SummaryWe randomly allocated 93 women in early active labour and requesting epidural analgesia to receive either epidural (n ¼ 48) or combined spinal-epidural analgesia (n ¼ 45). For epidural analgesia 15 ml of bupivacaine 0.1% with 75 mg of fentanyl were injected into the epidural space. For combined spinal-epidural analgesia 1 ml of bupivacaine 0.25% with 25 mg of fentanyl were injected into the subarachnoid space. For both groups subsequent top-ups of 10 ml of bupivacaine 0.1% with fentanyl 20 mg were given using a lightweight patient-controlled epidural analgesia (PCEA) pump with a lockout time of 30 min. We assessed analgesia and the degree of motor blockade and found no significant differences in pain or maternal satisfaction scores between the two groups. The time to first top-up was significantly longer in the epidural group than in the CSE group (p ¼ 0.01). The combined spinal-epidural group had significantly greater motor blockade at 30 min than the epidural group (p ¼ 0.01), but there was no difference after this. The PCEA machine failed completely twice and temporarily many times. We conclude that the combined spinal-epidural technique confers no advantages in early active labour. Also, a lightweight PCEA pump needs to be more reliable before we can recommend its use.

Summary Management of the airway in an intubated patient during formation of a tracheostomy can be hazardous. The usual method involves withdrawal of the tracheal tube, which has been providing a secure airway, prior to inserting the tracheostomy tube. A method of airway management, using a microlaryngeal tube, has been devised with the aim of maintaining full tracheal intubation and ventilation until the correct position of the tracheostomy tube can be verified. An audit of 250 successive cases of percutaneous tracheostomy demonstrated this method to be safe and effective.

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