First Child Delivery With Epidural Clinical Trial
Official title:
Comparison of Two Methods of Administration of the Epidural, by Programmed Intermittent Bolus or Continuous Perfusion, on the Incidence of Cesarean Sections and Instrumented Deliveries in Primiparous Women
The epidural has been recognized for many years as the most effective analgesia method for
obstetrical labor. Several different administration protocols have been evaluated over the
years with the aim of reducing side effects.
Epidurals have been incriminated in the increase of instrumented births. It is indeed
possible that the motor block induced by the epidural reduces the pelvic tonus and the
ability of the mother to push during the second stage of the labor. Furthermore, this motor
block might lead to a ill rotation of the foetal head within the pelvis, which could lead to
instrumentation (suction cups, forceps).
In the investigator's institution, an ongoing study also provided interim that showed that
the use of a low concentration of local anesthetics (as opposed to a higher concentration)
tends to decrease the instrumentation and cesarean sections rate in the institution's
population.However, the optimal administration mode of the local anesthetic in the epidural
remains unknown.
In the last few years, there has been a growing interest for a new method of administration
of the solution within the epidural, by programmed intermittent bolus. This method allows a
better distribution of the local anesthetics in the epidural space, compared to a continuous
perfusion.
This study therefore focuses on the relationship between the use of epidural with programmed
intermittent boluses and the rate of instrumented deliveries and cesarean sections.
The exact mode of administration of boluses is also subject to discussion in the literature.
One can question whether it is preferable to administer smaller boluses more frequently or
larger less frequent boluses. A few studies have investigated this issue and recommend to
administer larger and more spaced bolus (10 mL to 60 minutes).This better matches the sought
after physiology (ie a wider distribution in the epidural space) and provides equivalent
analgesia to smaller, more frequent boluses.
The epidural has been recognized for many years as the most effective analgesia method for
obstetrical labor. Several different administration protocols have been evaluated over the
years with the aim of reducing side effects.
Epidurals have been incriminated in the increase of instrumented births. It is indeed
possible that the motor block induced by the epidural reduces the pelvic tonus and the
ability of the mother to push during the second stage of the labor. Furthermore, this motor
block might lead to a ill rotation of the foetal head within the pelvis, which could lead to
instrumentation (suction cups, forceps).
In 2001, the COMET study showed that the use of low anesthetics concentrations decreases the
motor bloc and allows to increase the rate of vaginal deliveries and decrease the rate of
instrumented births.
In the investigator's institution, an ongoing study also provided interim that showed that
the use of a low concentration of local anesthetics (as opposed to a higher concentration)
tends to decrease the instrumentation and cesarean sections rate in the institution's
population.
However, the optimal administration mode of the local anesthetic in the epidural remains
unknown.
In the last few years, there has been a growing interest for a new method of administration
of the solution within the epidural, by programmed intermittent bolus. This method allows a
better distribution of the local anesthetics in the epidural space, compared to a continuous
perfusion.
Several studies have been performed and show that this mode of administration allows to
decrease the local anesthetics injected dosis and gives a better maternal satisfaction. A
meta-analysis performed in 2013 also shows a tendency towards the decrease of instrumented
deliveries with this method. Sadly, no studies up to this date have the needed power to prove
this point with certainty.
This study therefore focuses on the relationship between the use of epidural with programmed
intermittent boluses and the rate of instrumented deliveries and cesarean sections.
The exact mode of administration of boluses is also subject to discussion in the literature.
One can question whether it is preferable to administer smaller boluses more frequently or
larger less frequent boluses. A few studies have investigated this issue and recommend to
administer larger and more spaced bolus (10 mL to 60 minutes).This better matches the sought
after physiology (ie a wider distribution in the epidural space) and provides equivalent
analgesia to smaller, more frequent boluses.
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