Labour analgesia the VIP way…

Gambling D, Berkowitz J, Farrell TR et al. A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery. Anesthesia & Analgesia 1013; 116: 636-643.

RHH Journal Club. June 6th, 2013. Dr Vinayak Kumar

No free full-text available

Does a CSE technique provide superior analgesia for the first two stages of labour compared to a standard lumbar epidural?

Study design

  • Randomised Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural   Analgesia   during first and second stages of labour and at delivery.
  • Single centre – Private Practice Setting- USA (2007-09)



  • 802 patients. Combined Spinal-Epidural (CSE) –  402, Epidural Analgesia -400
  • Included- patients who can speak English, ASA – I to III, uncomplicated term labour, patient request for neuraxial labour pain relief.
  • Excluded-Inability to speak  English, ASA≥IV, gestational age <37 weeks, malpresentation ,  previous LSCS, multiple gestations, BMI >40kg/m2.


  • Epidural vs CSE for labour analgesia
  • Pain scores during first and second stages of labour and at delivery

–          Epidural  group -10 mL 0.125% bupivacaine with fentanyl 2 μg/mL in 2 equal divided doses          via the epidural needle, followed by 5 mL through the catheter.

–          CSE group – 2.5 mL of the same solution via the spinal needle before epidural catheter placement.


  • Primary outcome- Assessment of pain, using a verbal rating pain scale (VRPS) of scores from 0 to 10, made at the end of the first stage of labour and shortly after delivery.
  • Secondary outcome- PCEA use, number of epidural top-up doses, epidural catheter replacements, side effects, patient satisfaction and labour outcomes.


  • Patients were randomised and randomisation was concealed
  • Patients analysed in the similar groups to which they were randomised
  • Patients and outcome assessors were blinded


  • CSE group reported better analgesia during the first stage of labour -VRPS score (1.4 vs. 1.9; P < 0.001).
  • Time to complete analgesia –  shorter in the CSE group (21.9 vs.10.8mins:P<0.001)
  • Pain scores during the second stage of labour (1.7 vs. 1.9; P = 0.17 and at delivery 2.0 vs. 2.0; P = 0.77) were not different between groups.
  •  Hourly pain scores were similar between groups with the exception of first hour in which better analgesia was observed in the CSE.
  • No difference in secondary outcomes except the incidence of epidural top-up boluses -significantly less in the CSE group.

 Conclusions/In practice

  • The differences in pain scores demonstrated in this study are not clinically significant, even if they achieved statistically significant differences.
  • NAP 3-  CSE: <6% of CNB but reports of harm >13%. In Obstetrics-Harm/death-Epidural-1:166,667(opti/pessimistic) is safer than CSE (1:26,641-pessimistic, 0-optimistic))



Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s