Ropivacaine versus lidocaine infiltration for postpartum perineal pain: A systematic review and meta-analysis

Abstract

Aim

To systematically and meta-analytically examine the efficacy of ropivacaine versus lidocaine infiltration for controlling postpartum perineal pain secondary to spontaneous tear or selective episiotomy.

Methods

We searched four databases from inception to 20-September-2020. We included all relevant randomized and nonrandomized studies and assessed their risk of bias. We pooled data as standardized mean difference (SMD), weighted mean difference (WMD), or odds ratio (OR) with 95 % confidence intervals (95 % CIs).

Results

Four studies met the inclusion criteria (one and three studies were nonrandomized and randomized, respectively). There were 405 patients; 205 and 200 patients received lidocaine and ropivacaine, respectively. There was no significant difference between ropivacaine and lidocaine groups with regard to visual analogue scale (VAS) pain scores at suturing (WMD = −0.04, 95 % CI [−0.41, 0.32], P = 0.82), 2 h (SMD = −1.50, 95 % CI [−3.50, 0.50], P = 0.14), and 24 h (SMD = −0.40, 95 % CI [−1.15, 0.34], P = 0.29) post repair of perineal trauma. Proportion of patients with mild VAS pain score ≤3 at 24 h was significantly higher in the ropivacaine group (OR = 4.34, 95 % CI [2.03, 9.29], P < 0.001). Proportion of patients who did not require additional analgesia during the first 24 h post perineal repair did not significantly differ between both groups (OR = 2.44, 95 % CI [0.09, 68.21], P = 0.60). Ropivacaine group achieved higher maternal satisfaction (OR = 7.13, 95 % CI [3.63, 13.99], P < 0.001).

Conclusions

During repair of postpartum perineal trauma, pain efficacy is relatively longer with ropivacaine but safety is not well investigated. High-quality and large-sized studies are needed to consolidate these findings.

Introduction

Perineal trauma is a frequent complication that impacts a large proportion of women, particularly primiparas, during vaginal childbirth [1,2]. It can take place secondary to spontaneous natural tear, iatrogenic episiotomy, or both [1,2]. It is most often associated with intense pain that warrants immediate and sufficient nociceptive pain relief [3].

A wide array of pharmacologic and non-pharmacologic practices exist in place to relieve postpartum perineal pain, for example, perineal massage [4], cold packs [5], and application of local/topical anesthetics [6,7]. The most frequently utilized practice to palliate postpartum perineal pain is injection of a local anesthetic. It functionally blocks the transmission of nociceptive pain signals from the site of injection, thus culminating in loss of pain perception at the perineal region [7].

Lidocaine infiltration, with presence or absence of epidural anesthesia, is the most frequently employed local anesthetic in ameliorating postpartum perineal pain [8]. It is a rapid-onset amide local anesthetic with a short duration of action lasting up to two hours. Conversely, ropivacaine is a closely similar amide local anesthetic with a prolonged duration of action lasting up to 12 h [[8], [9], [10], [11], [12]]. Thus, ropivacaine is anticipated to produce long-lasting effects with satisfactory pain control outcomes.

Local infiltration with ropivacaine demonstrated superiority to saline placebo in patients who underwent hemorrhoidectomy [13]. Similar results were obtained among patients who underwent tonsillectomy under local anesthesia [14]. A handful of studies explored the utility of local infiltration with ropivacaine versus lidocaine in patients with postpartum perineal pain [8,[15], [16], [17], [18]]. However, the results were not conclusive and limited by sample size. Accordingly, the clinical usefulness of ropivacaine in relieving perineal pain remains a debatable question.

Thus, the purpose of this review is to systematically and meta-analytically pool all the available evidence from studies which scrutinized the efficacy of local infiltration of ropivacaine in controlling postpartum perineal pain post vaginal childbirth.