Combined spinal epidural for labor using sufentanil epidurally versus intrathecally: influence on fetal heart rate

Background: Non-reassuring changes in foetal heart trace following combined spinal epidural for labour are at times attributed to the intrathecal use of opioids. We retrospectively compared a protocol using sufentanil and ropivacaine intrathecally with a protocol in which only ropivacaine was administered intrathecally and sufentanil was used solely epidurally. Methods: 520 cardiotocographic tracings were examined for changes in foetal heart rate and uterine activity following combined spinal epidural analgesia. Corresponding charts were consulted for neonatal and labour outcome. In 231 cases the combined spinal epidural consisted of 3 mg ropivacaine together with 2.5 µg sufentanil intrathecally. In 289 cases 4 mg ropivacaine was used intrathecally followed by an epidural administration of 7.5 µg sufentanil. Results: Foetal heart rate patterns were found to be more prosperous when sufentanil was used solely epidurally, evidenced by a higher percentage of normal tracings (74.5% with respect to 60.4% when sufentanil was used intrathecally; p=0.007) and more tracings displaying 3 or more accelerations in foetal heart rate in 45 minutes (93.5% with respect to 83.9%; p-value of 0.003) together with less tracings showing bradycardia (7.5% with respect to 14.1%; p-value 0.035) and less tachycardia (3.5% with respect to 11.4% ; p-value 0.005). There were no differences in labour and neonatal outcome. Conclusions: In view of the foetal heart trace it may be favourable to ban sufentanil from the intrathecal compartment. This retrospective study provides arguments to introduce 4 mg ropivacaine intrathecally followed by epidural administration of 7.5 µg sufentanil as a valuable alternative for combined spinal epidural.

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