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58]

Original Article

Epidural labor analgesia: A comparison of

ropivacaine 0.125% versus 0.2% with fentanyl
Yogesh Kumar Chhetty1,2,
Udita Naithani1, Sunanda Gupta1,3,
Vikram Bedi1, Ila Agrawal4,
Lalatendu Swain1
1
Departments of Anesthesia,
R.N.T. Medical College,
2
Department of Anesthesiology
and Critical Care, Maa Gayatri
Hospital, 3Geetanjali Medical College,
4
Department of Obstetrics and
Gynecology, R.N.T. Medical College,
Udaipur, Rajasthan, India
Address for correspondence:
Dr. Sunanda Gupta, “aahna”, 26,
Navratna Complex, Near Mahalaxmi
Apartments, Near Bedla Road,
Udaipur 313001, Rajasthan, India.
E-mail: sunandagupta@hotmail.com
ABSTRACT
Background: Minimum effective concentration of local anesthetics for providing optimal labor
epidural analgesia and the strategies aiming to reduce their consumption are continuously
being searched.
Objectives: The objective of this study was to evaluate the efficacy of 0.125% and 0.2%
ropivacaine both mixed with fentanyl 2 mcg/ml for epidural labor analgesia.
Materials and Methods: A total of 80 parturients in active labor were randomly assigned to two
groups of 40 each, to receive an epidural injection of 15 ml ropivacaine 0.125% with fentanyl
(2 mcg/ml) in group R1 and 15 ml of ropivacaine 0.2% with fentanyl (2 mcg/ml) in group R2 as initial
bolus dose. Same dose regimen was used as subsequent top-up dose on patients demand for
pain relief. The duration and quality of analgesia, motor block, top-up doses required consumption
of ropivacaine and fentanyl and feto-maternal outcome in both groups were compared.
Results: Effective labor analgesia with no motor blockade was observed in both groups with
no failure rate. Onset of analgesia was significantly faster in group R2 (75% parturients in 0-5
min) as compared to group R1 (25% parturients in 0-5 min), P < 0.001. Duration of analgesia
after initial bolus dose was also significantly longer in group R2 (132 ± 56.81 min) than in group
R1 (72.25 ± 40.26 min), P < 0.001. Mean VAS scores were significantly less in group R2 than
in group R1 at 5, 60, and 90 min, P < 0.01. Requirement of top-up doses was significantly less
in group R2 (0.05 ± 0.22) as compared to group R1 (0.80 ± 0.65), P < 0.001. Consumption of
ropivacaine was comparable in both the groups (33.75 ± 12.16 mg in group R1 and 31.50 ±
6.62 mg in group R2 P > 0.05), but consumption of fentanyl was significantly more in group R1
(54.00 ± 19.45) as compared to group R2 (31.50 ± 6.62), P < 0.001. There were no significant changes
in hemodynamics, nor adverse effects related to neonatal or maternal outcomes in both groups.
Conclusion: We conclude that both the concentrations of ropivacaine (0.2% and 0.125%) with
fentanyl are effective in producing epidural labor analgesia. However, 0.2% concentration was
found superior in terms of faster onset, prolonged duration, lesser breakthrough pain requiring
lesser top-ups, and hence a lesser consumption of opioids.
Key words: Epidural labor analgesia, labor analgesia, ropivacaine 0.2% versus 0.125%,
fentanyl

INTRODUCTION Evidence is suggestive that labor disorders including maternal

hypertension, dystocia, meconium staining, and fetal distress
are stress related.[1,2] Hence, maternal pain relief not only
T he pains of labor result in a maternal stress response,
which is neither beneficial for the fetus nor the mother.[1] benefits the parturient, but her neonate also.

Access this article online Maternal and fetal effects of analgesia during labor remain
Quick Response Code: central to discussions among patients, anesthesiologists, and an
Website:
www.joacc.com obstetrical caregivers[3,4] with the controversies[5,6] in obstetrical
anesthesia including the effects of regional anesthesia on the
progress and outcome of labor as well as effects on the neonate.[3,4]
DOI:
10.4103/2249-4472.114284
Of all the available methods of labor analgesia, epidural
analgesia satisfies the basic requirements of labor analgesia

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Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia
by fulfilling the objective of decreasing the pains of labor
without affecting other sensations such as a desire to push and
to allow normal walking while preserving the tone of pelvic
floor muscles as well as retaining the sensation of the baby’s
head in the vagina; thus, allowing labor to proceed unhindered.
Ropivacaine, an amide local anesthetic is less cardiotoxic in
animals[7] as well as it may also be more selective for sensory
fibers when compared to other local anesthetics, producing less
motor block.[8] This allows for increased maternal ambulation
and also allows for normal progression of labor, which translates
into fewer instrumental deliveries and more vaginal deliveries[9]
although this is controversial.[10] These factors suggest that
ropivacaine may be superior to bupivacaine in obstetric
analgesia.
Minimum local anesthetic concentration (MLAC) studies
by up and down sequential allocation have found both 0.2%
and 0.1% ropivacaine to be effective for labor analgesia.[11]
OPRM A118G gene has been reported to be present in a higher
number of Asians as compared to their Western counterparts,
which pre-disposes the Asian populace to a higher degree
of pain perception.[12] Studies are lacking from the Indian
subcontinent, which highlight the efficacy of 0.2% versus
0.125% ropivacaine for labor analgesia, which prompted us
to undertake this study.
The objective of this study was to evaluate 0.125% versus
0.2% ropivacaine, with 2 μg/ml of fentanyl in epidural
labor analgesia, regarding their sensory and motor block
characteristics as well as the fetomaternal outcomes.
MATERIALS AND METHODS
After approval of the Institutional Ethical Committee, this
prospective randomized double-blinded study was conducted
at a teaching hospital in Rajasthan on 80 term parturients of
American Society of Anesthesiologists (ASA) grade I and II
having uncomplicated pregnancy in a vertex presentation.
Patient selection
Parturients in active labor, having contractions at least once
every 5 min, not having any contraindication to epidural
analgesia, and who requested epidural analgesia for pain
relief were enrolled in this study. Exclusion criteria included
hypersensitivity to study drugs, bleeding disorders, decreased
platelet counts, sepsis, and a history of drug abuse; spinal
column deformities and spine surgery.
Sample size and group allocation
Expecting ropivacaine (0.2% vs. 0.125%) + fentanyl 2 μg/ml to
decrease visual analog scale (VAS) scores to <3 values, a power
Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1
analysis resulted in a calculated sample size of a minimum of
28 subjects per group to obtain statistical significance assuming
and α error of 0.05 and power of 0.9. The study was designed
to provide 90% power to detect a decrease in success rate from
90% to 70% with a one-tailed test at 5% significance level.
However, since a minimum of 30 subjects are required for a
clinical study to be valid and to compensate for dropouts a
sample size of 40 subjects per group was chosen.
Study patients (n = 80) were randomly assigned to one of
two groups of 40 each, using a computer generated table of
random number to receive epidural injection using either,
15 ml of ropivacaine 0.125% with 2 μg/ml fentanyl (group R1)
or 15 ml of ropivacaine 0.2% with 2 μg/ml fentanyl (group R2).
For group R1, 15 ml of 0.125% ropivacaine was prepared
by taking 2.5 ml of 0.75% isobaric ropivacaine (Ropin®)
(Neon Laboratories Ltd. 140, Damji Samji Industrial Complex,
Mahakali Caves Road, Andheri East, Mumbai, Maharashtra
400093) and diluting it with 12.5 ml of 0.9% normal saline.
For group R2, 15 ml of ropivacaine (0.2%) was taken directly
from a 20 ml ampoule (Ropin®, Neon). 30 μg of fentanyl
(Trofentyl®, Troikaa Laboratories Ltd.) were taken by using
six parts from a tuberculin syringe graduated in markings to
divide 1 ml (50 mcg/ml) into 10 parts and added to 15 ml of
ropivacaine in both groups to achieve a final concentration of
fentanyl (2 mcg/ml).
Double blindness of the study was ensured by involving,
three different anesthesiologists for preparing the drugs,
administering them and for recording the data.
Labor analgesia technique
After informed consent patients were subjected to a thorough
pre-anesthetic evaluation. Before placement of the epidural
catheter, VAS score was noted with VAS 0 = no pain and
10 = the worst imaginable pain along with baseline vitals.
After starting a 500 ml infusion of Ringers’ lactate in an 18G
peripheral intravenous canula, parturients in both groups were
placed in the left lateral position. Following strict aseptic
techniques, and infiltrating 2% lignocaine HCl into the
intervertebral space, epidural space was identified at L3-4 or L4-5
space using a loss of resistance technique to normal saline with
an 18G Tuohy needle and an 18-gauge multi-orifice catheter
was threaded through the cephalad directed tip of the epidural
needle to a depth of 5 cm into the epidural space. If there was
no blood or cerebro spinal fluid (CSF) on aspiration from the
epidural catheter, depending on the group allocated, a 3-ml
test dose of the study medication was administered through
the catheter. The presence of clinical signs of an intravascular
injection were sought, for the following 2-3 min, by asking
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Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia
the patient whether she felt dizzy, had tinnitus, or a metallic
taste in her mouth. If there were no signs of an intravascular
injection, the catheter was secured and the woman was placed
in the supine position with left uterine displacement. Five
minutes after the test dose, if there were no clinical signs of
subarachnoid injection (as evidenced by the patient’s ability to
move her legs and the absence of hypotension), an additional
12 ml of the study solution was administered. This dose was
defined as first initial bolus dose and time was noted. On
intravascular placement of the catheter, it was removed and
resisted at another interspace while all patients with intradural
placement of catheter were removed from the study. The
adequacy of analgesia was assessed 5 min after the first initial
bolus dose of study drug had been administered. Analgesia was
considered adequate if pain score was <3. Onset of analgesia
was defined as from time of first bolus dose to time of achieving
VAS <3. If analgesia was not adequate 15 min after the first
initial dose, an additional 15 ml of study medication (second
initial dose) was administered, and analgesia reassessed in the
same manner. If pain relief was inadequate at the peak of a
contraction, 15 min after the second initial dose of ropivacaine;
the epidural anesthetic was classified as ropivacaine failure,
and patient withdrawn from the study. Presence of motor block
in the lower extremities was assessed using a Breen modified
Bromage scale (BMBS: Grade 1 as complete motor block to
Grade 6 as no motor block). VAS and BMBS was assessed
every 15 min. All parturients were given a trial walk to assess
their ability to ambulate. An additional dose of ropivacaine
15 ml was given as a top-up dose on patient request, with
a minimum gap of 15 min between two subsequent top-up
doses. Epidural analgesia was continued through the second
stage of labor.
At any point of time during the study period hypotension
was defined as systolic blood pressure of <90 mmHg and
was treated with bolus of 6 mg ephedrine HCl. Bradycardia
was defined as heart rate <60 bpm and was treated with bolus
doses of 0.4 mg atropine sulfate.
Data recording
Demographic data (age, weight, height), obstetric data
(parity, dilatation of the cervix [0-10 cm], station of the vertex
of the presenting part [−3 to +3], effacement of the cervix (%),
membrane status) were noted prior to the initiation of labor
analgesia.
Pain score (VAS), sensory and motor block characteristics and
vital parameters (pulse, mean arterial pressure, respiratory
rate) were recorded at 0 (before epidural), 5, 15 min and then
every 15 min till 1 h and then every 30 min until the delivery.
Sensory block height was assessed by loss of sensation to pin
prick (blunt head of a pin). Onset of analgesia was defined as
18
duration from injection of first initial epidural bolus dose to
attainment of VAS <3 and duration of analgesia of initial bolus
dose was defined as time of administration of study drug until
the time of demand of top-up for the first time.
Motor block assessment was carried out by BMBS, [1-6]
Romberg’s sign, straight leg raising test, rectus abdominalis
muscle test, and trial walk.
The time taken by the parturient to request for subsequent
top-up dose was recorded. Labor was managed according to our
obstetric department’s protocols and mode of delivery (normal/
instrumental delivery/caesarean delivery) was noted. Injection
delivery interval was defined as the time from administration of
first initial epidural dose until the delivery. Fetal heart rate was
monitored throughout the study by using a cardiotocograph,
and any evidence of fetal heart rate decelerations was recorded.
Neonatal assessment was performed by assessing the Apgar
score at 1 and 5 min.
Quality of maternal expulsive efforts was assessed by
an obstetrician as Grade 0 – Failure, 1 –Incomplete, 2 –
Good, 3 – Excellent. Quality of analgesia was assessed
by an esthesiologist as Grade 0 – Failure, 1 – Incomplete,
2 – Good, 3 – Excellent, 4 – Not possible to evaluate (NPE) if
delivered by cesarean section. Side-effects including nausea,
vomiting, hypotension, hypersensitive reaction, shivering,
fever, drowsiness, pruritus, respiratory depression, retention
of urine, and weakness in limbs were noted.
Statistical analysis
For categorical variables (presented as number [proportions]),
the proportions of variances in the two groups were compared
using the Chi-squared test with calculation of the 2 statistic
value and P value. For quantitative variables (data presented
as mean ± standard deviation [SD] measurements), the groups
were compared using Student’s t-test for independent samples.
For all statistical analyses, the level of significance was
P < 0.05 and the software used was Microsoft Excel 2007
and Statistical Package for the Social Sciences (SPSS) (IBM
Business analytics software) version 20.0.0.
RESULTS
Demographic data, obstetric data, and injection delivery interval
were comparable in both groups, P > 0.05 [Table 1]. Before
initiation of analgesia mean VAS score was 9.80 ± 0.61 in
group R1 and 9.90 ± 0.50 in group R2 (P > 0.05). Both the
concentrations of ropivacaine (0.125% in group R1 and 0.2%
in group R2) produced effective analgesia (defined by VAS <3)
after single initial bolus dose in parturients of both the groups,
stating no failure rate.
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After epidural injection majority of parturients (75%) achieved each group and was found to be significantly more in group R2
VAS <3 significantly earlier in group R2 (0-5 min), than in (132 ± 56.81 min) than in group R1 (72.25 ± 40.26 min)
group R1 (5-15 min), signifying onset of analgesia to be (P < 0.001). In group R2 only 2 (5%) patients required a single
significantly faster in group R2 as compared to group R1, top-up dose and 38 (95%) patients had adequate analgesia until
P < 0.001. After 5 min of epidural bolus injection, VAS score the delivery after initial bolus dose, whereas in group R1 only
was significantly less in group R2 (1.63 ± 2.89) than in group 13 (32.5%) parturients could achieve effective analgesia until
R1 (5.00 ± 2.89) P < 0.001. All the parturients in both the the delivery after initial bolus dose, 22 (55%) required a single
groups attained a sensory blockade level of T10 and none top-up dose and 5 (12.5) required two top-ups (P < 0.001).
of the patients in both the groups showed a sensory block Overall significantly higher number of parturients in group R1
higher than T10. Duration of analgesia of initial bolus dose, (n = 27, 67.5%) required one or more top-up doses (P < 0.001).
defined as the time until parturient requests for additional first top-up dose was required significantly earlier in group R1
analgesia (first top-up), was calculated for all 40 patients in (58.15 ± 22.65 min) than in group R2 (131.30 ± 57.11 min),
P < 0.001. Mean number of top-up doses for each patient was
significantly higher in group R1 (0.80 ± 0.65) than in group R2
Table 1: Demographic and obstetric data
(0.05 ± 0.22), P < 0.001. Total dose of ropivacaine consumed
Variable Group R1 Group R2 P value
(n=40) (%) (n=40) (%) in both groups was comparable (P > 0.05), but total dose of
Age (years) 24.13±3.46 24.15±2.76 NS fentanyl was significantly higher in group R1 (54.00 ± 19.45
Weight (kg) 54.90±5.82 55.50±5.67 NS mcg) than in group R2 (31.50 ± 6.62 mcg) P < 0.001 [Table 2].
Height (ft. in) 5.08±0.45 5.05±0.53 NS
Parity VAS scores were significantly lower in group R2 than in group
Multiparous 18 (45) 19 (47.5) NS R1 at 5 min, 60 min and 90 min of the study period, P < 0.001
Primi 22 (55) 21 (52.5) NS
[Figure 1]. Motor block characteristics in both groups were
Obstetric data
Dilation of cervix (cm) 3.43±0.64 3.33±0.73 NS
comparable. All parturients had negative Romberg’s sign and
Station of vertex 2.05±1.06 2.20±0.82 NS straight leg raising test with a positive trial walk and a BMBS of 6
Effacement of cervix (%) 85±14 86±13 NS significantly no motor blockade at all-time intervals of the study.
Presence of membrane
Absent 2 (5) 7 (17.50) NS Haemodynamic status of parturients in both groups was
Present 38 (95) 33 (82.50) NS comparable. None of the patients in any group required either
P>0.05 (NS: Not significant)
ephedrine or atropine [Table 3].

Table 2: Dose requirement, onset and block characteristics

Parameter Group R1 Group R2 P value
VAS score (mean±SD)
Before bolus dose 9.80±0.61 9.90±0.50 P>0.05 (NS)
5 min after bolus dose 5.00±2.89 1.63±2.89 P<0.001 (HS)
15 min after bolus dose 0.55±1.97 0.00±0.00
30 min after bolus dose 0.30±1.32 0.00±0.00
Patient distribution according to time of onset$
0-5 min (%) 8 (20) 30 (75) <0.001 (HS)
>5-15 min (%) 30 (75) 10 (25) <0.001 (HS)
>15-30 min (%) 2 (5) 0 <0.001 (HS)
Patient distribution according to doses required
Bolus dose only (%) 13 (32.5) 38 (95) <0.001 (HS)
Bolus dose+1 top-up (%) 22 (55) 2 (5) <0.001 (HS)
Bolus dose+2 top-up (%) 5 (12.5) 0 <0.001 (HS)
Duration of analgesia of bolus dose (min) 72.25±40.26 (n=40) 132.05±56.81 (n=40) <0.001 (HS)
Mean time to first top-up (min) 58.15±22.65 (n=27)× 131.30±57.11 (n=2)× <0.001 (HS)
Mean time to second top-up (min) 76.77±48.50 (n=5)×× NA
Mean number of top-up doses for each patient 0.80±0.65 0.05±0.22 <0.001 (HS)
Total dose of ropivacaine (mg) 33.75±12.16 31.50±6.62 >0.05 (NS)
Total dose of fentanyl (μg) 54.00±19.45 31.50±6.62 <0.001 (HS)
$
Time of bolus dose to time to achieve VAS<3, ×Number of patients requiring first top-up, ××Number of patients requiring second top-up. NS: Not significant, HS: Highly
significant, NA: Not applicable, VAS: Visual analogue scale, SD: Standard deviation

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Table 3: Hemodynamic parameters

10
Hemodynamic data Group R1 Group R2 P value
9 (mean±SD) (mean±SD)
8 Group R2
Baseline MAP (mmHg) 85.48±8.74 86.60±7.72 P>0.05 (NS)
7 Group R1
Lowest MAP (mmHg) 72.00±8.34 74.33±7.70 P>0.05 (NS)
6
% fall of MAP from 15.06 14.16 P>0.05 (NS)
VAS

5 P<0.001
baseline
4
Baseline heart rate (bpm) 73.53±6.66 72.53±8.05 P>0.05 (NS)
3
P<0.01 P<0.001 Lowest heart rate (bpm) 69±7.60 67±7.42 P>0.05 (NS)
2
% fall of heart rate from 6.16 7.62 P>0.05 (NS)
1 baseline
0
P>0.05 (NS: Not significant), MAP: Mean arterial pressure, SD: Standard
0 Min 5 Min 15 Min 30 Min 45 Min 60 Min 90 Min
deviation
Time

Figure 1: Mean visual analog scale values at various time intervals Table 4: Maternal expulsive efforts assessed by
obstetrician and quality of analgesia (as assessed
Spontaneous vaginal delivery occurred in all (100%) parturients by parturient and anesthesiologist)
in group R1 and 95% (n = 38) in group R2. 1 (2.5%) parturient Maternal expulsive Group R1 Group R2
each had forceps and cesarean delivery in group R2, P > 0.05. efforts No. % No. %
Grade 0 – Failure 0 0 1 2.5
Obstetrician’s graded maternal expulsive efforts as excellent Grade 1 – Incomplete 0 0 0 0
in most of the parturients in both groups (P > 0.05). Grade 2 – Good 9 22.5 7 17.5
Grade 3 – Excellent 31 77.5 32 80
Parturients and anesthesiologists graded acceptance rate
Parturient’s acceptance
as either excellent or “good” in both groups. However,
Grade 0 – Failure - - - -
significantly higher number of cases (97.5%) reported Grade 1 – Incomplete - - - -
acceptance rate as excellent in group R2, by both parturients Grade 2 – Good 7 17.5 - -
and anesthesiologists (P < 0.001) [Table 4]. Grade 3 – Excellent 33 82.5 39 97.5*
Grade 4 – NPE - - 1 2.5
Neonatal outcome was favorable in both the groups Anesthesiologist’s grading
(Apgar scores >7 at 1 and 5 min) with no side-effects. Grade 0 – Failure - - - -
Grade 1 – Incomplete - - - -
Grade 2 – Good 5 12.5 - -
DISCUSSION Grade 3 – Excellent 35 87.5 39 97.5*
Grade 4 – NPE - - 1 2.5
The last few years have been marked by the arrival of new 2
=8.50, df=2, *P<0.01 (S). NPE: Not possible to evaluate because of cesarean
local anesthetics; ropivacaine and levobupivacaine, with section

reduced systemic toxicity and a better preservation of motor

function.[13] Toxicity is not an issue when low concentrations
of local anesthetics are used as is the case in modern neuraxial
labor analgesia.[13] It seems evident that the adequate dilution
of local anesthetics and the strategies aiming to reduce their
consumption are more important than the choice of the local
anesthetic by itself when the goal is to provide optimal
neuraxial labor analgesia.
There are controversial data regarding minimum effective
concentration of ropivacaine for initiation of epidural labor
analgesia. Using up and down sequential allocation MLAC
of ropivacaine for epidural labor analgesia was reported to be
0.111% w/v (95% confidence interval [CI], 0.100-0.112).[14]
In another study MLAC of ropivacaine alone was 0.13%
(95% CI, 0.12-0.13) compared to 0.09% (95% CI, 0.08-0.1)
with sufentanil, P < 0.01.[15] On the other hand, many authors[16]
found that ropivacaine 0.2% offers adequate analgesia more
often than either 0.15% or 0.1% and the resultant motor blocks
and hemodynamic effects are minimal. Addition of fentanyl
2 mcg/ml to 0.1% ropivacaine improved analgesia to a quality
similar to 0.2% ropivacaine.[17]
In the present study, epidural labor analgesia with ropivacaine
0.125% or 0.2% both combined with fentanyl (2 mcg/ml)
produced adequate labor analgesia in all the 80 parturients in
both groups showing a 100% success rate of both concentrations.
However, we observed that the onset of analgesia was significantly
faster when labor analgesia was initiated with 0.2% ropivacaine
as reported earlier that a decrease in time for onset occurs
with increasing concentrations of epidural bupivacaine.[18,19] In
contrast, no difference in the onset of analgesia with increasing

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Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia
concentration of ropivacaine had also been reported.[20] Duration
of analgesia of initial bolus dose was also significantly more with
0.2% ropivacaine in our study as observed by others.[21] Addition
of adjuvant opioids leads to further increase in duration of
analgesia.[22] Time of first top-up was also significantly more
in 0.2% group, which is in concordance to other studies.[20,23]
Requirement of top-up doses was also significantly less frequent
in 0.2% group, but total dose of ropivacaine was comparable
in two groups (31.75 mg in group R2 and 33.75 mg in group
R1) because repeated top-ups of 0.125% ropivacaine resulted
in same total dose of ropivacaine. Nevertheless repeated
top-up doses had 2 mcg/ml fentanyl and led to consumption
of significantly higher amount of fentanyl in group R1
(54 mcg in group R1 vs. 31.50 mcg in group R2). The recent
trend in practitioners of labor analgesia is to use the least possible
concentration of local anesthetic and adjuvant for the purpose
of attaining analgesia. The main undesirable side-effects with
ropivacaine analgesia are hypotension, bradycardia, nausea,
paresthesia, and urinary retention, which are considered mild
and transient. However, the side-effects observed with opioids
are multivariate (nausea, pruritus, respiratory depression,
lower Apgar scores in the neonate). All of these undesirable
effects warrant a decrease in the dosage of epidural opioids that
are used for analgesia in the laboring patient. The amount of
ropivacaine and fentanyl that were required to attain analgesia
in our study were comparatively high. This could be attributed
to the differences in the techniques of administering analgesia:
Intermittent boluses versus infusion by patient controlled
epidural analgesia (PCEA). Studies have demonstrated that
PCEA labor analgesia consumes significantly lesser amount
of the local anesthetic opioid mixture.[24,25] Interestingly, Tan
et al. (2009),[12] in their study concluded that the A118G single
nucleotide polymorphism of the human mu opioid receptor
(OPRM) gene influences one’s requirement of additional
analgesia.
In the present study, no motor block was observed in both
groups, which is in concordance to others.[17,23,26] However, higher
incidence of motor block in previous studies could be attributed
to higher concentrations of ropivacaine (0.25%, 0.275%,[27]
0.5%[28]). In a Cochrane systematic review of epidural versus
no analgesic in labor that included 38 studies involving 9658
women; 13 of the studies reported hypotension as an adverse
effect.[29] We also observed slight fall in the MAP and heart
rate, but none of the patients had episodes of hypotension and
bradycardia requiring treatment as was also noted earlier[20,26]
that changes in maternal pulse rate (PR) and blood pressure are
not related to change in the dose of local anesthetic.
Injection delivery interval was comparable in both groups,
but it was shorter as compared to others.[20,30,31] The reason for
this difference is probably because other studies included only
Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1
nulliparous parturients, whereas we studied both nullipara and
multipara parturients and a significant correlation between
parity and duration of labor has been found in earlier studies.[32]
In our study, maternal expulsive effort, instrumental delivery,
and neonatal status were comparable in both groups as
observed by others.[17,30,33] Authors of the Cochrane systematic
review (2011)[29] opined that epidural analgesia appeared to
be effective in reducing pain during labor. However, women
who used this form of pain relief were at increased risk of
having an instrumental delivery. Epidural analgesia had no
statistically significant impact on the risk of cesarean section,
maternal satisfaction with pain relief and long-term backache
and did not appear to have an immediate effect on neonatal
status as determined by Apgar scores. However, they also
stated that further research would be helpful to evaluate rare
but potentially severe adverse effects of epidural analgesia on
women in labor and long-term neonatal outcomes. Our study
was not designed with the objective of assessing the mode of
delivery of the parturients participating in the study. Hence,
appropriately powered and designed studies may help in further
researching this aspect of labor analgesia.
No parturient had hypotension, hypersensitivity reaction,
pruritus, nausea, urinary retention, vomiting, respiratory
depression, weakness in the limbs or shivering, though
cases of pruritus,[26] hypotension,[30] have been reported with
epidural labor analgesia. Both concentrations produced
maternal expulsive efforts, parturient and anesthesiologist
acceptance grades in excellent or good range similar to Beilin
(92% satisfaction)[21] and Lee[17] who reported a satisfaction
grade of 8 on a scale of 10 for all concentrations. However,
in our study parturient and anesthesiologist acceptance was
significantly superior in R2 group, which could be attributable
to less breakthrough pain that caused significantly less number
of top-up requirement and VAS also remained significantly low
at various time intervals.
The limitations of this study could be a requirement of a
larger sample size which would give a wider perspective on
maternal and neonatal side-effects. Similarly, a comparison of
intermittent boluses versus a continuous infusion technique
would give a better estimation of local anesthetic and opioid
consumption in both groups.
CONCLUSION
In spite of the above limitations, we have arrived at the conclusion
that both the concentrations are effective in producing labor
analgesia. Group R2 (0.2% ropivacaine) parturients; however,
had a faster onset and significantly longer duration of analgesia
21
[Downloaded free from http://www.joacc.com on Wednesday, July 31, 2019, IP: 103.72.58.58]
Chhetty, et al.: Ropivacaine 0.125% versus 0.2% with fentanyl for labor analgesia
with a single dose and required lesser top-ups, resulting in a
significantly reduced consumption of opioids. Hence, our study
favors, the use of 15 ml of 0.2% ropivacaine with 2 mcg/ml
fentanyl over 0.125% ropivacaine for labor analgesia.
It would be further interesting to evaluate the effect of varying
the dose of administered drugs according to the stages and
intensity of labor, which could further regulate the requirement
of drugs and provide more effective analgesia.
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Conflict of Interest: Chhetty YK, Naithani U, Gupta S, Bedi V, Agrawal I,
Swain L. Epidural labor analgesia: A comparison of ropivacaine 0.125% versus
0.2% with fentanyl. J Obstet Anaesth Crit Care 2013;3:16-22.
Source of Support: Nil, Conflict of Interest: None declared.
Journal of Obstetric Anaesthesia and Critical Care / Jan-Jun 2013 / Vol 3 | Issue 1