Comparison of dural-puncture epidural (DPE) and epidural analgesia (EA)for labor-a prospective randomized double blind study

Epidural analgesia (EA) is the gold standard for pain relief during labor. Many new techniques have been  incorporated with EA to make it more effective like addition of various adjuvants, practice of spinal epidural technique and dural puncture epidural technique (DPE). DPE is relatively new technique where intentional dural puncture with spinal needle is done before insertion of epidural catheter while EA is being done. The proposed advantages are early onset of pain relief and better efficacy. We regularly use EA for labor analgesia. We want to compare this new approach with our standard EA technique.

Patients who are willing after informed consent for epidural analgesia for labor pain relief will be divided in two equal groups by random table. After explaining the visual analogue scale score (VAS score), with due aseptic precautions and with standard vital monitoring 18G tuohy epidural needle will be placed at L3-L4 level under local anaesthesia to locate epidural space by loss of saline. Afterwards, 27G Whitacre spinal needle will be inserted through epidural needle. In DPE group intentional dural puncture will be attempted (confirmed by CSF back -flow) while in EA group, needle will only be inserted for 1-2cm (sham puncture). After  removal of spinal needle, epidural catheter will be inserted and needle will be removed. The marking of catheter at skin will be calculated to keep catheter 3-5cm in the epidural space. After negative aspiration test, 3ml 0.125% bupivacaine will be given through catheter. After waiting for 3 minutes if no sign of spinal anaesthesia or accidental intravascular injection is noted, 9ml of same local anesthetic will be injected with repeated aspiration test over 2 minutes. Catheter will be fixed and dressed with transparent dressing. Then an infusion of 0.8% bupivacaine and fentanyl 2microgram/ml will be given by infusion pump @10ml/hr.  VAS score will be recorded every 2 minutes till it comes down to 3. Time to 50% reduction in VAS from base line value and time to achieve VAS 3 will be recorded. VAS will be monitored every hr till the delivery. Breakthrough pain will be managed by 5ml bolus of 0.125% bupivacaine every 15 minutes till VAS comes to 3. All the data about duration of labor, total dose of bupivacaine and fentanyl used, VAS scores, outcome of labor and APGAR of newborn  will be recorded and analysed by appropriate statistical tools for analysis.