Combined spinal-epidural vs. dural puncture epidural techniques for labour analgesia: a randomised controlled trial

Background: The dural puncture epidural technique is a modification of the combined spinal-epidural technique. Data comparing the two techniques are limited. We performed this randomised study to compare the quality of labour analgesia following initiation of analgesia with the dural puncture epidural vs. the combined spinal-epidural technique.

Methods: Term parturients requesting labour epidural analgesia were allocated randomly to receive either dural puncture epidural or combined spinal-epidural. Analgesia was initiated with 2 mg intrathecal bupivacaine and 10 μg fentanyl in parturients allocated to the combined spinal-epidural group and with 20 ml ropivacaine 0.1% with 2 μg.ml^-1 fentanyl in parturients allocated to the dural puncture epidural group. Analgesia was maintained using patient-controlled epidural analgesia with programmed intermittent epidural boluses. The primary outcome of the study was the quality of labour analgesia, which was defined by a composite of five components: asymmetric block after 30 min of initiation (difference in sensory level of more than two dermatomes); epidural top-up interventions; catheter adjustment; catheter replacement; and failed conversion to neuraxial anaesthesia for caesarean delivery, requiring general anaesthesia or replacement of the neuraxial block.

Results: One hundred parturients were included in the analysis (48 combined spinal-epidural, 52 dural puncture epidural). There were no significant differences between the two groups in the primary composite outcome of quality of analgesia (33% in the combined spinal-epidural group vs. 25% in the dural puncture epidural group), risk ratio (95%CI) 0.75 (0.40-1.39); p = 0.486. Median (IQR [range]) pain scores at 15 min were significantly lower in patients allocated to the combined spinal-epidural group compared with the dural puncture epidural group (0 (0-1[0-8]) vs. 1 (0-4 [0-10]); p = 0.018).

Conclusions: There were no significant differences in the quality of labour analgesia following initiation of a combined spinal-epidural compared with a dural puncture epidural technique.