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| ORIGINAL ARTICLE |
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| Year : 2015 | Volume
: 14
| Issue : 3 | Page : 143-147 |
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Combined spinal-epidural analgesia for laboring parturients in a Nigerian Hospital
Ambrose Rukewe1, Oluwaseun K Adebayo1, Akinola Fatiregun2
1 Department of Anaesthesia, University College Hospital, University College Hospital, Ibadan, Nigeria
2 Department of Epidemiology and Medical Statistics, College of Medicine, University College Hospital, Ibadan, Nigeria
| Date of Web Publication | 28-May-2015 |
Correspondence Address:
Ambrose Rukewe
Department of Anaesthesia, University College Hospital, Ibadan
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1596-3519.149920
 Abstract | | |
Background: Awareness and demand for neuraxial pain relief for labor are on the increase, but epidural technique appears to be the preferred option among anesthetists in Nigeria. We describe our experience with combined spinal-epidural (CSE) analgesia to fill the gap in knowledge in order to boost its utilization.
Materials and Methods: In this retrospective observational study, data were collected from the obstetric analgesia proforma completed for all CSE analgesia performed for labor pain relief between January 1, 2011 and June 30, 2014.
Results: Thirty parturients (21 nulliparous: 9 parous) with a singleton gestation in labor with a mean age of 31.0 ± 4.1 years were studied. In all, 56.7% of parturients requested for analgesia following oxytocin augmentation. The overall mean onset of analgesia and cervical os dilatation at initiation of analgesia were 2.23 ± 0.43 min and 3.4 ± 1.3 cm respectively, with no significant difference between groups. Overall analgesia was adequate in 90% of cases, and 76.7% had spontaneous vaginal delivery; although only nulliparous parturients (23.3%) had cesarean delivery, it was not significant (P = 0.07). There was a significant difference in Apgar score at 1-min between nulliparous and parous groups (7.7 vs. 8.9; P = 0.03), but no difference at 5-min. The side effects observed were vomiting and shivering.
Conclusion: CSE technique can be safely used in every laboring parturient irrespective of parity either in early or late labor situations. | Abstract in French | | |
Résumé
Contexte : Prise de conscience et de la demande pour soulager la douleur cas pour travail sont en augmentation, mais la technique péridurale semble être l'option privilégiée chez les anesthésistes au Nigeria. Nous décrivons notre expérience avec l'analgésie de la moelle-péridurale combinée (CSE) pour combler la lacune dans les connaissances afin de stimuler son utilisation.
Matériaux et Méthodes : dans cette étude observationnelle rétrospective, les données ont été recueillies de l'analgésie obstétricale proforma rempli pour tous les MCS analgésie réalisée pour soulager la douleur du travail entre le 1er janvier 2011 et le 30 juin 2014.
Résultats : Trente parturientes (21 nullipares: 9 femelles) avec une gestation de singleton en travail avec un âge moyen de 31,0 ± 4,1 ans ont été étudiés. En tout, 56,7 % des parturientes demandé pour l'analgésie suite d'ocytocine. L'apparition moyenne global d'analgésie et la dilatation de l'orifice cervical au début de l'analgésie sont 2,23 ± 0,43 min et 3,4 ± 1,3 cm respectivement, avec aucune différence significative entre les groupes. Dans l'ensemble, l'analgésie était adéquate dans 90 % des cas, et 76,7 % avaient un accouchement vaginal spontané ; Bien que seulement nullipares parturientes (23,3 %) avaient par césarienne, il n'était pas significative (P = 0,07). Il y avait une différence significative dans le score d'Apgar à 1 min entre les groupes nullipares et enceintes (7,7 vs 8,9 ; P = 0,03), mais aucune différence à 5 min. Les effets secondaires observés étaient vomissements et frissons.
Conclusion : Technique de la CST permet en toute sécurité dans chaque parturiente indépendamment de parité à travailler dans des situations de travail tôt ou tard.
Mots-clés: Analgésie, combinée à la moelle-péridurale, laborieuses parturiente, nullipares, enceintes Keywords: Analgesia, combined spinal-epidural, laboring parturient, nulliparous, parous
How to cite this article:
Rukewe A, Adebayo OK, Fatiregun A. Combined spinal-epidural analgesia for laboring parturients in a Nigerian Hospital. Ann Afr Med 2015;14:143-7 |
| Introduction | |  |
There is an increasing awareness and demand for neuraxial pain relief for labor in our environment. Imarengiaye and Ande reported that a high proportion (85.1%) of laboring parturients in their survey, desired pain relief during childbirth. [1] Neuraxial analgesia is expensive and labor-intensive, coupled with a shortage of anesthetic manpower; low rate of utilization persists in Nigerian hospitals with the requisite expertise. [2],[3] From the available literature in Nigeria, epidural analgesia appears to be the technique of choice and to the best of our knowledge, there is a gap in experience with combined spinal-epidural (CSE) for labor pains. Some authors have suggested that CSE is more appropriate for late labor in parous women and should not be offered to all women. [4],[5] The purpose of this study was to describe our experience with CSE in nulliparous and parous parturients in labor in order to boost its utilization for Nigerian women.
| Materials and Methods | | |
Approval for this retrospective, observational study was obtained from the Institutional Ethics Committee. Data were collected from the obstetric analgesia proforma completed for all CSE analgesia performed for labor pain relief between January 1, 2011 and June 30, 2014. The parturients were divided into two groups, nulliparous and parous. Neuraxial pain relief during labor is not a routine service but is provided on request; the parturient would have been reviewed during the antenatal period by the attending anesthetist. All CSE reviewed were performed by the lead investigator. Parturients who had opioid analgesia or epidural analgesia service were excluded from this review.
Monitoring comprised noninvasive blood pressure (BP), electrocardiography, pulse rate and arterial oxygen saturation. Every parturient had venous access at the nondominant arm with 500 ml normal saline infusion. Using a full aseptic technique with the patient in the sitting position, the epidural space was located via a median approach at L4/L5 interspace with a loss of resistance to saline method using Espocan set (B Braun, Melsungen, Germany), comprising an 18-gauge Tuohy epidural needle, a 27-gauge spinal needle and a 20-gauge multiorifice epidural catheter. Spinal needle was inserted through the epidural needle for needle-through-needle technique and intrathecal injection of 2.5 mg heavy bupivacaine 0.5% with 15 mcg fentanyl. A multi-orifice 20-gauge epidural catheter was inserted up to 5 cm cephalad in the epidural space followed by injection of 15 ml isobaric bupivacaine 0.1%, the parturient was thereafter placed in the lateral position after fixing the epidural catheter to the skin. Next, the midwife performed urethral catheterization for continuous draining of the urinary bladder. Analgesia was maintained by hourly intermittent bolus injection of 15 ml 0.0625% bupivacaine with 1.5 mcg/ml fentanyl. Pain was assessed using a visual analogue scale (VAS 0-10), the patient would have been instructed in the numeric score where 0 represented no pain, and 10 represented worst pain imaginable. According to our protocol, additional analgesia is provided by epidural injection of clonidine 50 mcg (as a single dose) if required. BP, pulse and oxygen saturation monitoring was recorded every 5 min during labor. A reduction in systolic BP <90 mmHg was considered hypotension to be treated with intravenous ephedrine 5 mg every 5 min to a maximum of 30 mg until BP was >100 mmHg. Bradycardia (pulse rate <50 beats/min) was to be treated with intravenous atropine 0.6 mg. Patient's satisfaction with CSE was recorded within 12-24 h postpartum on a 4-point descriptive scale which ranged from 1 "poor" to 4 "completely satisfied." Midwives and obstetricians conducted the obstetric management of all parturients in labor such as cardiotocographic monitoring of uterine contraction, fetal heart rate, and pelvic examinations 2-4 h. Anesthetic team of consultant and registrars monitored pain relief during labor, administered the epidural top-ups and managed complications related to the block. Complications such as vomiting and shivering were to be treated with intravenous chlorpheniramine 5 mg and intravenous pethidine 10-15 mg respectively. The observations terminate after vaginal delivery or when decision for cesarean delivery is made. The labor ward (LW) theater team usually different from the obstetric analgesia team take over anesthetic care and after evaluation either performed a single-shot spinal block using hyperbaric bupivacaine (≤10 mg) or epidural top-up with a mixture of 10-15 ml 2% lidocaine with 1:200,000 epinephrine plus 25 mcg fentanyl (LEF mixture).
The results are presented as the number of cases, mean and range as appropriate. Nonparametric data were analyzed using the Mann-Whitney U-tests, and parametric data were analyzed with the Student's t-test, using a statistical program (SPSS for windows 17.0, SPSS Inc., Chicago, IL, USA).
| Results | | |
Thirty parturients with a singleton gestation in labor with a mean age of 31.0 ± 4.1 years had CSE for pain relief. Our data showed that there were more nulliparous women (21) than parous (9) and a higher proportion of parturients (56.7%) who had augmentation with oxytocin requested for CSE analgesia [Table 1]. The demographic characteristics were similar apart from the age, nulliparous women in our study population were younger (P = 0.001). Both groups (nulliparous vs. parous) experienced a short onset time (2.24 ± 0.4 min vs. 2.22 ± 0.4 min, P = 1.01), while the mean pain scores (VAS) 30 min after initiating CSE was comparable (0.43 ± 0.87 vs. 0.56 ± 0.88, P > 0.5). There was also no difference in the cervical dilatation at the initiation of CSE (3.3 ± 1.3 cm vs. 3.7 ± 1.8 cm, P = 0.568). | Table 1: Demographic characteristics of laboring parturients who had CSE
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While the quality of analgesia experienced was similar, labor outcome showed that although only nulliparous parturients had cesarean delivery [Table 2]; there was no significant difference between groups (P = 0.07). The overall spontaneous vaginal delivery (SVD) rate was 76.7% and cesarean section rate was 23.3%. Patient satisfaction was high in both groups; parous parturients were more satisfied than the nulliparous. In a greater proportion (57.1%), the indication for operative delivery was cervical dystocia/poor progress of labor [Table 3]. There was a significant difference in Apgar score at 1-min between nulliparous and parous groups (7.7 vs. 8.9, P = 0.03), but no difference at 5-min. The birth weight was also comparable. The side effects observed were vomiting and shivering [Table 4].
| Discussion | | |
This study with a mean cervical dilatation of 3.4 cm at CSE initiation has demonstrated that the technique is a viable option for pain relief in all laboring parturients irrespective of parity. Indeed, there is no argument about its suitability in parturients in advanced labor and those in extreme pain who require rapid relief. [4],[5],[6],[7] Apart from rapid onset analgesia, a high proportion (90%) experienced adequate analgesia that is congruous with the findings of other workers. [7],[8],[9],[10] We had more nulliparous than parous patients requesting for CSE in contrast with Miro et al. data, [7] understandably, a high proportion (62%) of our cohort received oxytocin augmentations causing extreme pain situations.
Our finding that all parous parturients had SVD in contrast with nulliparous (67%) is not surprising; parity has been documented to have a significant effect on the mode of delivery. [7],[11] Fyneface-Ogan et al., [2] in their study of epidural analgesia in Port Harcourt, Nigeria, reported 32% cesarean deliveries among their multiparous cohort which in our view, was not unexpected because of the high dose of local anesthetic (0.125%) administered in contrast with our low-dose CSE followed by epidural low-dose (0.0625%) boluses. Some authors have opined that the local anesthetic dose has a telling effect on the delivery outcome hence low-dose regimens are promoted over the past 10-15 years because higher doses cause more motor block, prolong first and second stages of labor and increase instrumental/cesarean delivery. [7],[8],[9],[12]
On neonatal outcome, the mean 1-min and 5-min Apgar scores were 8.1 and 9.7 respectively, which were satisfactory in the absence of cord blood gas analysis. Only minor and easily treatable side effects such as vomiting and shivering were documented in our study population. The safety concerns that greeted the introduction of CSE for labor analgesia has abated over the past decade following the reduction in incidence and severity of complications. [13],[14] This must explain why CSE has become popular for neuraxial labor analgesia in many centers. [6],[9],[12]
We admit as limitations our small number of cases, lack of randomization and the retrospective observational design of this study. The small size in part is due to the fact that labor analgesia service is available only on maternal request and a study of this nature can impact positively by increasing demand, if myths are dispelled. We have tried to describe our experience with CSE for labor analgesia as we cannot draw conclusions based on causal relationships from purely observational case series set-up.
We suggest that CSE can be safely used in every laboring parturient irrespective of parity either in early or late labor situations. We recommend the use of anti-emetic prophylaxis to reduce the incidence of nausea and vomiting since fasting guidelines are difficult to implement in this patient population (obstetric analgesia service); the use of fentanyl as adjuvant and low-dose pethidine to treat shivering increases the risk of vomiting. To set-up CSE in a hospital, practice guideline must be developed, and personnel trained to follow the protocol. The personnel should comprise a dedicated multidisciplinary team of anesthetists (consultant anesthetist-led), obstetricians and midwives. Multiparameter monitors for feto-maternal wellbeing are required. Documentation must be thorough especially for handovers to the LW theater anesthesia team when cesarean surgeries are required; regular audits and follow-up of patients must be ensured.
| References | | |
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| 2. | Fyneface-Ogan S, Mato CN, Anya SE. Epidural anesthesia: Views and outcomes of women in labor in a Nigerian hospital. Ann Afr Med 2009;8:250-6. [ PUBMED]  |
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| 7. | Miro M, Guasch E, Gilsanz F. Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: A retrospective study of 6497 cases. Int J Obstet Anesth 2008;17:15-9. |
| 8. | Lee BB, Ngan Kee WD, Hung VY, Wong EL. Combined spinal-epidural analgesia in labour: Comparison of two doses of intrathecal bupivacaine with fentanyl. Br J Anaesth 1999;83:868-71. |
| 9. | Gambling D, Berkowitz J, Farrell TR, Pue A, Shay D. 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. Anesth Analg 2013;116:636-43. |
| 10. | Albright GA, Forster RM. The safety and efficacy of combined spinal and epidural analgesia/anesthesia (6,002 blocks) in a community hospital. Reg Anesth Pain Med 1999;24:117-25. |
| 11. | Norris MC, Fogel ST, Conway-Long C. Combined spinal-epidural versus epidural labor analgesia. Anesthesiology 2001;95:913-20. |
| 12. | Hughes D, Simmons SW, Brown J, Cyna AM. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2003;CD003401. |
| 13. | Van de Velde M, Teunkens A, Hanssens M, Vandermeersch E, Verhaeghe J. Intrathecal sufentanil and fetal heart rate abnormalities: A double-blind, double placebo-controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor. Anesth Analg 2004;98:1153-9. |
| 14. | Wong CA, Scavone BM, Loffredi M, Wang WY, Peaceman AM, Ganchiff JN. The dose-response of intrathecal sufentanil added to bupivacaine for labor analgesia. Anesthesiology 2000;92:1553-8. |
[Table 1], [Table 2], [Table 3], [Table 4]
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