Epidural maintenance strategies and second-stage feedback interventions during labour analgesia: a pairwise meta-analysis and narrative synthesis

Epidural maintenance strategies and second-stage feedback interventions address different aspects of labour care. We evaluated their effects on instrumental vaginal delivery, local anaesthetic consumption, labour and delivery outcomes, maternal safety, and neonatal outcomes. We conducted a systematic review of randomized controlled trials reported in accordance with PRISMA 2020. MEDLINE, Embase, CENTRAL, and Web of Science were searched from inception to September 7, 2026. The protocol-concordant primary comparison was programmed or automated intermittent epidural versus continuous epidural infusion after conventional epidural initiation. Combined spinal–epidural, dural-puncture epidural, and provider-administered manual-bolus regimens were examined in sensitivity analyses. Real-time visual feedback was analysed separately from prerecorded instruction. Random-effects meta-analyses used restricted maximum-likelihood estimation with modified Hartung–Knapp–Sidik–Jonkman inference. Twenty-eight independent randomized trials, reported in 29 publications and involving 6250 women in eligible comparisons, were included. Nine conventional-epidural trials involving 4041 women contributed to the registered primary analysis. Intermittent bolus did not clearly reduce instrumental vaginal delivery (OR 0.80, 95% CI 0.61–1.04; I 2 500%; conditional prediction interval 0.61–1.04). Seven trials involving 3682 women showed lower cumulative local-anaesthetic mass (RoM 0.80, 95% CI 0.74–0.86; I 2 %;73.0%; conditional prediction interval 0.68–0.93). Caesarean delivery was less frequent in the pooled analysis (OR 0.73, 95% CI 0.54–0.98), whereas second-stage duration was not clearly different (MD − 1.05 min, 95% CI − 2.44 to 0.34). The need for a supplemental analgesic intervention favoured intermittent bolus on average (OR 0.39, 95% CI 0.19–0.82), but heterogeneity was substantial ( I 2 .483.0%) and the conditional prediction interval crossed the null (0.06–2.63). Evidence for other maternal and neonatal safety outcomes was limited. Real-time visual feedback did not clearly reduce instrumental vaginal delivery (OR 0.81, 95% CI 0.29–2.21). Programmed or automated intermittent epidural did not clearly reduce instrumental vaginal delivery but was associated with lower cumulative local-anaesthetic mass. Apparent reductions in supplemental analgesic intervention and caesarean delivery require cautious interpretation because of heterogeneity, imprecision, and overall low or very-low certainty. Evidence for second-stage feedback interventions remains preliminary.