Combined spinal-epidural versus epidural analgesia in labour.

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. OBJECTIVES: To assess the relative effects of combined spinal-epidural versus epidural analgesia during labour. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group Trials Register (July 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to June 2002) and EMBASE (1974 to June 2002). 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: Trials identified from searching were assessed for inclusion by the same two reviewers independently. Review Manager software was used for calculation of the treatment effect represented by odds ratios (OR) and weighted mean difference (WMD) using a fixed effects model with 95% confidence intervals (CI). MAIN RESULTS: Fourteen trials (2047 women) met our inclusion criteria. Of the 25 outcomes analysed from these studies CSE shows a reduced time from first injection to effective maternal analgesia WMD -5.50 minutes (95% CI -6.47 to -4.52; four trials), an increased incidence of maternal satisfaction OR 4.69 (95% CI 1.27 to 17.29; three trials), and an increased incidence of pruritus OR 2.79 (95% CI 1.87 to 4.18; nine trials). No difference was found between CSE and epidural techniques with regards to maternal mobility, rescue analgesia requirements, the incidence of post dural puncture headache (PDPH) or blood patch, hypotension, urinary retention, mode of delivery, or admission of the baby to the neonatal unit. REVIEWER'S CONCLUSIONS: There is no standard CSE or epidural technique. Compared with epidural, CSE provides faster onset of effective pain relief from the time of injection, and increases the incidence of maternal satisfaction. However, CSE women experience more itch. There is no difference between CSE and epidural techniques with respect to: the incidence of forceps delivery, maternal mobility, PDPH, caesarean section rates or admission of babies to the neonatal unit. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.