Combined spinal-epidural versus epidural analgesia in labour

Simmons SW, Cyna AM, Dennis AT, Hughes D

Published Online:

January 21, 2009

Little difference overall between combined spinal-epidural (CSE) and other forms of epidural for pain relief in labour.

Regional analgesia has been shown to be effective in providing pain relief in labour. Regional analgesia can be an epidural, a spinal or a combination of the two. Because spinals are only effective for a short period of time, they are not used on their own for pain relief for labour. Epidural, is when the anaesthetic drugs are given through a very fine tube into the space around the spinal column (epidural space). Drugs for pain relief are infused through a very fine tube (catheter) positioned in the epidural space. Traditionally high concentrations of local anaesthetic drugs were used. These numbed the woman from the waist downwards giving pain relief for most women. However, it also caused leg weakness, poor mobility and difficulty for the mother giving birth. This led to increased instrumental vaginal births with subsequent increased bruising, pain and incontinence later on for the mother. More recently with epidurals, low-dose local anaesthetic drugs have been used in combination with opioid drugs. Here there is less numbing of the woman's legs but the opioid drugs cross the placenta and can make the baby sleepy. A spinal is when the anaesthetic drug is injected into the spinal column and is quicker to take effect than the epidural. A combined spinal-epidural (CSE) involves using both a spinal and an epidural for pain relief. It was thought this would have the benefits of being quicker to provide pain relief and so give more satisfaction for women. The review of trials compared CSE with traditional or low-dose epidurals. There were 19 randomised trials involving 2658 women. The data showed no difference in the mothers' satisfaction between CSE and epidurals. However, CSEs had a slightly faster onset of effective pain relief, but more women itched than with epidurals. There was no difference seen for mobility in labour, headaches, caesarean section or adverse effects for the baby. Any differences for rare complications such as nerve injury and meningitis remain unknown. There appears little difference overall between these techniques.

Abstract (click to read)

Background:

Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation, and increased incidence of instrumental vaginal delivery. The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia, which could contribute to increased maternal satisfaction.

Objectives:

To assess the relative effects of CSE versus epidural analgesia during labour.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2006).

Selection criteria:

All published randomised controlled trials involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour.

Data collection and analysis:

Three review authors independently asssessed the trials identified from the searches for inclusion and extracted the data.

Main results:

Nineteen trials (2658 women) met our inclusion criteria. Twenty-six outcomes in two sets of comparisons involving CSE versus traditional epidurals and CSE versus low-dose epidural techniques were analysed. Of the CSE versus traditional epidural analyses only three outcomes showed a difference. CSE was more favourable in relation to need for rescue analgesia and urinary retention, but associated with more pruritus.

For CSE versus low-dose epidurals, four outcomes were statistically significant. CSE had a faster onset of effective analgesia from time of injection but was associated with more pruritus. CSE was also associated with a clinically non-significant lower umbilical arterial pH.

No differences between CSE and epidural were seen for maternal satisfaction, mobilisation in labour, modes of birth, incidence of post dural puncture headache or blood patch and maternal hypotension. It was not possible to draw any conclusions with respect to maternal respiratory depression, maternal sedation and need for labour augmentation.

Authors' conclusions:

There appears to be little basis for offering CSE over epidurals in labour with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and less pruritus with epidurals. There is no difference in ability to mobilise, obstetric outcome or neonatal outcome. However, the significantly higher incidence of urinary retention and rescue interventions with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.

This record should be cited as:

Simmons SW, Cyna AM, Dennis AT, Hughes D. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003401. DOI: 10.1002/14651858.CD003401.pub2

Assessed as up to date:

May 22, 2007

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Primary Review Group:

Pregnancy and Childbirth Group

Health topics:

Pregnancy & childbirth > Pain during labour > Pharmacological methods

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Combined spinal-epidural versus epidural analgesia in labour

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