Компаративна студија на континуирана наспроти пациент-контролирана епидурална аналгезија за породување

Abstract

Introduction: Labour pain, being one of the strongest pain a woman can endure in her life, has been a subject of research in contemporary obstetric anaesthesia for a long time. The neuraxial blocks, epidural analgesia (EA) still remains the most effective and safest treatment of pain during labour. In the last three decades, patient-controlled epidural analgesia has become a routine technique, with respect to the advantages it has over continuous epidural analgesia (CEA). The advancement and implementation of various modalities of epidural pain relief have a purpose of obtaining a happy, satisfied, pain-relieved mother with a healthy newborn baby. Aims: To compare the effect of different modalities of epidural analgesia (CEA and PCEA) on pain control, expressed through Visual analogue scale (VAS), the level of induced motor block of lower limbs, the level of sensory block, to evaluate the amount of local anaesthetic consumed during labour, the level of serum cortisol both in mother and newborn immediately after delivery, as well as mother’s satisfaction from the analgesia. Materials and methods: This randomized study was conducted in the Private General Hospital Remedika in the period between June 2013 and June 2014, involving 120 parturiants at the age of 20-40, who fulfilled the requirements for participation in the study. The participants were divided in two groups. The first group, CEA (N=62) were pain-relieved using continuous infusion with epidural solution administered at rate of 10ml/h. The second group of parturients, PCEA (N=58) were treated using without background infusion model, 5ml bolus and a lockout bolus interval of 15 minutes. All parturients were prehydrated with 500ml of Ringer lactat. The epidural solution was the same in both groups and was consisted of bupivacaine 0,08% and fentanyl 2mcg/ml. After the insertion of the epidural catheter on L2-L3 or L3-L4 intervertebral space, the initial analgesia was reached using bolus 9-12ml of the same solution, depending on parturient’s body height. The VAS, the level of motor block, mother’s mobility and the hemodynamic parameters were measured every hour during the analgesia until the end of delivery. The inefficient analgesia during labour, defined as VAS > 4, was treated with an additional manual bolus of 5ml of the same solution administered by the anaesthesiologist or anaesthetist. After the delivery, the parameters of the infusion pump during the analgesia and the amount of consumed epidural solution were recorded. In case the delivery was performed using Sectio Caesarea, these parameters were recorded at the moment of deciding on conversion, i.e. after the pump had been switched off. Immediately after the delivery, the serum level of cortisol was being determined both in mothers and newborns. During the analgesia, side effects were monitored and treated according to the protocol of the study. The neonatal outcomes, blood pH of the umbilical cord and the Apgar scores in the first and the fifth minute, were monitored in all newborn babies. Mother’s satisfaction from the analgesia was determined right after delivery, according previously designed scale. Results: With respect to the hemodynamic parameters, such as systolic and diastolic blood pressure, there was no significant difference between both groups of participants. The heart rate was significantly lower in the PCEA group than in the CEA group, measured from the second to the seventh hour of the beginning of EA. Patientcontrolled epidural analgesia has shown superiority both in pain control, expressed through VAS, measured from the third to the sixth hour and in the motor block which was statistically more emphasised in the CEA group. The data analysis showed one very important result, and that is the paturiant’s mobility which was greater in the PCEA group than in the CEA group (67,2 % vs. 29 %, p=0,0001). The total consumption of local anaesthetic during EA expressed in mg/h was 10,54 in CEA compared to 9,41 in the PCEA group (p=0,0001). We found significant lower maternal cortisol level in the PCEA group 57,55 ± 17,51 mcg/dL compared with CEA group (p = 0,004), but the neonanatal cortisol level was similar in both groups. There were no differences in the neonatal outcomes and in mother’s satisfaction from the pain relief. Conclusion: Patient-controlled epidural analgesia is a safe model of labour pain relief which results in a good control of pain, lower incidence of motor block and greater mobility of the parturient, lower consumption of local anaesthetic and efficient suppression of hormonal stress response. The positive effects on the mother do not jeopardise the foetus’s wellbeing and the final neonatal outcomes.