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Review
. 2025 Jun 1;38(3):195-201.
doi: 10.1097/ACO.0000000000001487. Epub 2025 Mar 25.

Neuraxial initiation techniques for labor analgesia: Comparative insights on standard epidural, combined spinal-epidural and dural puncture epidural analgesia

Anthony Chau  1   2   3 , Lawrence C Tsen  4
Affiliations
Review

Neuraxial initiation techniques for labor analgesia: Comparative insights on standard epidural, combined spinal-epidural and dural puncture epidural analgesia

Anthony Chau et al. Curr Opin Anaesthesiol. .

Abstract

Purpose of review: In recent years, initiation techniques for neuraxial labor analgesia have focused on enhancing analgesic quality while minimizing complications. This review aims to summarize recent evidence on the standard epidural (EPL), combined spinal-epidural (CSE), and dural puncture epidural (DPE) techniques, emphasizing their benefits, risks, and relevance in contemporary obstetric anesthesia care.

Recent findings: The DPE technique offers unique values, combining the advantages from CSE and EPL techniques. DPE and CSE, compared with EPL, techniques involve a dural puncture with a spinal needle, and the resulting epidural-intrathecal conduit enables translocation of analgesic agents, providing faster onset, earlier sacral coverage, better catheter function, and more rapid epidural extension to surgical anesthesia. Moreover, by limiting the intrathecal dose administered with the CSE technique, the DPE technique lowers the risks of fetal bradycardia and pruritus.

Summary: EPL and CSE techniques are widely used for neuraxial labor analgesia. The DPE technique offers a novel alternative, delivering high-quality analgesia with minimal complications. While the benefits of the DPE technique are increasingly being recognized, additional comparative research will better support anesthesiologists in selecting the most appropriate technique across diverse clinical scenarios.

Keywords: combined spinal epidural; dural puncture epidural; epidural analgesia; labor analgesia; neuraxial initiation techniques; neuraxial labor analgesia; obstetric anesthesia.

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References

    1. Chau A, Tsen L. Neuraxial labor analgesia: initiation techniques. Best Pract Res Clin Anaesthesiol. 2022; 36:3–15.
    1. Heesen M, Rijs K, Rossaint R, Klimek M. Dural puncture epidural versus conventional epidural block for labor analgesia: a systematic review of randomized controlled trials. Int J Obstet Anesth. 2019; 40:24–31.
    1. Heesen M, Van de Velde M, Klohr S, et al. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. Anaesthesia. 2014; 69:64–71.
    1. Berger AA, Jordan J, Li Y, et al. Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study. Int J Obstet Anesth. 2022; 52:103590.
    1. Arnolds D, Scavone B. Neuraxial labor analgesia failure rates in women with a body mass index ≥50 kg/m 2 : a single-center retrospective study. Int J Obstet Anesth. 2021; 48:103176.

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