.6) mg—approximately 30% greater than the
mean dose administered in both the MWT and
PCEA groups. The greater mean dose of bupivacaine
resulted from a greater anaesthetist intervention rate
required to continue effective extradural analgesia.
The proportion of women requiring no or only one
anaesthetic intervention was 89.3 % in the PCEA
group, 86.7 % in the MWT group and 64.2 % in the
infusion group (P < 0.05). The total number of
anaesthetic interventions was 49 in the PCEA group
and 44 in the MWT group, compared with 120 in the
infusion group (P < 0.05). Some mothers required
several interventions.
Quality of analgesia
In the PCEA group, 21 women (28.4 %) were pain
free at all observations, compared with 26.2 % in the
infusion and 22.4% in the MWT groups (ns).
Twenty women in the PCEA group (27 %) recorded
distressing pain at one or more of the hourly
assessments (13 of whom experienced one or more
complication of rectal pressure, unilateral block or
missed segment). Similarly, in the infusion group 35
women (41.7%) recorded distressing pain at least
once (21 with the above complications), and in the
MWT group 26 women (34.2%) recorded dis-
tressing pain at least once (nine with the above
complications) (ns).
There was no statistically significant difference in
the cumulative scores of 3 (distressing pain or
pressure) among the three groups (table III).
However, of the total number of distressing pain
582 BRITISH JOURNAL OF ANAESTHESIA
TABLE II. Characteristics of extradural block: duration and dose (mean (so)), and linear analogue pain scores (median)

MWT PCEA Infusion P

Number 78 75 84
Extradural 369.1 (152.9) 383.5 (158.4) 384.5 (160.8) ns
duration (min)
Mean bupivacaine 110.24(57) 109.55(58.1) 144.18(70.6)
dose (mg)
Pain score (cm)
Before extradural 7.2 7.5 7.5 ns
After extradural 0.65 1 0.65 ns

TABLE III. Quality of analgesia, expressed as a percentage of all

ative satisfaction scores of 86.1% in the MWT,
hourly observations for each score in all techniques. 0 = No pain or 85 % in the PCEA and 87.2 % in the infusion groups
awareness of contractions; 1 = awareness of pressure or tightening; (table IV).
2 = slight pain or pressure; 3 >= distressing pain or pressure
Post-delivery questionnaire
MWT PCEA Infusion P In the MWT group, 44.9 % of women experienced
Cumulative complete pain relief throughout all or most of their
analgesia score (%) extradural, compared with 52 % in the PCEA group,
0 25.7 23.8 35 <0.01 and 54.4 % in the infusion group (ns). Extradural
1 35.7 39.5 30.4 <0.05 analgesia failed completely in four of the 237
2 28.7 25.2 20.7 <0.05
3 9.9 11.5 13.8 ns
primigravida—two women in each of the MWT and
Women scoring 3
PCEA groups. An additional 27 women experienced
34.2 27 41.7 ns
at least once (%)
unacceptable pain: 11.5% in the MWT group, 8%
in the PCEA and 14.8% in the infusion group (ns).
TABLE IV. Maternal satisfaction with analgesia provided, expressed Retrospective linear analogue pain score
as a percentage of all hourly observations for each score tn all There was no significant difference between
techniques. 1 = Satisfied; 2 = dissatisfied; 3 = very unhappy. No median linear analogue pain scores of analgesia
significant differences
throughout the duration of the extradural block
MWT PCEA Infusion (table II).
Cumulative maternal Analgesia for delivery
satisfaction score (%)
1 86 85 87.2
Complete or good analgesia throughout delivery
2 12 10 10.3 was experienced by 61.3% in the PCEA group,
3 1.8 5 2.6 54.8% in the infusion group and 38.5% in the
Women scoring 3 7.8 13.3 13.2 MWT group (P < 0.025). The proportion of women
at least once (%) experiencing unacceptable pain for some of the time
during their delivery was 2.8% in the infusion
group, 10% in the MWT group and 16.9% in the
episodes, significantly more were experienced by PCEA group (P < 0.5). No significant difference in
women in the MWT group in the absence of the mode of delivery was noted in the three groups.
complications (MWT 6.1 %, PCEA 4.3%, infusion
4.1% (P<0.01)). DISCUSSION
The greatest proportion of cumulative scores of 2
(mild contraction or pressure pain) (28.7 %) occurred Controversy persists over the association between
in the MWT group (P < 0.05). the degree of motor block and operative vaginal
The PCEA group experienced the greatest pro- deliveries. For this reason, despite the superior
portion of cumulative scores of 1 (painless tightening analgesia produced by 0.5% bupivacaine, 7-10 ml
or pressure) (39.5 %) (P < 0.05). demand top-ups of 0.25 % bupivacaine administered
The infusion group achieved the greatest pro- by midwives has been the routine regimen for
portion of cumulative scores of 0 (no sensation of continuous extradural analgesia in this Unit [4]. In
contraction or pressure) (35 %) (P < 0.01). 1987, Purdy, Currie and Owen concluded that
Combining analgesia scores 0 and 1 provided the 0.375 % bupivacaine administered regularly in doses
pain-free hourly recordings in each group: 61.4 % in of 0.5 mg kg"1 was the optimum solution for a top-
MWT, 63.3% in PCEA and 65.15% in the infusion up technique, abolishing severe pain in all women
group (ns). [5]. To be effective, regular top-up techniques result
inevitably in some women receiving interventions
Maternal satisfaction and bupivacaine when these are not required,
Fewer women in the MWT (7.8%) were "very resulting in a labour-intensive and potentially
unhappy" (grade 3) with their pain relief at some hazardous technique.
time during their extradural analgesia, compared In 1985 Li, Rees and Rosen concluded that
with 13.3% in the PCEA and 13.2% in the infusion 0.125% extradural bupivacaine delivered at an
groups (ns) (table IV). Similarly, there was no infusion rate of 10 ml h"1 offered the best compro-
statistically significant difference between the cumul- mise between significant prolongation of the block
PATIENT-CONTROLLED EXTRADURAL ANALGESIA
and patient safety [6]. In this study, 64.2% of
women in the infusion group required no or only one
anaesthetist-administered top-up, which is similar to
the 69% recorded in Li's study and 76% in the
study by Bogod, Rosen and Rees [7]. Both these
studies established the extradural block with 0.5 %
bupivacaine 10 ml and in the case of Bogod's
regimen, additional top-ups were also of 0.5%
bupivacaine, which may explain their lower in-
tervention rate. No infusion study using 0.125 % has
abolished severe pain in all women.
Recently, several authors have studied PCEA for
analgesia in labour and shown this technique to
provide a viable alternative for continuous extradural
analgesia [1-3]. Using 0.125% bupivacaine with
adrenaline 1 in 400000, Gambling and colleagues
showed that, in most subjects, the PCEA regimen
avoided the return of significant discomfort, but in
six of 30 women studied additional analgesia was
required [1]. PCEA dose requirements were reduced
compared with a previous study of plain 0.125%
bupivacaine with a background infusion [2]. Lysak,
Eisenach and Dobson concluded that the optimum
solution for PCEA was 0.125% bupivacaine with
fentanyl 1 ug ml"1 while the addition of adrenaline
increased motor block [3]. Although sensory block
extended above T6 in three of 46 women, no
complications were noted.
For the past 9 years, the routine midwife top-up
technique in this hospital has commenced with a
3-ml preliminary injection, and this volume was used
for the PCEA top-ups with a lockout period of 5 min
and a maximum hourly dose of 12 ml for safety. The
exact timing and frequency of the PCEA top-up
doses were controlled by the mother herself. Con-
fidence in PCEA was gained quickly and no problems
occurred with the Graseby PCEA pump. The
solution was prepared simply without the hazards of
dilution and anaesthetist top-ups could be given
from the same syringe.
The need to deliver small 3-ml boluses and the
resulting 15 min to deliver a 12-ml dose may prolong
the painful episode. However, the high proportion of
hourly satisfaction scores (85 %) confirms its efficacy
as a top-up technique. Request for anaesthetic
intervention as soon as painful rectal pressure or
unilateral block develop should result in earlier
delivery of a larger volume or greater dose top-up, as
occurred in our infusion group and may improve
further PCEA.
As in the study by Lysak, Eisenach and Dobson
[3], block extension above T7 occurred in seven
mothers in the PCEA group without complication—
five were receiving anaesthetist intervention. Tran-
sient mild hypotension occurred in one women,
unrelated to top-ups, possibly because of venocaval
occlusion.
The pain of labour is related to the force and
frequency of uterine activity and is, initially at least,
intermittent. As labour progresses, pain becomes
more severe, longer lasting and more frequent. For
this reason, it was believed that hourly assessment of
pain might prove to be inadequate, as pain may occur
between assessments and be relieved by top-ups.
Hourly recordings of maternal satisfaction experi-
583
enced during the preceding 1 h, although more
subjective, would reflect the occurrence of any pain
experienced. It might, therefore, be a more accurate
measure of the pain occurring during what would, on
hourly assessments alone, appear to be a satisfactory
extradural block.
In this study, it would appear that direct hourly
analgesic assessments are a more sensitive index of
extradural efficacy than retrospective analysis,
whether performed during labour or at post-partum
interview later, despite the fears that painful periods
may not coincide with the time of the assessment.
Distressing pain, if of brief duration, does not appear
to affect adversely the woman's assessment of the
efficacy of extradural analgesia.
Despite the difference in delivery technique,
surprisingly comparable analgesia was produced by
the three regimens, achieving equivalent maternal
satisfaction with no significant difference in the
mode of delivery and no complications. While
persistent distressing pain clearly reduces maternal
satisfaction, experiencing slight pain was considered
satisfactory analgesia by some women. Extradural
infusions produced more intense analgesia and the
PCEA technique was characterized by analgesia
associated frequently with sensation of tightening or
pressure. Some mothers were deliberately sparing
with their top-ups, content to feel a degree of
discomfort over which they knew they had
control—an aspect they found particularly satisfying.
In the MWT group, slight pain occurred more
frequently.
It is clear from this study that, irrespective of the
method of providing continuous extradural anal-
gesia, a significant proportion of women experience
episodes of distressing pain during an initially
effective extradural block. Pain arises from several
sources: regression of the block, a block of sufficient
spread but insufficient intensity, or complications
such as rectal pressure, unilateral block or missed
segment. Failure to identify the cause of the pain
allows it to persist. Some causes may be treated
successfully by manipulation of the delivery tech-
nique, for example posture and block regression,
while rectal pressure or unilateral block require
immediate attention from the anaesthetist to ensure
early elimination. The overall responsibility for
ensuring effective analgesia is provided rests with the
anaesthetist, but is dependent on continuous as-
sessment of the woman's analgesia by the attending
midwife.
This study has shown that PCEA was an effective
and safe alternative for continuous extradural an-
algesia and was popular with mothers, midwives and
anaesthetists. However, careful monitoring of the
upper level of the block was required as, in seven
mothers in the PCEA group, the block height was
above T7.
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ventional intermittent "top-up" injections during labour.
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2. Gambling DR, Yu P, Cole C, McMorland GH, Palmer L. A
584
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