ROPIVACAINE IS THE LOCAL ANAESTHESTIC OF CHOICE FOR LABOUR EPIDURAL ANALGESIA: CON
Author(s):
van der Marel, C.*
Affiliations:
Erasmus MC, Paediatric and Obstetric Anaesthesia, Rotterdam, The Netherlands
ESRA Academy. der Marel C. Sep 16, 2017; 195878; esra7-0500 Topic: REGIONAL ANAESTHESIA (RA) IN SPECIFIC SUBPOPULATIONS

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Learning Objectives
Abstract
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After viewing this presentation the participant will be able to:

- Evaluate the evidence for bupivacaine toxicity during labour
- Review limitations of previous studies and meta-analyses comparing the safety and efficacy of bupivacaine and ropivacaine for labour analgesia

Ropivacaine is the local anaesthetic of choice for labour epidural analgesia: con 

Introduction

For many years bupivacaine has been used for epidural labour analgesia, because of its long duration of action, lack of excessive motor block and minimal foetal and neonatal effects. Over the last years ropivacaine gained popularity for routine use in epidural labour analgesia. This is mainly attributed to causing less motor block and its less cardiotoxic effects. However literature does not consistently support the advantages of ropivacaine compared to bupivacaine in labour analgesia.

Bupivacaine for labour analgesia

Studying the analgesic potency, the potency of ropivacaine is approximately 60% compared to the analgesic potency of bupivacaine. Therefore to achieve comparable analgesic effect, ropivacaine should be administered in higher doses than bupivacaine. Assessing motor block, similar results are found: ropivacaine is 65-76% as potent as bupivacaine, suggesting a more favourable profile for ropivacaine. The advantage of ropivacaine causing less motor block than bupivacaine however, only becomes clinically relevant after prolonged administration and might more likely be attributable to differences in potency, rather than intrinsic differences between ropivacaine and bupivacaine.

In case of inadvert intravenous administration, local anaesthetics can be toxic for both the central nervous system (CNS), causing tinnitus or seizures, and the cardiovascular system, causing hypotension and ventricular dysrhythmias. CNS symptoms occur at lower blood levels than cardiovascular symptoms. Some studies show no difference in (cardiac) toxicity for ropivacaine and bupivacaine, other studies show a larger convulsive dose for ropivacaine compared to bupivacaine. However the doses in the latter studies are higher than currently advised in literature for epidural labour analgesia (respectively 0.1% and 0.0625% for ropivacaine and bupivacaine, both in combination with fentanyl or sufentanil). Using these dilute concentrations cardiac toxicity is very unlikely.

Considering maternal outcome, ropivacaine and bupivacaine are equally effective for labour analgesia in terms of maternal satisfaction, ability to ambulate (despite the motor block effect) and progress of labour. Studies showing a higher incidence of instrumental vaginal delivery when using bupivacaine, are studies based on bupivacaine concentrations of 0.25%. When using dilute concentrations of ropivacaine and bupivacaine, there is no difference in spontaneous vaginal delivery, instrumental vaginal delivery or caesarean delivery, neither are there differences in foetal or neonatal outcome.

Considering the above, there is a lack of consistent evidence in literature to support the routine use of ropivacaine over bupivacaine for epidural labour analgesia, showing both ropivacaine and bupivacaine suitable for epidural labour analgesia in dilute concentrations. Taking into account the higher costs of ropivacaine (5-10 fold), bupivacaine might be a better alternative to ropivacaine.


References

1 Beilin Y, Halpern S. Ropivacaine versus bupivacaine for epidural labor analgesia. Anesth Analg 2010; 111: 482-487.

2 Schwoere AP, Scheel H, Friederich P. A comparative analysis of bupivacaine and ropivacaine effects on human cardiac SCN5A channels. Anesth Analg 2015; 120: 1226-1234.

3 Bao-Sheng Lv, Wei Wang. Zhuo-qiang Wang, Xian-wang Wang, Jing-hua Wang, Fang Fang

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