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Excerpt
Intrathecal analgesia (ITA) is deemed particularly appropriate in late, rapidly progressing labor in multiparous women or when ambulation during labor is wanted. In 1998, the authors' hospital implemented routine use of single-shot spinal block in multiparae in advanced labor, after a pilot study (n=63) showed that 78% of parturients found spinal analgesia excellent in first-stage and 47% in second-stage labor. In 2002, as part of a quality assurance program, they prospectively assessed the efficacy, anesthetic-related complications, obstetric/neonatal outcomes, and maternal satisfaction with single-shot spinal block.
Over a period of 6 mo, consecutive multiparous women in active, rapidly progressing labor and requesting spinal analgesia were recruited. Standard ITA was performed at either L2-3 or L3-4 interspace, in lateral or sitting position, with hypobaric bupivacaine 2.5 mg (l mL) and fentanyl 25 μg (0.5 mL). Women remained in lateral position with slight head-up for 5 min, then took the opposite lateral position. Routine monitoring was used and visual analog pain scores (VAPS), sensory levels, motor block, side effects, and maternal satisfaction was recorded. "Satisfactory analgesia" was a decrease in pain scores to less than or equal to 3 within 20 min after injection.
Of 671 multiparae giving birth during this period, 268 (39.9%) received single-shot spinal block, with 209 included in analysis. Of these, 153 women (73%) achieved satisfactory analgesia within 20 min; 55 (26%) requested additional analgesia, 38 (18%) because of unsatisfactory pain relief, and 17 (8%) because block ended before delivery. Rescue analgesia used most often was nitrous oxide. Mean duration of analgesia was 101±34 min. On postpartum day 1; 136 (65%) women called their pain relief "excellent"; 41 (20%), "moderately adequate." Overall, 169 (81%) would request single-shot spinal block again; only 13 (6%) would not, due to inadequate analgesia or too many side effects (one). The most common maternal side effect was pruritus (134 subjects [64%]); others were shivering (22), leg weakness (8), hypotension (5) sedation (1), and nausea (1). Fetal bradycardia occurred in 15 (7%) cases; 10 during second stage, and 5 within 1 h of spinal block (none were associated with maternal hypotension or uterine hypertonicity). Spinal block at interspace L2-3 (used in 49% of cases) resulted in lower pain scores (P<0.05) and fewer requests for rescue medication than in L3-4 (P=0.1). Dilation at time of block did not affect pain scores or need for rescue analgesia.
The authors concluded that single-shot spinal analgesia is a viable method in most multiparous women in active labor; however, improvements are warranted. Of most importance is reliability of block, which may be improved by alternative patient positioning, a different IT solution or dosage, or greater use of CSEA. Further investigations are needed to determine the incidences of long-term complications associated with spinal block (e.g., post-dural puncture headache and transient neurological symptoms) in this population.
