A Comparative Study of Intrathecal Ropivacaine with Fentanyl Versus Bupivacaine with Fentanyl for Labour Analgesia

Karthikeyan, K S (2006) A Comparative Study of Intrathecal Ropivacaine with Fentanyl Versus Bupivacaine with Fentanyl for Labour Analgesia. Masters thesis, Stanley Medical College, Chennai.

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Abstract

INTRODUCTION: Labor is an extremely painful process. Traditionally a number of techniques have been employed to provide labor analgesia. Epidural analgesia is considered to be the gold standard in labor analgesia. Continuous epidural analgesia is ideal to provide analgesia because of the long duration of labor. Traditionally only high doses of local anesthetics were used. Though they provide excellent pain relief, they produce an unacceptably high level of motor blockade which impairs the parturient’s ability to bear down during labor, resulting in prolonged labor. Lower doses of Bupivacaine (0.04% -0.125%) by themselves are inadequate. The discovery of opioid receptors in spinal analgesia provides an interesting option. Opioid agonists selectively block pain impulses but leave the motor system intact. Doses used for central neuraxial blockade are also very little compared to other parenteral routes and does not result in significant fetal depression. Since opioids and local anesthetics acts at different sites their combination provides a synergistic effect permitting us to use lesser concentrations of both. When used in such low doses their individual side effects are minimized while maximizing the desired effects. Current obstetric practice aims to provide effective pain relief while Efforts to improve epidural analgesia led to Collins and colleagues1 popularizing the combined spinal-epidural technique (CSE) for analgesia in labor. This technique involved an initial Intrathecal injection of opioids (Fentanyl) and Bupivacaine to establish analgesia, and subsequent epidural injections to maintain the analgesia. The doses of drugs involved were such that ambulation in labor was possible. However after the initial Intrathecal injection, motor blockade was present for up to 20 min. Recent research has shown that, in the absence of motor weakness there is no functional impairment of balance in laboring women and therefore ambulation is safe. Ropivacaine is a newer local anaesthetic, which has been shown to cause less motor weakness and less cardio toxicity and is rapidly evolving as local anaesthetic of choice in Labor analgesia as well as in post operative analgesia. The aim of this study was to compare Intrathecal injection of Fentanyl 0.025 mg and Bupivacaine 2.5 mg, with an Intrathecal injection of Fentanyl 0.025 mg and Ropivacaine 2.5 mg as a part of CSE in labor analgesia. Efficacy, sensory and motor blockade and fetal effects were studied in detail. The CSE technique was selected so that the analgesia will be maintained by Epidural route in both the groups even though the study stops short with the comparison of Intrathecal injection of Bupivacaine and Fentanyl with Ropivacaine and Fentanyl. AIM: To compare Intrathecal Bupivacaine and Ropivacaine with Fentanyl in labor analgesia with regard to: 1. Efficacy of pain relief, 2. Effect on fetal and maternal outcomes, 3. Patient comfort and the ease of ambulation during labor, 4. Safety. MATERIALS AND METHODS: This is a prospective, randomized, double blinded, control study. Prior approval was obtained from the ethical committee of Government Stanley Medical College and Hospital and RSRM Lying in Hospital for the study. Fifty parturients who were admitted to the antenatal ward and who requested pain relief during labor were selected for the study. The procedure and complications of regional analgesia was explained to them in detail and written consent was obtained from them. Inclusion criteria: 1 Patients in established labor (cervical dilatation 3-5cms). 2 Patients belonging to ASA I. 3 Only primigravida patients with singleton pregnancy, in full term labor were included in the study. Exclusion criteria: 1. PIH, DM, bleeding disorder or other systemic disorders. 2. Patients who have already received any Opioid drugs or systemic analgesics within prior 24 hours. 3. Any contraindication for central neuraxial techniques. 4. Patients with known allergy to local anaesthetic or other drugs. 5. Patient refusal for regional technique. The patients were randomly divided into two groups of twenty-five each. Group I (Bupivacaine): Received 2.5mg Bupivacaine with 0.025mg Fentanyl (total volume 1 ml) Intrathecally, followed by epidural drugs (0.1% Bupivacaine with 2g/ml Fentanyl) as 5 ml top-ups. At the start of second stage of labor a top-up of 10 ml bolus was used. The top-ups were given only when the patient requested additional pain relief. Group II (Ropivacaine): Received 2.5mg Ropivacaine with 0.025mg Fentanyl (total volume 1 ml) Intrathecally, followed by epidural drugs (0.1% Bupivacaine with 2g/ml Fentanyl) as 5 ml top-ups. At the start of second stage of labor a top-up of 10 ml bolus was used. The top-ups were given only when the patient requested additional pain relief. SUMMARY: In our study both the drugs (Intrathecal Ropivacaine and Bupivacaine with Fentanyl) provided good pain relief while the incidence of motor blockade was significantly less in Ropivacaine group when compared with Bupivacaine group. The two drugs did not influence the outcome of labor such as the duration of labor or the type of delivery. There was no adverse fetal outcome in both the groups. Sensory blockade levels were similar in both the groups. Both the drugs had lesser impact on the haemodynamics. Complications were only few, were minor and easily manageable. CONCLUSION: In our study we conclude that Intrathecal Ropivacaine 2.5mg in combination with Fentanyl 25 micrograms as a part of CSE technique provides rapid and safe analgesia for labor as effective as that achieved by Bupivacaine 2.5mg with significantly less motor blockade. So it is an ideal drug to use for labour analgesia.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Intrathecal Ropivacaine ; Fentanyl ; Bupivacaine ; Fentanyl ; Labour Analgesia ; Comparative Study.
Subjects: MEDICAL > Anaesthesiology
Depositing User: Subramani R
Date Deposited: 22 Apr 2018 15:17
Last Modified: 28 Apr 2018 01:56
URI: http://repository-tnmgrmu.ac.in/id/eprint/7223

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