CSE for Labour : Creating Silly Extras?

Combined spinal epidural analgesia for labour pain has been the sexy product of obstetric anaesthesiology over the last decade. It was trumpeted in the Lancet, of all places, in the early 1995, and there was associated cover in the general media about this technique of labour analgesia which gives rapid relief and allows ambulation. But this study compared CSE and dilute (0.1% bupivacaine) epidural topups with epidural boluses of 0.25% bupivacaine so it is not surprising there were the differences observed. The later COMET trial, also published in Lancet, concluded there were no differences in obstetric outcomes between dilute epidural by infusion and CSE with intermittent dilute epidural topups. There were analgesic differences between the two techniques, but they can be explained by the differences in epidural management rather than the use of a spinal dose at the start of the neuraxial analgesia. The strongest argument for CSE in labour seem to be its rapid onset, but this onset only starts when the drug is injected into the CSF. The anaesthetists has to get there first (why not run faster?) assess the situation, and the get informed consent. In my experience I am always asked a to come to place an epidural; I have never been specifically asked by a parturient for a CSE. An obstetrician may occasionally suggest a spinal dose, but that is always for anaesthesia for delivery, rather than analgesia for labour pain. Is there an extra layer of consent needed for a spinal dose, thus making the time to achieve analgesia longer? In my view there seems to be an extra, albeit small, risk of meningitis, nerve root trauma, conus trauma, local anaesthetic toxicity to nerves, and in my hands, headache. If the dura is not breached there will not be a CSF leak. Even with a 27 G non-cutting needle there will be a chance of CSF leak that may rarely cause headache or cranial nerve symptoms (such as hearing loss or tinnitus). I have not had a epidural needle dural puncture in over 2000 cases, using a technique which uses forced loss of resistance to fluid and the lateral position. CSE seems easier in the sitting position, but this increases lumbar CSF pressure. Even in the sitting position finding CSF from the spinal needle can be tricky, increasing the time for some parturients to get their relief. And infection control in the dirty environment of a delivery room (visitors, street clothes, wandering partners, etc) and a possibly bacteraemic labouring woman is another dissuader from the use of CSE as a routine method of labour analgesia. The mentioned complications have and do occur. We can only speculate if for any case the complication would not have happened if it was epidural-only analgesia, but the breach of dura or the point of the long spinal needle often seem to be the likely culprit. Dilute, low dose bupivacaine and fentanyl epidural doses are an effective and safe means of analgesia for labour, and are effective and appropriate in the great majority of cases when “an epidural” is requested by a labouring patient.