OBSTETRICS Comparison between lidocaine-prilocaine cream (EMLA) and mepivacaine infiltration for pain relief during perineal repair after childbirth: a randomized trial Massimo Franchi, MD; Antonella Cromi, PhD; Stefano Scarperi, MD; Francesca Gaudino, RM; Gabriele Siesto, MD; Fabio Ghezzi, MD OBJECTIVE: The purpose of this study was to compare the effective- ness of topically applied lidocaine-prilocaine (EMLA) cream with local anesthetic infiltration in the reduction of pain during perineal suturing after childbirth. STUDY DESIGN: Sixty-one women with either an episiotomy or a per- ineal laceration after vaginal delivery were assigned randomly to re- ceive either the application of EMLA cream (n = 31) or infiltration with mepivacaine (n = 30) before perineal suturing. Primary outcome was pain during perineal repair. RESULTS: Women in the EMLA group had lower pain scores than those in the mepivacaine group (1.7  2.4 vs 3.9  2.4; P = .0002). The proportion of women who needed additional anesthesia was sim- ilar in the 2 groups (3/30 vs 5/31; P = .71). A significantly higher proportion of women expressed satisfaction with anesthesia method in the EMLA group, compared with the mepivacaine group (83.8% vs 53.3%; P = .01) CONCLUSION: EMLA cream appears to be an effective and satisfactory alternative to local anesthetic infiltration for the relief of pain during perineal repair. Key words: EMLA, lidocaine-prilocaine cream, pain, perineal suturing, vaginal delivery Cite this article as: Franchi M, Cromi A, Scarperi S, et al. Comparison between lidocaine-prilocaine cream (EMLA) and mepivacaine infiltration for pain relief during perineal repair after childbirth: a randomized trial. Am J Obstet Gynecol 2009;201:186.e1-5. P erineal infiltration with local anes- thetics is the most common tech- nique to provide anesthesia during peri- neal suturing. Although infiltrative anesthesia remains a mainstay for pain relief goals during minor surgical proce- dures, topical anesthetics in the form of sprays, gels, and ointments have emerged as a valuable alternative in sev- eral medical specialties. 1-6 The advan- tages of using topical anesthetics include their localized action with negligible sys- temic absorption, ease of administra- tion, painless application, and absence of edema at the surgical site that distorts wound margins in laceration repair. Pre- vious published trials on topically ap- plied anesthetics that were used to re- duce perineal pain yielded conflicting results; most of the trials addressed pain during the second stage of labor 7 or in the early puerperium period, 8-11 rather than pain during suturing. Lidocaine-prilocaine cream (EMLA cream; AstraZeneca, Basiglio, Italy) is an eutectic mixture of 2.5% lidocaine and 2.5% prilocaine that is used widely as topical anesthetic for pediatric, derma- tologic, reconstructive, and gynecologic minor procedures. Absorption from the genital mucosa is rapid, and onset time is between 5 and 10 minutes with an average dura- tion of effective analgesia from 15-20 minutes; however, on intact skin, the cream should be applied for at least 1 hour to provide satisfactory dermal analgesia. 12 We sought to assess in a randomized controlled trial whether the topical ap- plication of EMLA cream is an effective method for alleviating pain that is expe- rienced during perineal repair. We therefore compared the effectiveness of EMLA cream vs conventional local infil- trative anesthesia with mepivacaine in the reduction of pain during suturing of an episiotomy or a naturally occurring tear after vaginal delivery. MATERIALS AND METHODS The trial was designed as a prospective, randomized controlled trial with re- cruitment from August through Sep- tember 2007. The trial was conducted at a referring academic institution after the approval from the institutional review board. Inclusion criteria included gesta- tional age  37 weeks, uncomplicated pregnancy, singleton gestation, and ver- tex fetal presentation. Women were excluded because of epidural analgesia request, operative delivery, intact peri- neum, previous fourth-degree perineal tear, previous adverse reaction to a local anesthetic, and insufficient Italian lan- From the Departments of Obstetrics and Gynecology, University of Verona, Verona (Drs Franchi, Scarperi, and Gaudino), and University of Insubria, Varese (Drs Cromi, Siesto, and Ghezzi), Italy. Received Sept. 28, 2008; revised Nov. 23, 2008; accepted April 9, 2009. Reprints: Fabio Ghezzi, MD, Department of Obstetrics and Gynecology, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy. fabio.ghezzi@uninsubria.it. Authorship and contribution to the article is limited to the 6 authors indicated. There was no outside funding or technical assistance with the production of this article. 0002-9378/$36.00 © 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.04.023 Research www. AJOG.org 186.e1 American Journal of Obstetrics & Gynecology AUGUST 2009