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Abstract
Labor can be extremely painful for many women. Labor pain is among the most severe pain experienced by the mother and lack of treatment of labor pain can result in severe psychological effects, so freedom from this pain should be a basic human right. Epidural analgesia is one of the most useful techniques in labor pain relief, it will provide analgesia without loss of consciousness and minimal motor block thus allowing patient cooperation and making it an ideal form of analgesia for labor. Initial reports that ropivacaine produces less cardiovascular toxicity and motor blockade than bupivacaine offered promise that ropivacaine might be superior to bupivacaine for use in obstetric analgesia. Opioids, especially fentanyl or sufentanyl have been and still are added to local anesthetics for epidural pain relief during labor, addition of an opioid will improve the quality of pain relief and allow for a reduction in local anesthetic dose, thus reducing the intensity of motor blockade. Ketamine, an anesthetic agent with an unusual pharmacological profile, has also attracted some interest in this context as in subanesthetic doses provides marked analgesia without respiratory depression. Since the first publication on the epidural administration of ketamine, various studies on the pharmacology, toxicology, and clinical use of ketamine by the epidural route have been published. This work studied the epidural analgesia using ropivacaine with fentanyl or ketamine to assess their efficacy, safety, advantages and/or drawbacks, in pain relief during labor. 60 parturients in the first stage of labor were studied, their ages varied from 22 to 34 years, and their cervical dilatation was 5 cm at the onset of the technique. These patients were divided into three groups, each of them 20 patients. group I received ropivacaine 0.1%.group II received ropivacaine 0.1% + fentanyl 2 μg/ml. group III received ropivacaine 0.1% + ketamine 0.5 mg/kg. All mothers were in a good health and in labor. Initial dose was given as 15ml of the used concentration and (10ml for each of them) in case of increasing pain score more than 3 degrees or according to mother’s demand. Degree of pain measured by using score from Zero to 10 every 15min through the first hour then after each hour till delivery of foetus. Degree of pain relief was measured every 15 min through the first hour then every hour till delivery of foetus. Degree of motor block measured by Promage score every 15min through the first hour then after every hour till delivery of foetus. Following up the mother by measuring heart rate, blood pressure every 15mins through first hour then every hour till delivery. The foetal condition was evaluated immediately after labor by Apgar score, ABG in blood from the umbilical artery immediately after labor. The results of this thesis can be summarized in the following data: All the three groups succeeded to achieve pain relief during labor with some differences. group II (ropivacaine-fentanyl) recorded rapid onset and better quality of analgesia; and prolonged duration of analgesia than group I (ropivacaine) with nearly the same minimal, non-significant degree of motor block, and without adverse effects on the mother or the foetus. group III (ropivacaine-ketamine) recorded also rapid onset with more prolonged duration of analgesia than groups I and II, but with more adverse effects on the mother specially the degree of sedation and motor blockade. Regarding the comparison between the three groups in the degree of motor blockade, group II recorded the best result and thus with the ability to ambulate, followed by group I, then group III. There were no differences between the three groups as regard duration of labor, maximum level of sensory block, maternal heart rate, maternal systolic and diastolic blood pressure, and foetal Apgar score and umbilical artery pH. ConclusionWe can conclude that: Epidural analgesia succeeded to relief pain during labor with satisfactory onset, duration, and quality of analgesia without significant complications on the mother, fetus or the progress of labor. Walking can be achieved with epidural analgesia specially on using ropivacaine and ropivacaine-fentanyl but not ropivacaine-ketamine because of sedation. Both group II (ropivacaine-fentanyl) and group III (ropivacaine-ketamine) recorded the best results as regard onset and duration of analgesia specially group III, but the incidence of adverse events were more when ketamine added to ropivacaine. As epidural analgesia using ropivacaine with fentanyl provides sufficient ambulatory analgesia during labor with great margin of safety for the mother and the baby, we advise to use this technique and these drugs whenever painless labor is requested. Recommendation, we recommend that further studies for addition of ketamine to ropivacaine in management of labor pain are needed for further evaluation of this drug.