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Meta-Analysis
. 2012 Oct 17;10(10):CD003401.
doi: 10.1002/14651858.CD003401.pub3.

Combined spinal-epidural versus epidural analgesia in labour

Scott W Simmons  1 , Neda Taghizadeh, Alicia T Dennis, Damien Hughes, Allan M Cyna
Affiliations
Meta-Analysis

Combined spinal-epidural versus epidural analgesia in labour

Scott W Simmons et al. Cochrane Database Syst Rev. .

Abstract

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 methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 September 2011) and reference lists of retrieved studies. We updated the search on 30 June 2012 and added the results to the awaiting classification section.

Selection criteria: All published randomised controlled trials (RCTs) involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour. Cluster-randomised trials were considered for inclusion. Quasi RCTs and cross-over trials were not considered for inclusion in this review.

Data collection and analysis: Three review authors independently assessed the trials identified from the searches for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy.

Main results: Twenty-seven trials involving 3274 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 five outcomes showed a significant difference. CSE was more favourable in relation to speed of onset of analgesia from time of injection (mean difference (MD) -2.87 minutes; 95% confidence interval (CI) -5.07 to -0.67; two trials, 129 women); the need for rescue analgesia (risk ratio (RR) 0.31; 95% CI 0.14 to 0.70; one trial, 42 women); urinary retention (RR 0.86; 95% CI 0.79 to 0.95; one trial, 704 women); and rate of instrumental delivery (RR 0.81; 95% CI 0.67 to 0.97; six trials, 1015 women). Traditional epidural was more favourable in relation to umbilical venous pH (MD -0.03; 95% CI -0.06 to -0.00; one trial, 55 women). There were no data on maternal satisfaction, blood patch for post dural puncture headache, respiratory depression, umbilical cord pH, rare neurological complications, analgesia for caesarean section after analgesic intervention or any economic/use of resources outcomes for this comparison. No differences between CSE and traditional epidural were identified for mobilisation in labour, the need for labour augmentation, the rate of caesarean birth, incidence of post dural puncture headache, maternal hypotension, neonatal Apgar scores or umbilical arterial pH.For CSE versus low-dose epidurals, three outcomes were statistically significant. Two of these reflected a faster onset of effective analgesia from time of injection with CSE and the third was of more pruritus with CSE compared to low-dose epidural (average RR 1.80; 95% CI 1.22 to 2.65; 11 trials, 959 women; random-effects, T² = 0.26, I² = 84%). There was no significant difference in maternal satisfaction (average RR 1.01; 95% CI 0.98 to 1.05; seven trials, 520 women; random-effects, T² = 0.00, I² = 45%). There were no data on respiratory depression, maternal sedation or the need for labour augmentation. No differences between CSE and low-dose epidural were identified for need for rescue analgesia, mobilisation in labour, incidence of post dural puncture headache, known dural tap, blood patch for post dural headache, urinary retention, nausea/vomiting, hypotension, headache, the need for labour augmentation, mode of delivery, umbilical pH, Apgar score or admissions to the neonatal unit.

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 conversely less pruritus with low-dose epidurals. There was no difference in ability to mobilise, maternal hypotension, rate of caesarean birth or neonatal outcome. However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries 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.

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Conflict of interest statement

None known.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 2 Combined spinal‐epidural versus low‐dose epidural, outcome: 2.12 Hypotension.
1.1
1.1. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 1 Time from first injection to effective analgesia (minutes).
1.3
1.3. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 3 Need for rescue analgesia.
1.5
1.5. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 5 Number of women who mobilise.
1.6
1.6. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 6 Post dural puncture headache.
1.7
1.7. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 7 Known dural tap.
1.8
1.8. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 8 Number of women requiring blood patch for post dural puncture headache.
1.9
1.9. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 9 Pruritus.
1.10
1.10. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 10 Urinary retention.
1.11
1.11. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 11 Nausea/vomiting.
1.12
1.12. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 12 Hypotension.
1.13
1.13. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 13 Respiratory depression.
1.14
1.14. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 14 Headache (any).
1.15
1.15. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 15 Sedation.
1.16
1.16. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 16 Labour augmentation required.
1.17
1.17. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 17 Augmentation after analgesia.
1.18
1.18. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 18 Normal delivery.
1.19
1.19. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 19 Instrumental delivery.
1.20
1.20. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 20 Caesarean section.
1.21
1.21. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 21 Umbilical arterial pH.
1.22
1.22. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 22 Umbilical venous pH.
1.24
1.24. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 24 Apgar score < 7 at 5 minutes.
1.25
1.25. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 25 Apgar score < 8 at 5 minutes.
1.26
1.26. Analysis
Comparison 1 Combined spinal‐epidural versus traditional epidural, Outcome 26 Number admitted to neonatal unit.
2.1
2.1. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 1 Time from first injection to effective analgesia (minutes).
2.2
2.2. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 2 Number of women with effective analgesia 10 minutes after first injection.
2.3
2.3. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 3 Need for rescue analgesia.
2.4
2.4. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 4 Number of women satisfied with analgesia.
2.5
2.5. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 5 Number of women who mobilise.
2.6
2.6. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 6 Post dural puncture headache.
2.7
2.7. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 7 Known dural tap.
2.8
2.8. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 8 Number of women requiring blood patch for post dural puncture headache.
2.9
2.9. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 9 Pruritus.
2.10
2.10. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 10 Urinary retention.
2.11
2.11. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 11 Nausea/vomiting.
2.12
2.12. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 12 Hypotension.
2.13
2.13. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 13 Respiratory depression.
2.14
2.14. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 14 Headache (any).
2.16
2.16. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 16 Labour augmentation required.
2.18
2.18. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 18 Normal delivery.
2.19
2.19. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 19 Instrumental delivery.
2.20
2.20. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 20 Caesarean section.
2.21
2.21. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 21 Umbilical arterial pH.
2.22
2.22. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 22 Umbilical venous pH.
2.23
2.23. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 23 Umbilical cord pH.
2.24
2.24. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 24 Apgar score < 7 at 5 minutes.
2.25
2.25. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 25 Apgar score < 8 at 5 minutes.
2.26
2.26. Analysis
Comparison 2 Combined spinal‐epidural versus low‐dose epidural, Outcome 26 Number admitted to neonatal unit.
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Update of

References

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Backus 1996 {published data only}
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Leighton 1996 {published data only}
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    1. Nielson PE, Erickson R, Abouleish E, Perriatt S, Sheppard C. Fetal heart rate changes after intrathecal sufentanil or epidural bupivacaine for labor analgesia: incidence and clinical significance. Anesthesia & Analgesia 1996;83:742‐6. - PubMed
Norris 1994 {published data only}
    1. Norris MC, Grieco WM, Borkowski M, Leighton B, Arkoosh VA, Huffnagle HJ, et al. Complications of labor analgesia: epidural versus combined spinal epidural techniques. Anesthesia & Analgesia 1994;79:529‐37. - PubMed
Norris 2001 {published data only}
    1. Norris MC, Fogel ST, Conway‐Long C. Combined spinal‐epidural versus epidural labor analgesia. Anesthesiology 2001;95(4):913‐20. [12456] - PubMed
Pan 1996 {published data only}
    1. Pan P, Fragneto R, Moore C, Ross V. Do obstetric outcomes differ between early combined spinal‐epidural and epidural anesthesia in nulliparous patients receiving intravenous oxytocin?. Anesthesiology 1996;85(3A):A854.
    1. Pan P, Moore C, Fragneto R, Ross V, DiNunzio G. Do obstetric outcomes differ between early combined spinal‐epidural and epidural anesthesia in spontaneously laboring nulliparous paturients?. Anesthesia & Analgesia 1998;86:S382. [9895]
    1. Pan PH, Fragneto R, Moore C. Does combined spinal‐epidural labor analgesia result in better obstetric outcome than epidural anesthesia?. Southern Medical Journal 1996;89:S10.
Patel 2003b {published data only}
    1. Patel N, Fernando R, Columb MO, Bray JK, Sodhi V, Lyons GR. Combined spinal‐epidural (cse) vs epidural labour analgesia: does initial intrathecal analgesia reduce subsequent epidural bupivacaine requirements [abstract]. International Journal of Obstetric Anesthesia 2003;12:197. [13222]
Pham 1996 {published data only}
    1. Pham LH, Camann WR, Smith MP, Datta S, Bader AM. Hemodynamic effects of intrathecal sufentanil compared with epidural bupivacaine in laboring parturients. Journal of Clinical Anesthesia 1996;8:497‐501; discussion 502‐3. - PubMed
Pinto 2000 {published data only}
    1. Pinto G, Collini S, Favaro R, Turkiewicz AM, Pizzicaroli C, Massullo D, et al. Combined spinal‐epidural: selective sequential analgesia during labour. Acta Anaesthesiologica Italica/Anaesthesia & Intensive Care in Italy 2000;51:245‐59. [13219]
Rosenfeld 1998 {published data only}
    1. Rosenfeld DJ, Ackal T, Fournet K, Rosinia FA. A comparison of intrathecal sufentanil and epidural bupivacaine with PCEA throughout labor. Anesthesiology 1998;89:A31.
Stocche 2001 {published data only}
    1. Stocche R, Klamt J, Antunes‐Rodrigues J, Garcia L, Moreira A. Effects of intrathecal sufentanil on plasma oxytocin and cortisol concentrations in women during the first stage of labor. Regional Anaesthesia and Pain Medicine 2001;26(6):545‐50. - PubMed
    1. Stocche RM, Garcia LV, Klamt JG. Effects of analgesic intrathecal sufentanil and 0.25% epidural bupivacaine on oxytocin and cortisol plasma concentration in labor patients. Revista Brasileira de Anestesiologia 2001;51(4):285‐97. [14645]
Van de Velde 2004 {published data only}
    1. Velde M, Teunkens A, Hanssens M, Vandermeersch E, Verhaege J. Intrathecal sufentanil and fetal heart rate abnormalities: a double‐blind, double placebo‐controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor. Anesthesia & Analgesia 2004;98(4):1153‐9. [13676] - PubMed
    1. Velde M, Verhaeghe J, Teunkens A, Spitz B, Vandermeersch E. Non‐reassuring fetal heart rate changes and uterine hyperactivity following combined spinal‐epidural or conventional epidural analgesia during labor: the effect of intrathecal opioids. Anesthesiology 2002;96 Suppl:A1048.

References to studies awaiting assessment

Arya 2007 {published data only}
    1. Arya VK, Jain V, Mehdi B, Bhatia A. Comparison of epidural with CSE for 'walking labor analgesia' and fetal fentanyl levels at delivery. Anesthesiology 2007;107:Abstract no: A1766.
Celik 2005 {published data only}
    1. Celik M, Pirbudak, Balat O, Ugur MG, Sahinoz S, Oner U. Comparison of clinical efficacies of combined spinal‐epidural and epidural analgesia techniques with continuous patient controlled infusion method in labor analgesia [abstract]. Regional Anesthesia and Pain Medicine 2005;30(5 Suppl 1):71.
de Souza 2009 {published data only}
    1. Souza MA, Pinto e Silva JL, Maia Filho NL. Combined spinal‐epidural block versus continuous epidural block in labor analgesia for primiparous women: newborns and women outcomes [Bloqueio combinado raquiperidural versus bloqueio peridural continuo para analgesia de parto em primigestas: resultados materos e perinatais]. Revista Brasileira de Ginecologia e Obstetricia 2009;31(10):485‐91. - PubMed
Gupta 2002 {published data only}
    1. Gupta S, Raiger LK, Raman V. Ambulatory labour analgesia ‐ comparison of two regional techniques. Indian Journal of Anaesthesia 2002;46(1):44‐8.
Kayacan 2006 {published data only}
    1. Kayacan N, Ertugrul F, Cete N, Coskunfirat N, Akar M, Karsli B, et al. Comparison of epidural and combined spinal‐epidural analgesia in the management of labour without pain. Journal of International Medical Research 2006;34(6):596‐602. - PubMed
Lee 2007 {published data only}
    1. Lee SC, Grondin L, Mertz H, Pan PH, Eisenach JC. Effect of spinal vs epidural analgesia on cervical dilation and cytokine expression in laboring women. Anesthesiology 2007;107:Abstract no: A670.
Lee 2007a {published data only}
    1. Lee SC, Pan PH, Mertz H, Smith JG, Grondin L, Harris LC, et al. Effect of spinal versus epidural analgesia on uterine cervical dilution and cytokine expression in laboring women [abstract]. Anesthesiology 2007;106(Suppl 1):9.
Lian 2008 {published data only}
    1. Lian Q, Ye X. The effects of neuraxial analgesia of combination of ropivacaine and fentanyl on uterine contraction. Anesthesiology 2008;109:A1332.
Mantha 2007 {published data only}
    1. Mantha VR, Vallejo MC, Ramesh V, Daftary A, Ramanathan S. Does intermittent epidural analgesia have better labor outcome compared to continuous analgesia? [abstract]. Anesthesiology 2007;106(Suppl 1):37.
Nakamura 2009 {published data only}
    1. Nakamura G, Ganem EM, Rugolo LM, Castiglia YM. Effects on mother and fetus of epidural and combined spinal‐epidural techniques for labor analgesia. Revista Da Associacao Medica Brasileira 2009;55(4):405‐9. - PubMed
Olmez 2003 {published data only}
    1. Olmez G, Dag IH, Ozyilmaz MA, Yalinkaya A. Can combined spinal‐epidural analgesia be an alternative to epidural analgesia alone in labour?. Turk Anesteziyoloji Ve Reanimasyon 2003;31(2):66‐72.
Pascual 2011 {published data only}
    1. Pascual J, Haya J, Perez F, Gil S, Garrido RA, Calatayud L. Combined spinal(morphine)‐epidural analgesia does not shorten labor and delivery compared to epidural analgesia: a randomised study. European Journal of Anaesthesiology 2011;28 Suppl:156.
Pascual‐Ramirez 2010 {published data only}
    1. Pascual Ramirez J, Haya J, Gil S, Calatyud L, Pretel M, Alvarez E, et al. Spinal fentanyl‐morphine in a combined vs epidural labor analgesia does not shorten labor and delivery times. Regional Anesthesia and Pain Medicine 2010;35(5):E154.
Pascual‐Ramirez 2011 {published data only}
    1. Pascual‐Ramirez J, Haya J, Perez‐Lopez FR, Gil‐Trujillo S, Garrido‐Esteban RA, Bernal G. Effect of combined spinal‐epidural analgesia versus epidural analgesia on labor and delivery duration. International Journal of Gynecology and Obstetrics 2011;114(3):246‐50. - PubMed
Patel 2012 {published data only}
    1. Patel NP, Armstrong SL, Fernando R, Columb MO, Bray JK, Sodhi V, et al. Combined spinal epidural vs epidural labour analgesia: does initial intrathecal analgesia reduce the subsequent minimum local analgesic concentration of epidural bupivacaine?. Anaesthesia 2012;67(6):584‐93. - PubMed
Salem 2007 {published data only}
    1. Salem ICF, Fukushima FB, Nakamura G, Ferrari F, Navarro LC, Castiglia YMM, et al. Side effects of subarachnoid and epidural sufentanil associated with a local anesthetic in patients undergoing labor analgesia. Revista Brasileira de Anestesiologia 2007;57(2):125‐35. - PubMed
Sweed 2011 {published data only}
    1. Sweed N, Sabry N, Azab T, Nour S. Regional versus IV analgesics in labor. Minerva Medica 2011;102(5):353‐61. - PubMed
Wilson 2011 {published data only}
    1. Wilson MJA, Moore PAS, Shennan A, Lancashire RJ, MacArthur C. Long‐term effects of epidural analgesia in labor: a randomized controlled trial comparing high dose with two mobile techniques. Birth 2011;38(2):105‐10. - PubMed

Additional references

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