E pidural analgesia has been used to provide labor pain relief for more than 40 years. The technique has been refined over the past 20 years to provide laboring women with higher-quality pain relief, less leg weakness, and more control over the administration of pain relief medication. Since the early 1990s, the combined spinal-epidural (CSE) technique has become popular because it provides more rapid onset pain relief with minimal motor weakness. 1,2 Various studies have suggested that CSE

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... ared with epidural analgesia may provide superior overall pain relief during labor and faster rates of cervical dilation. [3] [4] [5] However, other studies have shown no difference between the techniques in terms of pain relief or the incidence of cesarean deliveries. 6, 7 Poor study design and low numbers of subjects limit many early studies. Additionally, mostly trainees initiated epidural analgesia. To our knowledge, no large prospective study of CSE has been conducted in a private practice setting by experienced practitioners. The primary outcome of this randomized clinical research trial was an 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 labor and shortly after delivery. The secondary outcomes were patient-controlled epidural analgesia (PCEA) use, number of epidural supplemental top-up doses administered by an anesthesiologist, epidural catheter replacements, side effects, and labor outcomes. We hypothesized that CSE would provide superior analgesia throughout labor and delivery. BACKGROUND: There has been no prospective evaluation of combined spinal-epidural (CSE) analgesia in a private practice setting and few studies have focused on pain relief during the second stage of labor and at delivery. In this randomized controlled trial, we compared verbal pain scores during the first and second stages of labor and at delivery in women receiving CSE or traditional epidural analgesia at a busy private maternity hospital. METHODS: Healthy, term parturients received epidural or CSE analgesia for labor pain upon request. Epidural analgesia was initiated with 0.125% bupivacaine plus 2 μg/mL fentanyl, 15 mL; CSE analgesia was initiated with intrathecal plain bupivacaine 3.125 mg plus 5 μg fentanyl. Thereafter, patient-controlled epidural analgesia with 0.125% bupivacaine plus 2 μg/mL fentanyl was used for maintenance analgesia in both groups. The primary outcome was an assessment of "typical" pain, using a verbal rating pain score from 0 to 10, made at the end of the first stage of labor and shortly after delivery. RESULTS: Data from 398 epidural and 402 CSE subjects were analyzed. The typical verbal rating pain score during the first stage was lower in the CSE group (mean: 1.4 vs 1.9; P < 0.001; 99.5% confidence interval [CI] for difference: −0.92, −0.14). Pain scores during the second stage of labor (1.7 vs 1.9; P = 0.17; 99.5% CI for difference: −0.82, 0.28) and at delivery (2.0 vs 2.0; P = 0.77; 99.5% CI for difference: −0.73, 0.59) were the same between groups. Fewer patients received an epidural top-up dose in the CSE group (16.4% vs 25.6%; P = 0.002; 99.5% CI for difference: −17.0%, −1.0%). Epidural catheters were replaced in 1.2% CSE vs 2% in the epidural group (P = 0.39; 99.5% CI for difference: −3.3%, 1.8%). CONCLUSIONS: Compared with traditional epidural labor analgesia, CSE analgesia provided better first-stage analgesia despite fewer epidural top-up injections by an anesthesiologist.