Universal adoption of combined spinal–epidural for labour analgesia is the antithesis of patient-centric care

Abstract

Zang et al. compared the quality of labour analgesia using dural puncture epidural (DPE) versus combined spinal–epidural (CSE) techniques [1]. In an accompanying editorial, George and Landau assert that the superior labour analgesia provided by the CSE over standard epidurals is undeniable [2]. They suggest that anaesthetists who do not universally adopt CSE are disadvantaging their patients [2]; we disagree.

George and Landau cited three trials to support their assertion, but only one directly compared CSE with standard epidurals for quality of analgesia [3]. This reported a statistically significant, yet clinically insignificant, mean pain score difference at 1 h and 5 h in favour of CSE over a 9-h period. A Cochrane review concluded that there was little basis for offering CSE over epidurals, as the only advantage was a slightly faster onset of analgesia [4]. A recent systematic review was unable to conclude that CSE provided better labour analgesia quality than standard epidurals [5].

Zang et al. reported no significant differences between DPE and CSE for a composite measure of quality of analgesia or for post-procedure pain scores, with 29% of all patients reporting poor block quality and 24% requiring a supplemental epidural bolus [1]. This small trial does not suggest that an intrathecal injection of bupivacaine and fentanyl in the CSE added any advantage to the dural puncture. The question remains whether the dural puncture adds any advantage to the quality of labour epidural analgesia. The dural puncture may provide faster onset initial analgesia, if the initial epidural loading volume of the low-dose local anaesthetic mixture is parsimonious, for example, 10 ml vs. 20 ml. With a 20-ml volume, there is minimal significant difference between a DPE and a standard epidural for onset of initial analgesia, and there is no difference in analgesia by 10 min [6, 7]. When compared with DPE or CSE, a standard epidural provides more prolonged initial analgesia if an adequate loading volume is used. Additionally, a smaller subsequent dose is necessary to maintain analgesia [8].

The benefit of the dural puncture is postulated to be the conduit it provides for translocation of epidural local anaesthetic into the cerebrospinal fluid. Conduits can be bidirectional with cerebrospinal fluid leakage causing intracranial hypotension and postdural puncture headache (PDPH), a significant inherent risk with DPE and CSE techniques. Zhang et al. reported a PDPH incidence of 1% [1]. The excess risk of PDPH with CSE has been estimated to be at least 0.3% [9]. Universal use of CSE for labour analgesia would likely increase the burden of PDPH morbidity, which has recognised long-term postpartum health implications. The intrathecal opioids given with a CSE increase the risk of fetal bradycardia and maternal pruritus significantly [10]. In the study of patient preferences for outcomes associated with labour epidural analgesia cited by George and Landau, faster labour analgesia onset was only ranked fourth in importance, while avoiding complications was ranked fifth [11].

Standard epidurals provide effective and satisfactory labour analgesia for many parturients without acceptance of the added risks of CSE and dural puncture. There is a role for the CSE in labour analgesia but on a selective basis, including those parturients too distressed to safely allow epidural cannulation; analgesia request in the second stage of labour; replacement epidural analgesia; or maternal request. That would be regarded as a patient-centric and patient-personalised approach to care and not the universal adoption of the CSE for labour analgesia advocated by George and Landau.