From the Guidelines
Bupivacaine and fentanyl are the recommended local anesthetic and opioid combination for labor epidural, with an initial bolus of 2.5 mg bupivacaine and up to 15 mcg fentanyl. The use of these medications is supported by recent guidelines from the obstetric anaesthetists' association, which suggest that this combination provides effective pain relief during childbirth while minimizing motor blockade 1.
Key Considerations
- The initial bolus dose of bupivacaine can be used with the addition of up to 15 mcg fentanyl for initiation of labor analgesia via an intrathecal catheter 1.
- For maintenance of labor analgesia, bupivacaine 0.1–0.125% with 2–2.5 mcg/mL fentanyl are suitable solutions, which can be given as intermittent boluses or a continuous infusion 1.
- The same local anesthetic solution should be used throughout labor, and breakthrough pain can be managed with additional boluses of the solution used to maintain labor analgesia 1.
Medication Details
- Bupivacaine: initial bolus of 2.5 mg, maintenance dose of 0.1–0.125%
- Fentanyl: up to 15 mcg for initial bolus, 2–2.5 mcg/mL for maintenance dose
- Administration: intermittent boluses or continuous infusion via an intrathecal catheter
Clinical Implications
The combination of bupivacaine and fentanyl provides synergistic analgesia, allowing for effective pain relief during labor while minimizing motor blockade. This enables the mother to maintain some mobility during labor, which is beneficial for both the mother and the fetus. The use of these medications should be guided by recent clinical guidelines and tailored to the individual patient's needs 1.
From the FDA Drug Label
Epidural sufentanil was tested in 340 patients in two (one single-center and one multicenter) double-blind, parallel studies. Doses ranged from 10 to 15 mcg sufentanil and were delivered in a 10 mL volume of 0. 125% bupivacaine with and without epinephrine 1:200,000. Individual doses of 10 to 15 mcg sufentanil plus bupivacaine 0. 125% with epinephrine provided analgesia during the first stage of labor with a duration of 1 to 2 hours.
The local anesthetic and opioid used for labor epidural are:
- Bupivacaine (0.125%)
- Sufentanil (10-15 mcg) 2
From the Research
Local Anesthetics and Opioids for Labor Epidural
- Bupivacaine and ropivacaine are commonly used local anesthetics for labor epidural analgesia, often combined with opioids like fentanyl 3, 4.
- The combination of bupivacaine or ropivacaine with fentanyl provides effective analgesia with minimal motor blockade, allowing for ambulation during labor 3, 4.
- Other local anesthetics like levobupivacaine have also been studied for labor epidural analgesia, with similar efficacy to bupivacaine and ropivacaine 5, 6.
Comparison of Local Anesthetics
- Ropivacaine has been shown to produce less motor block than bupivacaine when combined with fentanyl for labor epidural analgesia 4.
- Levobupivacaine has been compared to ropivacaine and bupivacaine, with no significant differences in pain scores or motor block 5, 6.
- A study comparing levobupivacaine 0.0625% + fentanyl 2mcg/mL to ropivacaine 0.075% + fentanyl 2mcg/mL found that ropivacaine provided better analgesia with less motor blockade and higher patient satisfaction 6.
Opioids for Labor Epidural
- Fentanyl is a commonly used opioid for labor epidural analgesia, often combined with local anesthetics like bupivacaine or ropivacaine 3, 4, 7.
- Sufentanil has been compared to fentanyl as an adjunct to bupivacaine for labor epidural analgesia, with some evidence suggesting that sufentanil may be clinically superior 7.