Should women in labour receive IV paracetamol?

IBe patient. Sometimes you have to go through the worst to get to the best. – Mark Twain

I.V. paracetamol as an adjunct to patient-controlled epidural analgesia with levobupivacaine and fentanyl in labour: a randomized controlled study. Gupta et al. British Journal Of Anaesthesia, 117 (5): 617–22 (2016)

This study looked at the effect of IV paracetamol on reducing the consumption of opioids during patient-controlled epidural analgesia (PCEA) in labouring parturients. The authors commented that paracetamol is a widely used antipyretic and analgesic but there are limited studies assessing its intrapartum use.

The study was conducted from June 2013 to June 2014 at a tertiary care teaching hospital in North India.

It was a randomized, double-blind, placebo-controlled study. 80 parturients were randomly assigned to two groups of 40 each, to receive either 1000 mg (100 ml) I.V. paracetamol or 100 ml normal saline as placebo, 30 min before the procedure. After insertion of the epidural catheter, all patients received 10 ml of levobupivacaine 0.1% with 2 mg/ml fentanyl, followed by continuous background epidural infusion of 6 ml/hr with a provision of patient-controlled bolus 5 ml of same drug with a lock-out interval of 12 min.

The primary outcome was hourly mean consumption of levobupivacaine and fentanyl mixture (ml/hr). Secondary outcomes included pain score, sensory and motor block, haemodynamic parameters of mother, duration of second stage of labour, mode of delivery, Apgar scores, foetal heart rate and adverse effects.

The results showed that the hourly mean drug consumption in the Paracetamol group was significantly lower as compared with the Placebo group (7.03 ml/hr, SD 0.83 vs. 8.12 ml/hr, SD 1.34; p < 0.001). The mean number of boluses taken were also significantly less in the paracetamol group (1.00, SD 0.93 vs. 1.43, SD 0.90; p = 0.036).

The authors concluded that use of 1000 mg I.V. paracetamol decreases the mean hourly drug consumption through epidural route. Thus I.V. paracetamol is a safe and effective adjunct to PCEA in labour analgesia.

The paper did not publish data on the duration of labour. Therefore it was unclear whether additional doses of paracetamol should have been given and therefore if the participants were under dosed. The difference in effect between the two groups equates to one extra patient controlled bolus demand every 5 hours, therefore depending on the duration of labour this effect seems very small. Another potential drawback of the study was that it only considered parturients at term which potentially decreases its generalised application to all patients in a labour ward.

Overall, this was a well-planned study but while the reduction in hourly mean drug consumption was statistically significant the effects did not appear to have any clinical significance.

Summary by Dr Emma Pack

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