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Epidural analgesia still have an impact on obstetric outcomes and especially on instrumented delivery rates.
To assess the best maintainance regimen of epidural analgesia during labor the investigators plan to include 300 nulliparous in this multicenter randomized, double blind trial. The primary outcome will be a composite set of criteria that can lead to instrumented delivery. Secondary outcome will focus on analgesia motor block and satisfaction.
Patients will be informed during the anaesthetic consultation and recruited at the beginning of the labor if they comply with inclusion criteria. Habitual proceedings of the placing and induction of epidural analgesia (Local Anaesthetics (AL): Levobupivacaine 0.100% 15mL Sufentanil 10”g). Patients who will not obtain at 30min a pain score < 1/10 will be excluded (epidural analgesia not functional). The upkeep of analgesia will be provided by an automatic pump and randomized in: classic pump and new pump. The mixture used will be the same in the 2 groups: Levobupivacaine 0.0100% + Sufentanil 0.5”g/mL. The classic pump administers AL with a continuous output (8mL/h)even though the new pump administers AL in bolus (8mL every hour; beginning 1h after the induction). The classic pump is a pump CADD SMITHS PCEA (Patient Controlled Epidural Analgesia) with the programming: continuous output 8mL/h; Additional bolus if necessary: 8mL; Maximal dose by hour: 24mL.
The new pump is a pump CADD SMITHS called PIEB (Programmed Intermittent Epidural Bolus) with the programming: intermittent bolus 8mL every hour; Additional bolus if necessary: 8mL; Ban period during 10min between patient bolus and automatic bolus; Maximal dose by hour: 24mL.
In case of the pain reappears and which is not calmed with 2 successive patient bolus, the anaesthetist will be called for the evaluation and administration of a doctor bolus if necessary (Levobupivacaine 0.125% 5mL associated with 50”g of Clonidine).
Collected data will be demographic data, data about the obstetrical labor proceedings, data about pain, motor block, maternal satisfaction, total quantity of administered analgesia, number of patient and doctor bolus wich are asked and administered and neonatal data.
Endpoints will be collected by a doctor in blind of the type of pump (the 2 pumps are the same extern aspect, only the intern programming is different).
In case of caesarean during the labor, patient will be excluded of the study. When a decision of extraction will be taken, patient will receive a bolus of AL according to the anaesthetist decision but not accounted for the dose calculation.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| CEI-PCEA | Active Comparator | Continuous Epidural Infusion coupled with Patient Controlled Epidural Analgesia |
|
| PIEB-PCEA | Experimental | Programmed Intermittent Epidural Bolus coupled with Patient Controlled Epidural Analgesia |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Release analgesia by CADD SMITHS PCEA pump | Device | Analgesia will be release by continuous manner with an automatic pump |
|
| Measure | Description | Time Frame |
|---|---|---|
| Occurence of a specific clinical criteria which can lead to a complication of the delivery | Specific clinical criteria are:
| Up to 10 hours |
| Measure | Description | Time Frame |
|---|---|---|
| Instrumental delivery rate | up to 10 hours | |
| Pain during the end of labor | up to 10 hours | |
| Efficacity of epidural analgesia |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Estelle MORAU, PhD | CHU Montpellier - Department of gynaecology and obstetric | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| HĂŽpital MĂšre Enfant | Bron | 69500 | France | |||
| CHU d'Estaing |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 31335447 | Result | Morau E, Jaillet M, Storme B, Nogue E, Bonnin M, Chassard D, Benhamou D, Nagot N, Dadure C. Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, randomised, controlled, triple-blind study. Eur J Anaesthesiol. 2019 Oct;36(10):755-762. doi: 10.1097/EJA.0000000000001053. |
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| ID | Term |
|---|---|
| D000077554 | Levobupivacaine |
| D017409 | Sufentanil |
| ID | Term |
|---|---|
| D002045 | Bupivacaine |
| D000813 | Anilides |
| D000577 | Amides |
| D009930 | Organic Chemicals |
| D000814 |
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| Release analgesia by CADD SMITHS PIEB pump | Device | Analgesia will be release by bolus with an automatic pump |
|
| Levobupivacaine | Drug |
|
| Sufentanil | Drug |
|
| up to 10 hours |
| Efficacity of epidural analgesia | Efficacity of epidural analgesia is defined by a EVN score < 3 at several times of delivery. | up to 10 hours |
| Presence of motor block | Presence of motor block is estimated with Bromage and Straigh Raising leg scales. | Up to 10 hours |
| Clermont-Ferrand |
| 63003 |
| France |
| CHU BicĂȘtre | Le Kremlin-BicĂȘtre | 94275 | France |
| CHU of Montpellier | Montpellier | 34000 | France |
| Aniline Compounds |
| D000588 | Amines |
| D005283 | Fentanyl |
| D010880 | Piperidines |
| D006573 | Heterocyclic Compounds, 1-Ring |
| D006571 | Heterocyclic Compounds |