The dural
puncture epidural technique may improve
analgesia quality by confirming midline placement and increasing intrathecal translocation of epidural medications. This would be advantageous in obese parturients with increased risk of block failure. This study hypothesizes that quality of labor
analgesia will be improved with dural
puncture epidural compared to standard epidural technique in obese parturients.
METHODS: Term parturients with body mass index greater than or equal to 35 kg · m-2, cervical dilation of 2 to 7 cm, and
pain score of greater than 4 (where 0 indicates no
pain and 10 indicates the worst
pain imaginable) were randomized to dural
puncture epidural (using 25-gauge Whitacre needle) or standard epidural techniques.
Analgesia was initiated with 15 ml of 0.1%
ropivacaine with 2 µg · ml-1
fentanyl, followed by programed intermittent boluses (6 ml every 45 min), with patient-controlled
epidural analgesia. Parturients were blinded to group allocation. The data were collected by blinded investigators every 3 min for 30 min and then every 2 h until delivery. The primary outcome was a composite of (1) asymmetrical block, (2) epidural top-ups, (3)
catheter adjustments, (4)
catheter replacement, and (5) failed conversion to
regional anesthesia for cesarean delivery. Secondary outcomes included time to a
pain score of 1 or less, sensory levels at 30 min, motor block, maximum
pain score, patient-controlled
epidural analgesia use, epidural medication consumption, duration of second stage of labor, delivery mode, fetal heart tones changes, Apgar scores, maternal adverse events, and satisfaction with
analgesia.
RESULTS: Of 141 parturients randomized, 66 per group were included in the analysis. There were no statistically or clinically significant differences between the dural
puncture epidural and standard epidural groups in the primary composite outcome (34 of 66, 52% vs. 32 of 66, 49%; odds ratio, 1.1 [0.5 to 2.4]; P = 0.766), its individual components, or any of the secondary outcomes.
CONCLUSIONS: A lack of differences in quality of labor
analgesia between the two techniques in this study does not support routine use of the dural
puncture epidural technique in obese parturients.
EDITOR’S PERSPECTIVE: