Introduction

In the modern era every woman wants to deliver the child with joy and smile, not with pain and tears. Many methods of pain relief were tried since pre-historic era, but with the invention of syringe and needle and the era of MRI and CT Scan the definition of pain and methods of pain relief have changed. Epidural analgesia is one of the safe, effective and documented methods of pain relief. Addition of narcotic analgesics is a well established method. To study the benefits of addition of sufentanyl with bupivacaine epiduraly for labor analgesia was the main aim of this study.

Other objectives were to compare the efficacy of Sufentanyl epiduraly, its hemodynamic effects, effects on foetal outcome, and the side effects.

Inclusion criteria were age 18 – 35 years, A S A grade 1 and 2, A N C registered cases with basic obstetric workup .

Exclusion criteria were patient's refusal, known allergies, contraindications to regional techniques and bad obstetric history

Material and methods

A prospective and randomized study of 50 cases was done during the period of January 2006 to June 2007. The procedure of epidural analgesia was explained to the patients and consent was obtained. After thorough clinical and obstetric examination all the vitals were noted, Pulse B P, E C G FHR, and cervical dilation. The patients were preloaded with 500 ml of Ringer lactate. Under all aseptic precautions an epidural catheter was introduced in the L2 -L3 space in sitting position. The patients were divided into two groups. Group 1 received 10 c.c of 0.125% bupivacaine with 10 microgram of sufentanyl and group 2 received plain bupivacaine of 0.125 %. In case of inadequate pain relief further top ups were titrated to the patients need, to a maximum of 15 cc of total volume if VAS score was > 5 after initial dose of drug. Vitals were monitored till 6 hours post delivery. Any complication like hypotension, nausea vomiting, sedation, pruritus, high sensory or motor blockage during the procedure was noted and treated accordingly. Pain score was graded on visual analogue scale and assessed prior to epidural placement, immediately after injection of drugs than every half hourly till delivery of the baby. The maximum VAS was recorded and regarded as a measure of quality of analgesia. The mode of delivery, foetal apgar score, any complication like foetal tachycardia, bradycardia, resuscitation of the newborn, feeding problems, and N I C U stay were noted. Data were analyzed using chi square test, independent t test, and paired test. Bon ferroni correction was applied for paired t test.

Results and observations

Figure 1

Table 1: Maternal data

Figure 2

Table 2: Educational status

Figure 3

Table 3: Obstetric outcome

Figure 4

Table 4: Patient's opinion for pain relief

Figure 5

Table 5: Maternal complications

Figure 6

Table 6: Foetal complications

Figure 7

Graph 1: Showing changes in blood pressure

Figure 8

Graph 2: Showing changes in heart rate

Figure 9

Graph 3: Showing changes in V A S Score

Figure 10

Graph 4: Showing requirement of no of top ups

Figure 11

Graph 5: Showing changes in Apgar score.

Discussion

Opioids are a popular choice for labour analgesia since ages. Sufentanyl is a newer synthetic opioid pure µ receptor agonist, 5 to 10 times potent than fentanyl ₈ . Onset of action by epidural route is five minutes. Minimum dose required as a sole agent is 21.1 microgram as shown in study in 66 null Para ₄. Steinburg et al showed that a dose of 5 microgram and 50 microgram of sufentanyl as a sole agent did not make a significant difference ₇. Erickson et al showed that a combination of 10-15 microgram of sufentanyl + 10 c.c of 0.125% bupivacaine can be repeated twice after 1 hr.₂ Increased motor blockade with increased concentration of local anesthesia causes pelvic muscle relaxation, fetal malposition, and maternal inability to push and a high incidence of instrumental delivery ₁. In our study with10 microgram of sufentanyl, a significant difference in VAS Score was observed between both the groups. Top up was given when Vas Score was more than 5 and top ups were more in the bupivacaine group. Maternal satisfaction was higher in the sufentanyl group with the P value of 0.0533. Hemodynamic changes in heart rate and BP was higher in the plain bupivacaine group whereas the sufentanyl group patients were more stable with the p value of <0.01 which is significant. There was a decrease in motor blockade, minimal changes in B.P., no difference in caesarian section rate, and no increase in postdural puncture headache ₆. M . Van der Vyer showed fewer analgesic interventions, reduced requirement of local anesthetic and reduced motor blockade, increased patient satisfaction is seen in patient controlled epidural analgesia with no difference in caesarian section and instrument delivery ₅. In our study, no increase in instrumentation was seen in either group. Addition of sufentanyl decreased the requirement of bupivacaine and increased the duration of analgesia. Pruritus as a common complication of sufentanyl as documented in literature was not seen in our study; low dose might be the reason. Other reported complications are maternal fever with epidural labor analgesia and neonatal sepsis which was not seen .₉ No adverse effect were seen on breast feeding₃. Out of 50 neonates, 1 neonate needed bag and mask ventilation for apnea, and the 2 minutes apgar score was normal.

Conclusion

10 microgram sufentanyl achieves reduction in dose of bupivacaine and reduces related complications. It does not increase fetal complications and it has a definite role in labour analgesia.

Acknowledgement

Correspondence to

drmanjusarkar@yahoo.com manjusarkar@hotmail.com Phone no 26212680 Cell no 9869984017