Effects of Bupivacaine Induced Motor Blockade During the Second Stage of Labor (BUP)

A Randomized Double-blinded Trial of the Effects of Bupivacaine Induced Motor Blockade on the Second Stage of Labor

The aim of this study is to measure the effects of bupivacaine administered via epidural catheters on indices of motor blockade ascertained during the second stage of labor. This is a randomized, double-blind, controlled trial designed to address the primary research question: Does bupivacaine lengthen the second stage of labor? The secondary research question is: Is there other evidence of motor blockade attributable to bupivacaine during the second stage of labor?

The investigators know from prior studies that the length of the second stage in nulliparous women delivered at Parkland Hospital without epidural analgesia is 28 minutes. The investigators hypothesize in this now proposed study that epidural analgesia with bupivacaine will significantly increase this baseline from 28 minutes to 37 minutes or more (a 33% increase) thus implicating motor blockade. Baseline data for the Bromage and Breen scores during the second stage as well as the uterine contractility data are not available as these indices of motor blockade have not here-to-fore been studied in this context.

Currently at Parkland Hospital, 82% of nulliparous women undergoing induction of labor at term receive continuous epidural infusions with bupivacaine during the first and second stages of labor. Such women will be identified when admitted for scheduled inductions at Parkland. After informed consent is obtained standard management of labor induction will be provided. Those consented women reaching 8 cm cervical dilation will be randomized. Group I will receive bupivacaine plus fentanyl via epidural catheter during the second stage (i.e. 10 cm dilation) and Group II will receive only fentanyl infusion via epidural catheter (see study procedure below). Both the patient and the caregiver will be blinded as to whether the patient is in the bupivacaine plus fentanyl arm or the fentanyl only arm. To detect a 33% increase (from 28 minutes to 37 minutes) in the primary outcome the investigators need a total of 310 women enrolled in the study (or 155 per arm). Assuming a 30% consent rate and given that approximately 1000 women meet the inclusion criteria each year at Parkland, the investigators project that this study could be completed in 12 months.

Study Overview

• Status: Completed
• Conditions: Pregnancy
• Intervention / Treatment: Drug: Epidural fentanyl; Drug: Epidural Bupivacaine plus fentanyl

Detailed Description

Nulliparous women scheduled for labor inductions on Monday through Friday and who have consented to this study will be randomized to one of two arms: bupivacaine plus fentanyl epidural analgesia throughout labor and delivery (including the second stage) or epidural bupivacaine plus fentanyl until 8 cm cervical dilation and only fentanyl thereafter. From activation of epidural analgesia to 8 cm cervical dilation the prevailing standard epidural technique in use at Parkland Hospital will be used. Briefly, 19-ga multi-orifice epidural catheter is placed using 17-ga 3 ½cm Tuohy needle into the L3-L4 lumbar interspace. Lactated Ringers solution, 500-1000mL will be infused during placement of the epidural catheter to mitigate hypotension. A test dose using 1.5% lidocaine with 1:200,000 epinephrine, 3mL, will be given via the epidural catheter. If the test dose is negative, then an initial bolus of 0.25% bupivacaine, 4-8mL, with fentanyl 100mcg is given via the catheter. After securing the epidural catheter the patient will be placed in the supine position and the anesthetic sensory level measured with the desired level of T6-T8. Once a T6-T8 sensory block is secured the epidural infusion using 0.125% bupivacaine with 2mcg/mL fentanyl at 10mL/hr will be started.

At any time during epidural infusion the epidural catheter may be replaced at the discretion of the anesthesia provider for inadequate analgesia. Ephedrine or phenylephrine will be given intravenously for maternal hypotension defined as systolic blood pressure ≤ 90 mmHg or a decrease of 20% systolic blood pressure from patient's baseline.

Randomization will occur when the woman reaches 8 cm cervical dilation. Envelopes containing cassettes will be sequentially randomized by Dr. McIntire and given to the attending obstetrical anesthesiologist containing one of two medications. Group I will receive a 100mL epidural cassette of 0.125% bupivacaine with fentanyl 2mcg/mL to be infused at 10mL/hr. Group II will receive a 100mL cassette of fentanyl 10mcg/mL (to be infused at 10mL/hr. Both groups will have the same rate of epidural infusion such that the patient, nurse, obstetrician, and anesthesia providers will be blinded to the randomized treatment group. The Parkland Investigational Drug Service (IDS) will provide the study drugs.

The patient may request a 5mL bolus from the epidural infusion every 30 minutes if pain relief is inadequate. The obstetrician can also give patients in either study group 25mg of intravenous meperidine every hour for up to two doses if pain relief is unsatisfactory. The study regimen will continue until spontaneous delivery of the infant or until which time operative vaginal delivery or cesarean delivery is planned. At this point the study will be over and routine anesthesia care resumed.

The standard of care for management of labor induction at Parkland requires continuous electronic fetal heart rate monitoring (EFM) as well as uterine contraction monitoring. The standard is to apply EFM internal transducers when the membranes are ruptured. Standard fetal monitors equipped with laptop computers will be used to electronically store the fetal heart rate and uterine contraction data during this study. This will permit qualification of uterine contractility during the second stage of labor. The Bromage and Breen scores for motor blockade will be assessed at complete cervical dilation and at 30, 60, and 90 minutes thereafter. The scoring system is as follows:

Score Criteria

1. Unable to move feet or knees (complete block)
2. Able to move feet only
3. Just able to move knees
4. Detectable weakness of hip flexion while supine
5. No weakness of hip flexion
6. Able to perform partial knee bend

Visual analog pain (VAS) scores for the adequacy of epidural analgesia from 1-10 will also be assessed at each time point used for the Bromage and Breen scores.

Data collection will include maternal demographic characteristics as well as antepartum and intrapartum obstetrical features. Condition of the infant at birth based on Apgar scores and umbilical artery blood pH, as well as neonatal outcomes will be ascertained.

• Study Type: Interventional
• Enrollment (Actual): 481
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Texas
    • Dallas, Texas, United States, 75235
      • Parkland Health and Hospital System

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 44 years (ADULT, CHILD)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Nulliparous women at 37 weeks gestation or greater.
• Scheduled for induction of labor for any indication, to include hypertensive disorders, diabetes, decreased fetal motion, or prolonged pregnancy.
• Single without known malformations.
• Maternal age > or equal to 16 years.
• ASA classification 1 or 2.

Exclusion Criteria:

• Women who refuse epidural analgesia.
• Women with contraindications to epidural analgesia, i.e., severe thrombocytopenia.
• Any renal disease with serum creatinine > 1.0 mg/dL.
• Allergy to bupivacaine or fentanyl.
• Known liver disease such as hepatitis.
• Known contraindications to internal electronic fetal monitoring i.e., active herpes, maternal HIV seropositivity.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: DOUBLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Epidural fentanyl; A continuous epidural infusion of fentanyl 10 mcg/cc at a basal infusion rate of 10 ml/hr with a patient-controlled epidural analgesia (PCEA) demand dose of 5 mL/hr for pain. Meperidine 25 mg intravenously every 1 hour for breakthrough pain as needed.	Drug: Epidural fentanyl; The subjects will receive epidural fentanyl 10 mcg/mL with the rate of 10mL/hr.; Other Names: Epidural continous infusion of fentanyl
PLACEBO_COMPARATOR: Epidural bupivacaine plus fentanyl; A continuous epidural infusion of bupivacaine plus fentanyl during the second stage (i.e. 10 cm dilation) of labor. Epidural infusion are 10 ml/hr basal infusion plus 5 ml/hr demand dose via patient-controlled epidural analgesia (PCEA). Meperidine 25 mg intravenously every 1 hour for breakthrough pain as needed .	Drug: Epidural Bupivacaine plus fentanyl; The subjects will receive 0.125% bupivacaine with fentanyl 2 mcg/mL at a rate of 10 mL/hr.; Other Names: Epidural continous infusion of bupivacaine and fentanyl

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Duration of the Second Stage of Labor	The length of the second stage of labor (measured as minutes a parturient spends in Stage II) in nulliparous women received a epidural bupivacaine plus fentanyl or fentanyl alone.	Duration of second stage of labor approximately 30 minutes to 150 minutes

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Local Anesthetic Motor Blockade Indices During Stage II of Labor	Motor blockade will be estimated using Bromage and Breen scores (measured on a 6-point standardized scale, 1= Unable to more feet, 6= Able to perform partial knee bend) that estimate motor blockade. This scoring system is based upon the laboring womans' ability to move her lower extremities.	Duration of second stage of labor approximately 30 minutes to 150 minutes
Mode of Delivery in Women Randomized to Bupivacaine vs. No Bupivacaine During the Second Stage of Labor		At the time of Delivery
Number of Participants Whose Newborns Received an APGAR Score of <=3 at 1 Min	Number of participants whose newborns received an APGAR score of <=3 at 1 min. A lower APGAR score represents poor health or a worsening in the Outcome,	At the time of Delivery, up to 3 hours
Number of Participants Whose Newborns Received an APGAR Score of <=3 at 5 Min	Number of participants whose newborns received an APGAR score of <=3 at 5 minutes. A lower APGAR score represents poor health or a worsening in the Outcome	At the time of Delivery, up to 3 hours

Collaborators and Investigators

• Sponsor: University of Texas Southwestern Medical Center
• Investigators: Study Chair: Kenneth Leveno, MD, UT Southwestern Medical Center; Study Director: Lisa Moseley, UT Southwestern Medical Center

Publications and helpful links

General Publications

• Craig MG, Grant EN, Tao W, McIntire DD, Leveno KJ. A randomized control trial of bupivacaine and fentanyl versus fentanyl-only for epidural analgesia during the second stage of labor. Anesthesiology. 2015 Jan;122(1):172-7. doi: 10.1097/ALN.0000000000000454.

Study record dates

Study Major Dates

• Study Start: September 1, 2009
• Primary Completion (ACTUAL): July 1, 2012
• Study Completion (ACTUAL): July 1, 2013

Study Registration Dates

• First Submitted: February 6, 2012
• First Submitted That Met QC Criteria: June 13, 2012
• First Posted (ESTIMATE): June 18, 2012

Study Record Updates

• Last Update Posted (ACTUAL): August 24, 2020
• Last Update Submitted That Met QC Criteria: August 14, 2020
• Last Verified: August 1, 2020

More Information

Terms related to this study

• Keywords: Epidural; Randomized Controlled Trial; Fentanyl; Bupivacaine; Second Stage of Labor
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Analgesics, Opioid; Narcotics; Adjuvants, Anesthesia; Anesthetics, Local; Fentanyl; Bupivacaine
• Other Study ID Numbers: STU 042011-045