PubMed · 6998326
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S Datta, M H Alper. 1980. Anesthesia for cesarean section.. https://doi.org/10.1097/00000542-198008000-00008
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OBJECTIVE: To determine whether epidural anaesthesia during labour and delivery is a risk factor for postpartum back pain. DESIGN: Prospective cohort study with follow up at one day, seven days, and six weeks after delivery. SETTING: Teaching hospital in Montreal. SUBJECTS: 329 women who delivered a live infant(s) during the study period. Exclusion criteria were back pain before pregnancy and delivery by elective caesarean section. INTERVENTION: Epidural anaesthesia during labour and delivery. MAIN OUTCOME MEASURES AND RESULTS: The primary outcome variable was development of postpartum low back pain. Back pain was quantified with self reports (yes/no), a pain score (numeric rating scale), and degree of interference with daily activities. Of the 329 women, 164 received epidural anaesthesia during labour and 165 did not. The incidence of low back pain in epidural v non-epidural group was 53% v 43% on day one; 21% on day seven; and 14% v 7% at six weeks. The relative risk for low back pain (epidural v non-epidural) adjusted for parity, delivery, ethnicity, and weight was 1.76 (95% confidence interval 1.06 to 2.92) on day one; 1.00 (0.54 to 1.86) on day seven; and 2.22 (0.89 to 5.53) at six weeks. There were no differences between the two groups in pain scores or the frequency of interference with daily activities. Similar results were obtained in the subgroup of women with low back pain of new onset--that is, those women with no back pain during their pregnancy. CONCLUSIONS: Postpartum low back pain was common but decreased considerably over the short term. The association between epidural anaesthesia and postpartum low back pain was inconsistent over time with a significantly increased risk of low back pain (epidural v non-epidural) noted only on the first day after delivery.
Epidural analgesia has a well-established role in labour, but has the drawbacks of delayed onset and motor blockade. The combined spinal-epidural technique may overcome these drawbacks. We carried out a randomised observational study to assess maternal satisfaction with the standard and combined techniques among 197 women in labour. For combined spinal-epidural analgesia, bupivacaine (2.5 mg) and fentanyl (25 micrograms) were initially injected into the subarachnoid space, followed by top-ups of 15 mL 0.1% bupivacaine with 2 micrograms/mL fentanyl into the epidural space, as required. For standard epidural analgesia, 25 mg (10 mL of 0.25%) bupivacaine was injected into the epidural space, followed by top-ups of 6-10 mL 0.25% bupivacaine, as required. Post partum, each woman completed a questionnaire about her labour and scored various items on a visual analogue scale (0 = best, 100 = worst outcome). Overall satisfaction was greater in the combined spinal-epidural group than in the standard epidural group (median [IQR] score 3 [2-10] vs 9 [3-22]; p = 0.0002). Good analgesia was achieved in both groups, but the combined spinal-epidural had faster onset of analgesia and more of this group were satisfied with analgesia at 20 min (92/98 vs 68/99, p < 0.0001). 12 women in the combined spinal-epidural group had leg weakness (as shown by an inability to raise the straight legs) at 20 min, but this initial motor block had resolved in most of these mothers by 1 h. In the standard epidural group 32 had leg weakness at 20 min (p = 0.001), and the proportion of mothers with weakness increased in this group during labour. There were no differences in side-effects, except for mild pruritus, which was more common in the combined spinal-epidural group (42 vs 1%; p < 0.0001). Overall, women seem to prefer the low-dose combined spinal-epidural technique to standard epidurals, perhaps because of the faster onset, less motor block, and feelings of greater self-control.
A 58-year old man who had combined spinal-epidural anaesthesia for a total knee alloplasty suffered a sudden and unexpected cardiac arrest during an otherwise uncomplicated anaesthesia. The patient was promptly resuscitated by ephedrine i.v. The reason for the cardiac arrest is thought to be relative hypovolaemia. The importance of monitoring the patient, giving proper fluid-treatment and early use of ephedrine is emphasized.