Comparative Study between Epidural Analgesia, Intrathecal Analgesia and Intravenous Remifentanil Analgesia in Management of Labor Pain

Background: Epidural analgesia is considered to be the standard method of labor analgesia, however the intrathecal (spinal) analgesia provides rapid onset with smaller doses of drugs and the intravenous remifentanil is the easiest method with rapid onset and offset. Aim of the study: To compare the analgesic efficacy, side effects and maternal satisfaction in these three methods. Method: A sample of 75 full term pregnant women at labor were recruited for this clinical trial , during the period from April 2017 to March 2018 at AL Basra General Hospital .They precluded into 3 equal groups each with 25 parturients . Epidural group: parturients received continuous epidural infusion with a combination of bupivacaine 0.1%and fentanyl 2μg/ml at rate of 10-15 ml/hour. Intrathecal (spinal) group: parturients received intrathecal (spinal) single-dose of a combination of bupivacaine 2.5 mg and fentanyl 25 μg. Intravenous remifentanil group: parturients received (continuous) intravenous infusion of remifentanil 0.05—0.07 μg/kg/min and a bolus (20-60 μg) doses were given during the peak of uterine contraction . Data collected were; Labor pain intensity measured by numerical rating scale (NRS) 0-10. NRS>3 was considered as failure of analgesia, maternal vital signs, with SPO2 and level of consciousness were observed every 15 minutes ( in first  hour) then every 30 minutes till delivery. Fetal heart rates were observed by continuous cardiotocography machine. Results: There were no significant differences between the characters of parturients in the three groups. Epidural analgesia provided the leas pain scores during the first stage of labor with means of NRS 1.8 ± I.5.The mean time onset of analgesia was 11±3.3 minutes in the epidural group, 5.2±1minutes in the spinal group, and 2.7± 0.7 minutes in the remifentanil group. During the second stage of labor the means of NRS were the least in the spinal 2±1. Remifentanil group showed complications like , SPO2 < 92 %(room air breathing) in 20/25 patients (80%), decrease of respiratory rate below 12 breath/minutes in 4/25 (16%) and over sedation with Ramsay score >3 in 5/25 (20%). Maternal satisfaction was higher in epidural and spinal groups than remifentanil group. Conclusion: The most effective analgesia during the first stage of labor was the epidural, while in the second stage was the spinal analgesia. However maternal respiratory complications were significantly more in the remifentanil group. Maternal satisfaction was higher in both epidural and spinal than the intravenous remifentanil.