Which Epidural Analgesia Is Best?

December 19, 2012

Is epidural analgesia or combined spinal-epidural (CSE) analgesia better for pain management in labor?

There appears to be little overall difference between epidural analgesia and combined spinal-epidural (CSE) analgesia, concluded an updated intervention review by the Cochrane Pregnancy and Childbirth Group.1

All published randomized controlled trials that compared CSE with epidural analgesia initiated during the first stage of labor were considered, as were cluster-randomized trials. A total of 27 trials involving 3274 women met inclusion criteria, and 26 different outcomes were analyzed using comparisons between CSE and traditional epidurals and CSE and low-dose epidurals.

When compared with traditional epidurals, the CSE technique had a quicker onset of action from the time of injection-an average of 2.87 minutes faster. Women who had CSE also had less need for rescue analgesia, less urinary retention, and lower rates of instrument delivery than women who received traditional epidurals. Overall, however, there were no differences between analgesia techniques in terms of mobility during labor, the need for labor augmentation, cesarean delivery rates, incidence of post dural puncture headache, maternal hypotension, neonatal Apgar scores, or umbilical pH.

When low-dose epidurals were compared with CSE, researchers found that in concert with the previous finding, CSE was associated with a significantly faster onset of effective analgesia from the time of injection. However, CSE was also associated with significantly more cases of pruritis compared with low-dose epidurals. Despite more reports of pruritis with CSE, maternal satisfaction ratings were similar for analgesia types.

According to the CDC, about 60% of all spontaneous singleton vaginal births involve the use of epidural or spinal anesthesia, or a combination of the two.2 Women who had a forceps delivery or a vacuum extraction had significantly higher rates of epidural, spinal, or CSE anesthesia use-83.8% and 77.3%, respectively. Overall, women who receive these types of anesthesia have an increased risk for instrumental delivery, fetal malposition, longer second stage of labor, fetal distress, severe headache, maternal hypotension, maternal fever, and urinary retention.

The researchers suggested that the significantly higher incidence of urinary retention, need for rescue interventions, and need for instrumental deliveries associated with traditional epidurals made use of low-dose epidurals more favorable.1 Overall, there is no evidence that CSEs are a better option than traditional epidurals or low-dose epidurals.

Pertinent Points:
- In terms of adverse effects and patient satisfaction, low-dose epidurals are probably the most favorable option for pain relief during labor.
- There is no evidence that combined spinal-epidural technique, compared with traditional epidurals or low-dose epidurals, improves maternal mobility during labor.


1. Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev. 2012;10. Art No: CD003401. DOI: 10.1002/14651858.CD003401.pub3.
2. Osterman MJK, Martin JA. Epidural and spinal anesthesia use during labor: 27-state reporting area, 2008. Natl Vital Stat Rep. 2011;59(5):1-13, 16.