title: Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: the effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women.
abstract: BACKGROUND
  Programmed intermittent epidural anesthetic bolus (PIEB) technique may result in reduced total local anesthetic consumption, fewer manual boluses, and greater patient satisfaction compared with continuous epidural infusion (CEI). In this randomized, double-blind study, we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia. The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery.
  
  
  METHODS
  Nulliparous, term women with spontaneous labor and cervical dilation <4 cm were eligible to participate in the study. Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625% with sufentanil 0.5 μg/mL. After an initial epidural loading dose of 20 mL, patients were randomly assigned to receive PIEB (10 mL every hour beginning 60 minutes after the initial dose) or CEI (10 mL/h, beginning immediately after the initial dose) for the maintenance of analgesia. Patient-controlled epidural analgesia (PCEA) using a second infusion pump with levobupivacaine 0.125% was used to treat breakthrough pain. The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor; the end point was any motor block in either limb. We also evaluated PCEA bolus doses and total analgesic solution consumption.
  
  
  RESULTS
  We studied 145 subjects (PIEB = 75; CEI = 70). Motor block was reported in 37% in the CEI group and in 2.7% in the PIEB group (P < 0.001; odds ratio = 21.2; 95% CI: 4.9-129.3); it occurred earlier (P = 0.008) (hazard ratio = 7.8; 95% CI: 1.9-30.8; P = 0.003) and was more frequent at full cervical dilation in the CEI group (P < 0.001). The incidence of instrumental delivery was 20% for the CEI group and 7% for the PIEB group (P = 0.03). Total levobupivacaine consumption, number of patients requiring additional PCEA boluses, and mean number of PCEA boluses per patient were lower in the PIEB group (P < 0.001). No differences in pain scores and duration of labor analgesia were observed.
  
  
  CONCLUSIONS
  Maintenance of epidural analgesia with PIEB compared with CEI resulted in a lower incidence of maternal motor block and instrumental vaginal delivery.
authors.affiliation: Department of Anesthesia, Città di Roma Hospital, Via Maidalchini 20, 00151 Roma, Italy. dipartimento.anestesia@gruppogarofalo.com
authors.forename: Giorgio
authors.initials: G
authors.lastname: Capogna
authors.forename: Michela
authors.initials: M
authors.lastname: Camorcia
authors.forename: Silvia
authors.initials: S
authors.lastname: Stirparo
authors.forename: Alessio
authors.initials: A
authors.lastname: Farcomeni
mesh_terms: D000328:Adult; D016362:Analgesia, Obstetrical / Q000009:adverse effects / Q000379:methods*; D016058:Analgesia, Patient-Controlled / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D002045:Bupivacaine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives; D016009:Chi-Square Distribution; D004311:Double-Blind Method; D004338:Drug Combinations; D005113:Extraction, Obstetrical; D005260:Female; D006801:Humans; D007263:Infusions, Parenteral; D007268:Injections, Epidural; D007558:Italy; D053208:Kaplan-Meier Estimate; D048949:Labor Pain / Q000188:drug therapy*; D000077554:Levobupivacaine; D009043:Motor Activity / Q000187:drug effects*; D016017:Odds Ratio; D010147:Pain Measurement; D010298:Parity; D011247:Pregnancy; D016016:Proportional Hazards Models; D011446:Prospective Studies; D017409:Sufentanil / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D004338:Drug Combinations; D000077554:Levobupivacaine; D017409:Sufentanil; D002045:Bupivacaine