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A patient experienced a severe vasovagal attack during regional anaesthesia for elective Caesarean section. The combination of vagal over-activity and sympathetic block produced profound hypotension that threatened the life of the mother and infant. The vasovagal syndrome is described, and its prevention and management discussed.

We have performed a randomized, double-blind comparison of two epidural drug regimens for analgesia in labour. In the bupivacaine group (BUPIV), 101 healthy parturients received 0.1% bupivacaine with fentanyl 2 microg ml(-1). In the ropivacaine group (ROPIV), 102 women received 0.2% ropivacaine. Both groups received an initial loading dose of 15 ml, a continuous infusion of 8 ml h(-1), and top-ups of 10 ml. Breakthrough pain not responding to a routine top-up was treated with an 'escape' top-up of 10 ml 0.25% bupivacaine. The two groups were compared for complete analgesia at 30 min, routine and 'escape' top-up requirements, midwife assessment of analgesic efficacy, delivery mode, patient visual analogue scores (VAS) for first and second stage analgesia, overall satisfaction, and patient assessment of motor blockade. Patients receiving ropivacaine received fewer routine top-ups (median 1.0 vs. 2.0, P=0.001) and fewer escape top-ups (9.8% vs. 21.8%, P=0.02). The ropivacaine group was more likely to be pain free in the first stage (51% vs. 33.7%, P=0.01). There were no significant differences in patients' assessment of motor block or mode of delivery between the groups. Pain relief and satisfaction scores from midwives and patients were consistently better in the ropivacaine group, but did not reach statistical significance.

We have performed a randomized comparison of two low-dose epidural regimens for analgesia in labour, differing only in the manner in which initial analgesia was established. In the epidural (EPI) group, 484 women received a loading dose of 20 ml of 0.1% bupivacaine with fentanyl 2 micrograms ml-1. In the combined spinal-epidural (CSE) group, 524 women received a spinal injection of plain bupivacaine 2.5 mg with fentanyl 25 micrograms. In both groups, these initial doses were followed by 0.1% bupivacaine with fentanyl 2 micrograms ml-1 infused at a rate of 12 ml h-1, with 20-ml top-ups for breakthrough pain. The groups were compared for midwife assessment of analgesic efficacy, delivery mode, patient assessments of first stage analgesia, second stage analgesia, overall analgesia, motor block and complications. Midwives, who were not blinded to the treatment groups, assessed 61.6% of CSE as providing 'excellent' analgesia compared with 56.4% of epidurals (P = 0.02). Patients assessed overall analgesia as 'excellent' in 74.8% of CSE compared with 71.7% of epidurals (P = 0.14). Other comparisons between groups revealed no differences. These findings may have been affected by an uneven distribution of multiparous women between the groups (25% in the EPI group and 34.2% in the CSE group; P = 0.002). However, subgroup analysis of primiparous and multiparous women did not alter the results.

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