title: A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during first and second stages of labor and at delivery.
abstract: BACKGROUND
  There has been no prospective evaluation of combined spinal-epidural (CSE) analgesia in a private practice setting and few studies have focused on pain relief during the second stage of labor and at delivery. In this randomized controlled trial, we compared verbal pain scores during the first and second stages of labor and at delivery in women receiving CSE or traditional epidural analgesia at a busy private maternity hospital.
  
  
  METHODS
  Healthy, term parturients received epidural or CSE analgesia for labor pain upon request. Epidural analgesia was initiated with 0.125% bupivacaine plus 2 μg/mL fentanyl, 15 mL; CSE analgesia was initiated with intrathecal plain bupivacaine 3.125 mg plus 5 μg fentanyl. Thereafter, patient-controlled epidural analgesia with 0.125% bupivacaine plus 2 μg/mL fentanyl was used for maintenance analgesia in both groups. The primary outcome was an assessment of "typical" pain, using a verbal rating pain score from 0 to 10, made at the end of the first stage of labor and shortly after delivery.
  
  
  RESULTS
  Data from 398 epidural and 402 CSE subjects were analyzed. The typical verbal rating pain score during the first stage was lower in the CSE group (mean: 1.4 vs 1.9; P < 0.001; 99.5% confidence interval [CI] for difference: -0.92, -0.14). Pain scores during the second stage of labor (1.7 vs 1.9; P = 0.17; 99.5% CI for difference: -0.82, 0.28) and at delivery (2.0 vs 2.0; P = 0.77; 99.5% CI for difference: -0.73, 0.59) were the same between groups. Fewer patients received an epidural top-up dose in the CSE group (16.4% vs 25.6%; P = 0.002; 99.5% CI for difference: -17.0%, -1.0%). Epidural catheters were replaced in 1.2% CSE vs 2% in the epidural group (P = 0.39; 99.5% CI for difference: -3.3%, 1.8%).
  
  
  CONCLUSIONS
  Compared with traditional epidural labor analgesia, CSE analgesia provided better first-stage analgesia despite fewer epidural top-up injections by an anesthesiologist.
authors: Department of Anesthesiology, Sharp Mary Birch Hospital for Women and Newborns, 3003 Health Center Dr., San Diego, CA 92123, USA. dgamb@san.rr.com
authors: David
authors: D
authors: Gambling
authors: Jonathan
authors: J
authors: Berkowitz
authors: Thomas R
authors: TR
authors: Farrell
authors: Alex
authors: A
authors: Pue
authors: Dennis
authors: D
authors: Shay
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000379:methods*; D016362:Analgesia, Obstetrical / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage; D036861:Delivery, Obstetric / Q000379:methods*; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007743:Labor, Obstetric / Q000187:drug effects* / Q000502:physiology; D010147:Pain Measurement / Q000187:drug effects / Q000379:methods*; D011247:Pregnancy; D011256:Pregnancy Outcome; D011331:Private Practice; D055815:Young Adult
chemical_list: D000779:Anesthetics, Local