Dural Puncture Epidural versus Combined Spinal-Epidural versus Epidural Techniques for Labor Analgesia: A 10-year Network Analysis of Randomized Controlled Trials

Background and Objectives: Neuraxial anesthesia, which includes techniques such as spinal anesthesia, traditional epidural, combined spinal-epidural (CSE), and dural puncture epidural (DPE), is considered the most effective, safe, and reliable method for providing pain relief during labor and delivery. The choice between DPE, CSE, and EPL depends on various factors, including the parturient’s labor, pain intensity, and preferences. This network meta-analysis (NMA) aimed to determine which analgesic technique among DPE, CSE, and pure epidural (EPL) techniques would be more effective in providing adequate analgesia and producing fewer adverse effects and/or complications for parturients undergoing labor. Methodology: In this study, the different analgesia techniques were assigned. DPE is assigned as group A, CSE as group B, and EPL as group C. This NMA combines direct and indirect evidence obtained from randomized controlled trials (RCTs). An electronic systematic search was done using electronic databases and online published RCTs. Critical appraisal of studies, collection, and extraction of data was facilitated by the primary investigator and a peer. A total of 31 journal articles were initially identified for screening and a total of 5 studies – 1 from database searches and 4 from citation chaining – were included in this meta-analysis after Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Outcome measures were pooled and analyzed using Review Manager Web version 5.4.1. Results: Among parturients, the likelihood of experiencing a rapid onset of analgesia was significantly greater among those on CSE, whereas the onset of DPE approximates that of EPL. Subsequent sensitivity analysis improved the onset of DPE over EPL, thus overall CSE > DPE > EPL. The odds of developing maternal hypotension were CSE > DPE. Overall, the comparative odds are as follows: CSE > EPL = DPE. The incidence of fetal bradycardia is almost equal for both interventions in studies comparing DPE versus CSE analgesia and DPE versus EPL although there is a greater likelihood of developing fetal bradycardia when parturients are on CSE > EPL, hence the comparative odds of developing fetal bradycardia are as follows: CSE > EPL = DPE. Conclusion: Overall, these findings suggest that CSE may offer advantages for labor analgesia among parturients in labor, in terms of faster onset of analgesia, although potentially causing higher risk of maternal hypotension and fetal bradycardia when compared to DPE and EPL. Based on the results of the current NMA article, further studies are required to compare DPE, CSE, and EPL for labor analgesia, to fully evaluate the risks and benefits of each intervention, particularly in relation to maternal and fetal outcomes.