Evaluate Efficacy Levobupivacaine 0.125% Versuss Ropivacaine 0.2% in Hemodynamic Alterations in Labor and Fetal Repercussions

Pregnancy Clinical Trial

Official title:

Randomized Clinical Trial to Evaluate the Efficacy of Levobupivacaine 0.125% vs Ropivacaine 0.2%, in Hemodynamic Alterations in Pregnant Women in Labor and Their Fetal Repercussions

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT05877131
• Other study ID #: CEI-pendiente
• Status: Not yet recruiting
• Phase: Phase 4
• Start date: June 1, 2023
• Est. completion date: December 1, 2023

Study information

• Verified date: May 2023
• Source: Althaia Xarxa Assistencial Universitària de Manresa
• Contact: Mauricio Roberto Argañaraz Quinteros, Physician
• Phone: 0034600609107
• Email: mraq1969[@]gmail.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

INTRODUCTION:

Most studies on analgesia in pregnant women in labor mainly evaluate the effect of anesthetics on pain, mentioning hypotension as a side effect without investigating its impact on fetal well-being. The objective of the present study is to evaluate the efficacy of the use of low doses of local anesthetic (LA) to prevent hemodynamic alterations that manifest as a loss of fetal well-being.

METHODOLOGY/DESIGN:

It is a randomized clinical trial. Patients will be pregnant women in labor (dilation period) who want epidural anesthesia (EA), who will randomly receive 0.125% levobupivacaine (Group L) versus 0.2% ropivacaine (Group R). In both groups, controls of hemodynamic parameters and their relationship with changes in fetal heart rate (FHR) and cardiotocographic recording (RCTG) will be carried out during the first 60 minutes after the administration of the local anesthetic via the epidural route. In case of hypotension and/or subsequent FHR and RCTG alterations, they will also be recorded. The follow-up period will extend from the moment the patient enters the delivery room and requests epidural anesthesia until the moment the patient is discharged from the delivery room. The percentage of patients with hemodynamic alterations will be evaluated as a primary result, as well as the percentage of patients whose hemodynamic alterations are related to changes in FHR and RCTG, when using low doses of LA. In the following will also be evaluated in relation to analgesia, the onset time, level reached and degree of satisfaction; and various intra and postpartum side effects.

DISCUSSION:

Both groups of pregnant women in labor will be studied in order to obtain data on the potential impact of the use of low doses of local anesthetic via the epidural route on hemodynamic parameters and the state of well-being of the fetus.

Description:

Any patient presenting in the delivery room or gynecology-obstetrics office of the hospital with prodromes, midwives or gynecologists will inform the principal investigator (PI). The IP will contact the patient to inform them of what the study consists of and if they wish to participate in it. In case of acceptance, the explanatory documentation and a questionnaire will be delivered to determine if it meets the inclusion criteria. If the pregnant patient at term meets the inclusion criteria, she is recruited to enter the study, it will also be used to resolve any doubts that the patient may have. Once the patient has signed the informed consent, the collaborating researcher (CI) of the recruiting center will be notified to contact the Althaia Innovation and Research Unit to find out the patient's assignment group. The collaborating researcher will be in charge of notifying the patient of the group to which she has been assigned (Intervention Group A or B).

Initially, the basal hemodynamic constants will be recorded: systolic blood pressure (SBP), mean blood pressure (TAM), diastolic blood pressure (TAD), pulse pressure (PP), systemic vascular resistance (SVR), cardiac output (CO), index Pulse Pressure Variation (PPV), Stroke Volume Variation (SVV), Heart Rate (HR), Stroke Volume (SV), Partial Pressure Oxygen Saturation (SpO2) via Clearsight device ®; pain score (VAS); degree of anxiety/depression by filling in a questionnaire to complete yourself; the degree of dilation. The FHR will also be recorded, as well as the different pathological patterns of the RCTG that appear, the Philips Avalon FM 30 monitor will be used for this.

The steps to follow for the administration of local anesthetic through the epidural catheter will be the following:

The mother's data (before and after AE) will be collected, including hemodynamic data:

systolic blood pressure (SBP), mean blood pressure (TAM), diastolic blood pressure (TAD), pulse pressure (PP), vascular resistance heart rate (SVR), cardiac output (CO), cardiac index (CI), pulse pressure variation (PPV), stroke volume variation (VSV), heart rate (HR), stroke volume (SV), blood saturation partial pressure of oxygen (SpO2); pain score (VAS), degree of analgesia achieved, satisfaction obtained, time onset of analgesia, level of sensory block using the pin-prick test and the hot-cold test; degree of anxiety/depression by filling in a questionnaire to complete yourself; the degree of dilation. The fetal data (before and after the AE) of the FHR (values above or below the normal limits) will also be included, as well as the different pathological patterns of the RCTG that appear, due to hypotension or alterations. associated hemodynamics.

All pregnant women who will participate in this study will carry an intravenous cannula and will receive a fluid load of 500 cc. The position of the patients will be in a sitting position and the epidural puncture will be performed at the level of the L2-3 or L3-4 intervertebral space using a Tuohy 18 epidural needle. The loss of resistance technique with air or saline will be used according to the standards of our service.

A volume of 2 ml of 2% lidocaine will be administered via the epidural via the epidural catheter, after 3 minutes (it will be evaluated if undesirable effects appear: such as motor block due to accidental dural puncture, hypotension, nausea, vomiting), it will be administered to pregnant women the final volume (10 cc) of the local anesthetic randomly assigned via epidural.

After the administration of the initial bolus (Group A - Group B), the different constants or parameters to be evaluated will be recorded.

The measurement of the different hemodynamic variables will be recorded through a non-invasive device, the Clearsight®. The device will automatically determine the constants, which will be recorded at 5, 10, 15, 30, 45 and 60 minutes.

In the event of recording an episode of hypotension after the first 60 minutes, a record of all the hemodynamic variables evaluated will be made every 5 minutes for the following 60 minutes.

It will be determined which of the local anesthetics at low concentrations administered via the epidural is related to alteration of the hemodynamic parameters. To measure the different parameters, a non-invasive device (Clearsight) will be used, which will determine the existing hemodynamic alterations before, after, and during the first hour after the administration of the initial dose through the lumbar epidural catheter, as well as in the event of an episode. of hypotension or changes in FHR and/or RCTG after the first hour of catheter placement.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 40
• Est. completion date: December 1, 2023
• Est. primary completion date: December 1, 2023
• Accepts healthy volunteers: No
• Gender: Female
• Age group: 18 Years to 40 Years

Eligibility

Inclusion Criteria:

• - Woman > 18 years

• Request epidural anesthesia (EA)

• Expansion period

• Low obstetric risk

• ASA I-II (only one associated comorbidity, example: arterial hypertension, etc.)

• Cervix dilation = 3

• single fetus

• Gestational age > 36 weeks

• Normal Fetal Heart Rate (110 -160 beats / minute)

• Normal Cardiotocographic record or absence of fetal heart rate patterns suggestive of risk of loss of fetal well-being or non-reassuring cardiotocographic record.

Exclusion Criteria:

• VAS = 2

• Breech presentation

• Maternal fever > 38 years

• Pre-eclampsia and severe eclampsia

• Prenatal bleeding

• ASA II (more than one comorbidity)

• Chronic pain

• Substance abuse

• Contraindications for epidural analgesia (EA)

• Allergy to local anesthetics

• BMI >40 kg/m²

• Presence of RCTG not reassuring

Related Conditions & MeSH terms

• Epidural
• Fetal Cardiac Disorder
• Heart Diseases
• Hemodynamic Instability
• Pregnancy

Intervention

Drug:
• Levobupivacaine
To evaluate the efficacy of low-dose levobupivacaine (0.125%) (0.2) in avoiding hemodynamic changes after performing regional analgesia in pregnant women in labor and preventing changes in fetal heart rate and cardiotocographic recording.
• Ropivacaine
To evaluate the efficacy of low-dose ropivacaine (0.2) in avoiding hemodynamic changes after performing regional analgesia in pregnant women in labor and preventing changes in fetal heart rate and cardiotocographic recording.

Locations

Country	Name	City	State
Spain	Althaia Xarxa Assitensial i Universitaria Manresa	Manresa	Barcelona

Sponsors (1)

Lead Sponsor	Collaborator
Althaia Xarxa Assistencial Universitària de Manresa

Country where clinical trial is conducted

Spain, 

References & Publications (9)

ACOG Committee on Practice Bulletins. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 44, July 2003. (Replaces Committee Opinion Number 252, March 2001). Obstet Gynecol. 2003 Jul;102(1):203-13. No abstract available. — View Citation

Collins KM, Bevan DR, Beard RW. Fluid loading to reduce abnormalities of fetal heart rate and maternal hypotension during epidural analgesia in labour. Br Med J. 1978 Nov 25;2(6150):1460-1. doi: 10.1136/bmj.2.6150.1460. — View Citation

Hofmeyr G, Cyna A, Middleton P. Prophylactic intravenous preloading for regional analgesia in labour. Cochrane Database Syst Rev. 2004 Oct 18;2004(4):CD000175. doi: 10.1002/14651858.CD000175.pub2. — View Citation

Kubli M, Shennan AH, Seed PT, O'Sullivan G. A randomised controlled trial of fluid pre-loading before low dose epidural analgesia for labour. Int J Obstet Anesth. 2003 Oct;12(4):256-60. doi: 10.1016/S0959-289X(03)00071-2. — View Citation

Lappen JR, Chien EK, Mercer BM. Contraction-Associated Maternal Heart Rate Decelerations: A Pragmatic Marker of Intrapartum Volume Status. Obstet Gynecol. 2018 Oct;132(4):1011-1017. doi: 10.1097/AOG.0000000000002808. — View Citation

Peyronnet V, Roses A, Girault A, Bonnet MP, Goffinet F, Tsatsaris V, Lecarpentier E. Lower limbs venous compression reduces the incidence of maternal hypotension following epidural analgesia during term labor. Eur J Obstet Gynecol Reprod Biol. 2017 Dec;219:94-99. doi: 10.1016/j.ejogrb.2017.10.016. Epub 2017 Oct 16. — View Citation

Preston R, Crosby ET, Kotarba D, Dudas H, Elliott RD. Maternal positioning affects fetal heart rate changes after epidural analgesia for labour. Can J Anaesth. 1993 Dec;40(12):1136-41. doi: 10.1007/BF03009602. — View Citation

Umstad MP, Ross A, Rushford DD, Permezel M. Epidural analgesia and fetal heart rate abnormalities. Aust N Z J Obstet Gynaecol. 1993 Aug;33(3):269-72. doi: 10.1111/j.1479-828x.1993.tb02083.x. — View Citation

Valensise H, Lo Presti D, Tiralongo GM, Pisani I, Gagliardi G, Vasapollo B, Frigo MG. Foetal heart rate deceleration with combined spinal-epidural analgesia during labour: a maternal haemodynamic cardiac study. J Matern Fetal Neonatal Med. 2016;29(12):1980-6. doi: 10.3109/14767058.2015.1072156. Epub 2015 Aug 28. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Systemic vascular resistance ( units of measure:dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	10 minutes before epidural
Primary	Systemic vascular resistance ( units of measure:dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	5 minutes after epidural
Primary	Systemic vascular resistance ( units of measure:dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	10 minutes after epidural
Primary	Systemic vascular resistance ( units of measure:dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	15 minutes after epidural
Primary	Systemic vascular resistance ( units of measure:dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	30 minutes after epidural
Primary	Systemic vascular resistance ( units of measure:dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	45 minutes after epidural
Primary	Systemic vascular resistance ( units of measure :dyn*s/cm5)	Systemic vascular resistance (SVR) is expressed by the equation: SVR = (MAP - CVP)/CO, where MAP is mean arterial pressure and CVP is central venous pressure.	60 minutes after epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	10 minutes before epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	5 minutes after epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	10 minutes after epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	15 minutes after epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	30 minutes after epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	45 minutes after epidural
Secondary	Systolic Blood Pressure (units of measure :mmHg)	Systolic pressure refers to the pressure of blood in the artery when the heart contracts. It is the upper (and highest) number in a blood pressure measurement.	60 minutes after epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	10 minutes before epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	5 minutes after epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	10 minutes after epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	15 minutes after epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	30 minutes after epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	45 minutes after epidural
Secondary	Diastolic Blood Pressure (units of measure :mmHg)	Diastolic blood pressure refers to the pressure of blood in the artery when the heart relaxes between beats. It is the lower (and lower) number in a blood pressure measurement.	60 minutes after epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	10 minutes before epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	5 minutes after epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	10 minutes after epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	15 minutes after epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	30 minutes after epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	45 minutes after epidural
Secondary	Mean Arterial Pressure (units of measure :mmHg)	Mean arterial pressure (MAP) is determined by cardiac output (CO), peripheral vascular resistance (PVR), and central venous pressure (CVP). The formula that integrates these concepts is: PAM = (GC x RVP) + PVC	60 minutes after epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	10 minutes before epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	5 minutes after epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	10 minutes after epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	15 minutes after epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	30 minutes after epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	45 minutes after epidural
Secondary	Pulse Pressure (units of measure :mmHg)	Pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), and is an index of arterial compliance.	60 minutes after epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	10 minutes before epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	5 minutes after epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	10 minutes after epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	15 minutes after epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	30 minutes after epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	45 minutes after epidural
Secondary	Cardiac Output (units of measure :L/min)	The volume of blood pumped from a ventricle each minute is known as cardiac output. It is the product of heart rate and stroke volume: Cardiac output = heart rate x stroke volume	60 minutes after epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area	10 minutes before epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area	5 minutes after epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area	10 minutes after epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Arealimits) will also be included	15 minutes after epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area	30 minutes after epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area	45 minutes after epidural
Secondary	Cardiac Index ( units of measure :L/min/m2)	A cardio dynamic measure based on the cardiac output, which is the amount of blood the left ventricle ejects into the systemic circulation in one minute, measured in liters per minute (l/min). Cardiac output is indexed to a patient's body size by dividing by the body surface area to yield the cardiac index.; Cardiac Index = Cardiac Output / Body Surface Area = (Heart Rate * Stroke Volume) / Body Surface Area	60 minutes after epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	10 minutes before epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	5 minutes after epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	10 minutes after epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	15 minutes after epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	30 minutes after epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	45 minutes after epidural
Secondary	Pulse Pressure Variation ( units of measure :% Percent)	Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict the increase in cardiac output after fluid administration. Ideally, PPV measurement should be performed with a closed chest and mechanical ventilation with a tidal volume of 8 mL/kg.PPV was calculated as the percentage changes in arterial pulse pressure during a ventilatory cycle as [(PPmax - PPmin)/(PPmax; + PPmin)/2] × 100, where PPmax and PPmin represent the maximal and minimal arterial pulse pressure, respectively	60 minutes after epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	10 minutes before epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	5 minutes after epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	10 minutes after epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	15 minutes after epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	30 minutes after epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	45 minutes after epidural
Secondary	(Maternal) Heart Rate (units of measure: beats per minute)	The number of times the heart beats during a certain period, usually one minute.; The resting heart rate normally ranges from 60 to 100 beats per minute in a healthy adult at rest.	60 minutes after epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	10 minutes before epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	5 minutes after epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	10 minutes after epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	15 minutes after epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	30 minutes after epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	45 minutes after epidural
Secondary	Stroke Volume (units of measure :ml)	Stroke volume is the volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction. The SV volume may be calculated as the difference between the left ventricular end-diastolic volume and the left ventricular end-systolic volume (ESV).	60 minutes after epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	10 minutes before epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	5 minutes after epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	10 minutes after epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	15 minutes after epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	30 minutes after epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	45 minutes after epidural
Secondary	Systolic Variation Volume ( units of measure :% Percent)	Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness.SVV is assessed using the following equation: SVV (%) = (SVmax - SVmin)/SVmean	60 minutes after epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	10 minutes before epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	5 minutes after epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	10 minutes after epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	15 minutes after epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	30 minutes after epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	45 minutes after epidural
Secondary	Arterial Oxigen Saturation ( units of measure :% Percent)	Arterial oxygen saturation (SaO2) is a measure of hemoglobin oxygenation in the arterial compartment of the circulatory system. It is not a measure of the total oxygen content in the arterial blood because a small fraction of oxygen (about 2%) is dissolved in the plasma. To determine overall oxygen-carrying capacity of the blood, multiply 1.34 ml/g by the patient's hemoglobin level in g/dL and by Spo2.	60 minutes after epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	10 minutes before epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	5 minutes after epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	10 minutes after epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	15 minutes after epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	30 minutes after epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	45 minutes after epidural
Secondary	Fetal heart rate (units of measure: beats per minute)	The average fetal heart rate is between 110 and 160 beats per minute. It can vary by 5 to 25 beats per minute. The fetal heart rate may change by differents conditions in the uterus. An abnormal fetal heart rate may mean that is not getting enough oxygen or that there are other problems.	60 minutes after epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	10 minutes before epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	5 minutes after epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	10 minutes after epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	15 minutes after epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	30 minutes after epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	45 minutes after epidural
Secondary	Variability (units of measure: beats per minute)	This the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace	60 minutes after epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	10 minutes before epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	5 minutes after epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	10 minutes after epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	15 minutes after epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	30 minutes after epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	45 minutes after epidural
Secondary	Accelerations (units of measure: beats per minute)	These are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.	60 minutes after epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	10 minutes before epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	5 minutes after epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	10 minutes after epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	15 minutes after epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	30 minutes after epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	45 minutes after epidural
Secondary	Decelerations (units of measure: beats per minute)	These are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds.	60 minutes after epidural