Epidural analgesia versus dural puncture epidural analgesia in labouring parturients: a meta-analysis of randomised controlled trials.

Abstract

Background: Epidural analgesia and dural puncture epidural (DPE) analgesia are widely used techniques for alleviating labour pain. This meta-analysis compared clinical outcomes between parturients receiving epidural analgesia vs DPE analgesia for labour pain.

Methods: Medical databases were searched to identify randomised controlled trials comparing epidural analgesia with DPE analgesia in labouring parturients published up to October 2024. Results were pooled using an inverse variance random-effects model, and 95% prediction intervals were calculated. Clinical outcomes were used as defined by individual trials. The primary outcome was time to onset of analgesia. Secondary outcomes were unilateral block, motor block, sacral sparing, adequate analgesia, Caesarean/operative vaginal delivery, additional doses, and hypotension. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation guidelines, and subgroup analyses were performed based on the types of local anaesthetics used.

Results: Eighteen trials involving 2144 parturients were included. DPE labour analgesia slightly reduced the time to onset (mean difference: 3.4 min, 95% confidence interval: 2.1-4.7, P<0.01, I²=97%; moderate certainty). All statistically significant results demonstrated clinical advantages for DPE analgesia, including fewer unilateral blocks, reduced motor block, improved sacral coverage, and higher rates of adequate analgesia. Substantial heterogeneity was observed in the outcome data for time to onset of analgesia, unilateral block, and sacral sparing. Pooled results for Caesarean/operative vaginal delivery, additional doses, and hypotension failed to achieve statistical significance.

Conclusions: DPE labour analgesia offers a slightly faster onset and reduced incidence of motor and unilateral blocks compared with traditional epidural analgesia. However, high heterogeneity in some outcomes, likely attributable to clinical and dosing variability, requires cautious interpretation. Although the clinical relevance of the faster onset with DPE analgesia might be modest, when considered alongside its benefits in secondary outcomes it supports the use of DPE analgesia over traditional epidural analgesia. Imputed prediction intervals cross zero for many outcomes, and further studies might alter these findings.

Clinical trial registration: PROSPERO- CRD42024602115.