Sensory innervation of the breast is complex, thereby making it difficult to perform any surgical procedure with a single regional anesthesia technique. Because of the involvement of pectoral muscles and extension of the incision into the axilla, a modified radical mastectomy makes it further challenging and requires multiple techniques. We have used a new combination of regional techniques in this case series and found that it provided complete surgical anesthesia with a smaller volume of local anesthetic.

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Background: Instrumental vaginal delivery is a major concern during epidural labour analgesia. In previous studies levobupivacaine 0.1% was associated with increase in instrumental vaginal delivery when compared to 0.1% ropivacaine. Reducing the concentration of levobupivacaine may decrease the incidence of instrumental delivery. Hence, we compared 0.08% levobupivacaine and 0.1% ropivacaine with fentanyl as adjuvant for epidural labour analgesia in terms of mode of delivery. Methods: This prospective randomised controlled trial was conducted on 70 nulliparous parturients with singleton uncomplicated pregnancy. They were randomized into two groups to receive 0.08% levobupivacaine or 0.1% ropivacaine with 2g/ml fentanyl as intermittent epidural boluses. The epidural analgesia was initiated with 12ml of study drug solution in active stage of labour and was maintained by repeated demand boluses whenever the Visual Analogue Scale (VAS) score was > 3. Onset, duration and quality of analgesia, degree of motor blockade was analysed. Primary outcome measure was the mode of delivery. Onset and duration of analgesia and Apgar score of baby were the secondary outcomes. Results: Instrumental vaginal delivery was 6.45% in levobupivacaine(L) and 4.54%in ropivacaine(R) group. However,11.4% and 37.1% parturients underwent caesarean section in group L and group R respectively (p=0.012**). Mean onset of analgesia and duration of analgesia was comparable. More than 80% of parturients had excellent pain relief in both the groups with good baby APGAR score. Conclusion: We conclude that 12ml of intermittent epidural boluses of 0.08% levobupivacaine and 0.1% ropivacaine with 2g/ml fentanyl (equipotent dose) provided equal and effective analgesia during labour with comparable incidence of instrumental vaginal delivery.

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Introduction: Epidural analgesia is the most effective technique of labour analgesia. However increase in instrumental delivery is one of the hindrance factor in practise of epidural labour analgesia. Our previous study on labour analgesia with 0.1% Levobupivacaine showed 32% instrumental delivery and none in 0.1% Ropivacaine group. We hypothesized that 0.08% Levobupivacaine with fentanyl may reduce the incidence of instrumental delivery similar to 0.1% Ropivacaine with fentanyl and provide better maternal outcome. Hence, we decided to compare the effectiveness of 0.1% Ropivacaine and 0.08% Levobupivacaine with fentanyl 2g/ml as an adjuvant for epidural labor analgesia in terms of mode of delivery, onset, duration and quality of analgesia.