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28: Obstetric outcomes and maternal satisfaction using patient controlled epidural analgesia in nulliparous women

      Objective

      Patient-controlled epidural analgesia (PCEA) has been shown to reduce local anesthetic use during labor. It is unclear if obstetric outcomes and maternal satisfaction are improved with the use of PCEA. Our aim was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor using PCEA vs continuous epidural infusion (CEI).

      Study Design

      We conducted a double-masked trial in which 270 nulliparous women were randomized to one of three groups. Initially, an intrathecal dose of 2 mg bupivicaine/20mcg fentanyl was given followed by maintenance epidural infusion 0.1% bupivicaine/2 mcg/ml fentanyl. Group 1 CEI background only (10 mls/hr); Group 2 CEI+PCEA(CEI at 10 ml/hr plus PCEA 10 ml, 20 min lockout; Group 3 PCEA only (PCEA 10 ml, 20 min lockout). PCEA bolus button was given to each subject and the pump acknowledged the request regardless of group assignment. The primary outcome was dosage of local anesthetic used. Secondary outcomes include obstetric outcomes and maternal satisfaction.

      Results

      Total mg bupivicaine used was less in the PCEA only group compared to CEI; group 1 (74.9 ± 36 mg), group 2 (95.9 ± 52 mg), group 3 (52.8 ± 42 mg) p<.001. No differences were seen in total time of labor; group 1 (8.4 hr), group 2 (7.9 hr), group 3 (8.0 hr) or cesarean delivery; group 1 (26/87), group 2 (23/84), and group 3 (22/85). Number of instrumented vaginal deliveries was slightly higher in subjects with a continuous background infusion; group 1 (8/87), group 2 (8/84), group 3 (3/85). Neither lower extremity strength or urge to push were affected by method of epidural. Pain with pushing, however, was worse in PCEA only. Median satisfaction scores were similar; 0 (best)-100(worst); group 1: 0 (0-100), group 2: 0 (0-100), group 3: 0 (0-100).

      Conclusions

      PCEA results in less anesthetic used and maternal satisfaction remains high without a continuous infusion. Cesarean delivery and time of labor are unaffected by using PCEA alone. There was a trend toward reduction in instrumented vaginal deliveries in the PCEA only group.