Beenakkers, I.*
University Medical Centre Utrecht, anesthesiology, Utrecht, The Netherlands
ESRA Academy. Beenakkers I. Sep 16, 2017; 195877; esra7-0507 Topic: REGIONAL ANAESTHESIA (RA) IN SPECIFIC SUBPOPULATIONS
Ingrid Beenakkers
Ingrid Beenakkers

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After viewing this presentation the participant will be able to:

- Review studies comparing levels of motor block with ropivacaine and bupivacaine during labour
- Discuss safety and efficacy of using ropivacaine in different clinical scenarios

Pro-con debate

Ropivacaïne is the local anaesthetic of choice for labour epidural analgesia: pro


Among the amide local anesthetics bupivacaïne, levo-bupivacaïne and ropivacaïne are suitable for labour analgesia, because of their long duration of action. However bupivacaïne is the most cardiotoxic agent and it is more difficult to resuscitate patients from bupivacaïne-induced cardiac arrest compared to the other local anesthetics. Bupivacaïne also has important motor blockade at higher concentrations leading to instrumental deliveries. Bupivacaïne is a racemic mixture of levorotatory (L) and dextrorotatory (R) forms. These forms behave different in their affinity to the site of action and in the sites involved with side effects. R-enantiomers contribute more  to systemic toxicity, especially when used in high doses or inadvertent intravascular injection. Levo-bupivacaïne, the pure s-enantiomer of bupivacaïne was developed for better outcome. Ropivacaïne, which is less lipophilic than bupivacaïne has a propylgroup attached to the pipechol ring instead of a butylgroup in bupivacaïne. Ropivacaïne also is a pure s-enantiomer and this quality reduces potential toxicity. This debate will focus on the comparison of bupivacaïne versus ropivacaïne.  

Ropivacaïne for labour analgesia 

For labour analgesia high sensory and low motor block profiles are essential. Because ropivacaïne is less lipophilic than bupivacaïne, ropivacaïne may be more selective for sensory fibres and less likely penetrates large myelinated motor fibres. Ropivacaïne has less potential for central nervous system toxicity and cardiotoxicity. Convulsive dose (convulsion threshold) is 1,5-2 times larger for ropivacaïne than bupivacaïne on a mg/kg basis, even when correcting for the greater potency of bupivacaïne. At equal (mg/kg), high doses, ropivacaïne shows less motor block than bupivacaïne and thereby more spontaneous deliveries. Because ropivacaïne is 60% as potent as bupivacaïne, equipotent doses should be used to compare the two drugs. Diverse dosing regiments were compared from 0,25% to 0,075% supplemented with opioïds. It seems that ropivacaïne 0,1% with opioïd produces adequate pain relief with little or no motor block compared to bupivacaïne, especially during longer labours. Side effects like nausea, vomiting, hypotension, pruritus and respiratory depression were similar among ropivacaïne and bupivacaïne used in low doses. No difference in oxytocin use was observed. Neonatal outcome is not different among the two local anesthetic agents.

Because of less risk for cardiotoxicity and neurotoxicity and less motor blockade during longer labours ropivacaïne should be used as first choice in labour analgesia.  

Key words: bupivacaïne, ropivacaïne, labour analgesia, toxicity                               


  1. Bawdane KD, Magar JS, Tendolkar BA. Double blind comparison of combination of 0.1% ropivacaine and fentanyl to combination of 0.1% bupivacaine and fentanyl for extradural analgesia in labour. J Anaesth Clin Pharmacology 2016;32:38-43
  2. Guo S, Li B, Gao C, Tian Y. Epidural Analgesia with Bupivacaine and fentanyl versus Ropivacaine and Fentanyl for Pain Relief in Labor. A meta-analysis. Medicine 2015;94:1-10
  3. Lv B-S, Wang W, Wang Z-q, Wang X-w, Wang J-h, Fang F, Mi W-d. Efficacy and safety of local anesthetics bupivacaine, ropivacaine and levobupivacaine in combination with sufentanil in epidural anesthesia for labor and delivery: a meta-analysis. Curr Med Research and Opinion 2014;30:2279-89
  4. Beilin Y, Halpern S. Ropivacaine versus Bupivacaine for epidural labor analgesia. Anesth
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