¹Assistant Professor, Department of Anaesthesia, MGM Medical College, Aurangabad, Maharashtra, INDIA.

{²Professor, Department of Anaesthesia} {³Professor, Department of OBGY} Pacific Institute of Medical Sciences, Udaipur, Rajasthan, INDIA.

⁴Associate Professor, Department of Anaesthesia, IQ City Medical College, Durgapur, West Bengal, INDIA.

Email: vrajput214@gmail.com  , shalinikarad787@gmail.com , shashikant.dahifalkar@rediffmail.com

RESULTS

Total 60 labouring women were enrolled and 30 each were allotted to group F (fentanyl 25 μg) and group FB (fentanyl 20 μg plus 0.5% hyperbaric bupivacaine 2.5 mg). Baseline maternal characteristics such as age, weight, height, parity, gestational age, baseline VAS, cervical dilation at time of entry in study were comparable in both groups.

Table 1: Maternal characteristics

Onset and Duration of labor analgesia, oxytocin units used till completed second stage, VAS score (60 min, 120 min, 180 min, 240 min, 300 min) were comparable in both groups. We did not noticed any significant difference for above parameters. VAS scores were less in group FB as compared to group F, but difference was not statistically significant. Other parameters such as maternal heart rate, mean arterial pressure, fetal heart rate were comparable in both groups.

Table 2: Onset and duration of analgesia

Labour characteristics such as duration of active 1^st stage, 2^nd stage, total duration of labor and rate of cervical dilatation were comparable in both groups and no statistically significant difference noted.

Table 3: Comparison of the progress of labor

Pruritis was noted in 3 patients in group FB and 1 patient from group F, was transient in nature and managed conservatively. No sedation, post-dural puncture headache (PDPH) were noted.

Table 4: Side-effects

DISCUSSION

Transcutaneous electrical nerve stimulation (TENS), continuous support in labour, touch and massage, water bath, intradermal sterile water injections, acupuncture and hypnosis, all may be beneficial for the management of pain during labour. However, the number of women studied has been small and there have been no proven scientific data analysis of the quality of pain relief offered by these techniques.⁷ Fentanyl provides dense blockade with complete intra‑ and postoperative analgesia without causing hemodynamic instability. It has relatively fewer side effects which are manageable and very well tolerated by the patients.⁸ While because of least placental transfer, due to high protein binding and minimal motor block compared to sensory block in lower doses, bupivacaine has become the popular choice for labor analgesia.⁹ Fentanyl has been used along with bupivacaine for labor analgesia extensively to decrease motor block, however the addition of opioids to local anesthetics has disadvantages of pruritus and respiratory depression. Palmer et al. studied the effect of different doses of fentanyl for labor analgesia and found that at 25 μg dose, the duration of analgesia was 90 min with least maternal and fetal hemodynamic changes.¹⁰ Tomar GS et al.,¹¹ found that 2 μg/ml extradural fentanyl is better than 1 μg/ml when combined with bupivacaine in the intermittent bolus technique, as it leads to faster onset, longer duration of analgesia, higher maternal satisfaction, and lesser drug requirement of the local anesthetic with a comparable side effect profile.¹¹ Paddalwar S et al.,¹² found that 0.125% Ropivacaine with Fentanyl 2 µg/ml produced excellent labor analgesia, which was clinically indistinguishable from a similar concentration of Bupivacaine and Fentanyl, with the advantage of less incidence of motor block and slightly longer duration of analgesia, apart from its lesser propensity to cause cardiotoxicity, when used as intermittent doses. Gowrisree K.,¹³ concluded that single shot intrathecal analgesia using fentanyl 25 μg or fentanyl 20 μg +bupivacaine 2.5 mg, is useful when given in the active phase of the first stage of labor, had rapid onset with satisfactory pain relief in both the groups with VAS scores <4 and good maternal and fetal hemodynamics. Similar findings were noted in present study. Minimal motor block was noted in fentanyl 20 μg plus 0.5% hyperbaric bupivacaine 2.5 mg (0.5 ml) group.¹³ In a survey for practice of labor analgesia among anesthesiologists across India, they noted that 64% of the respondents agreed with bupivacaine have the common local anesthetic for neuraxial analgesia which has been used conventionally all over the world.¹⁴ Similarly, a survey conducted in Czech-republic showed that 80% of the anesthesiologists used bupivacaine followed by levobupivacaine for neuraxial analgesia. ¹⁵ Fentanyl is the common adjuvant used while administering labor analgesia according to 83.34% respondents. The reason being its short duration and safe for both fetus and mother. ¹⁴Over the ages many techniques to relieve labour pain have been tried like physical, psychological and pharmacological means but none has been so efficacious and successful than the present day’s technique of Combined Spinal Epidural (CSE) Analgesia.¹⁶ Boluses of higher concentrations, as used in the earlier years, have been associated with a dense motor block resulting in reduced mobility, decreased pelvic tone and loss of the bearing-down sensations usually experienced in the second stage of labour. Tsen et al. ¹⁷ demonstrated a faster rate of cervical dilation in women randomized to receive combined spinal epidural analgesia compared with those who received epidural analgesia (2.3 vs 1.3 cm/h, respectively; P = 0.015). The rapid onset of analgesia decreases the maternal catecholamine levels (mainly epinephrine that has been found to have tocolytic action), leading to increase uterine activity. This leads to a decrease in the duration of first stage of labor.¹⁷ Combined-spinal-epidural (CSE) involves a single injection of local anaesthetic or opiate or both into the cerebral spinal fluid, as well as insertion of the epidural catheter. CSE combines the advantages of spinal analgesia (faster onset of pain relief, from the time of injection and more reliable analgesia) with the advantages of epidural analgesia, such as continuing pain relief, potentially maintained throughout the entire duration of labour.¹⁸

CONCLUSION

Excellent and longer pain relief with minimal side effects, maternal satisfaction, no adverse neonatal outcome and no delay in the progress of labor were noted in labouring women who received intrathecal labor analgesia using fentanyl 25μg alone and fentanyl 20μg plus bupivacaine 2.5mg. Both regimens were comparable to each other.

Conflict of Interest: None to declare

Source of funding: Nil

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