Application efficacy of dural puncture epidural versus traditional combined spinal epidural for labour analgesia: A systematic review and meta-analysis with trial sequential analysis

Abstract

Background and Aims:

This study aimed to systematically evaluate the effectiveness and safety of dural puncture epidural (DPE) and combined spinal epidural (CSE) for labour analgesia in parturients.

Methods:

Searches were performed in PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang Database, VIP Database, and CBM Database up to June 2025 to identify randomised controlled trials (RCTs) investigating the application of DPE and CSE techniques for labour analgesia in parturients. Data from eligible studies were pooled to calculate the combined standardised mean difference (SMD) or risk ratio (RR).

Results:

Eleven studies with 1461 parturients were included. DPE had higher visual analogue scale (VAS) pain scores at 10 min [SMD: 0.60; 95% confidence interval (CI): 0.24, 0.95; P = 0.001; I² = 76%] compared to CSE but fewer parturients requiring physician top-up boluses (RR = 0.64; 95% CI: 0.46, 0.88; P = 0.006; I² = 11%). It also showed significantly lower incidences of abnormal foetal heart rate patterns (RR = 0.27; 95% CI: 0.16, 0.44; P < 0.001; I² = 0%), pruritus (RR = 0.27; 95% CI: 0.14, 0.53; P < 0.001; I² = 54%), and maternal hypotension (RR = 0.36; 95% CI: 0.15, 0.89; P = 0.030; I² = 74%). No significant intergroup differences were found in first-stage labour duration, neonatal Apgar scores, or adverse reactions. The trial sequential analysis suggested the need for further data.

Conclusion:

Compared with CSE, although DPE has a slower onset of analgesia, it may provide more reliable analgesic effects and result in lower incidence rates of adverse reactions in both parturients and foetuses. Substantial heterogeneity in some outcomes, driven by clinical heterogeneity including dose variations and limited studies, warrants cautious interpretation.

INTRODUCTION

With the widespread adoption of painless labour, research into various labour analgesia anaesthetic techniques has increased significantly, with neuraxial techniques predominating. Traditional methods primarily include epidural analgesia (EA) and combined spinal-epidural analgesia (CSE). However, EA has the disadvantage of a slower onset,[1] while CSE presents a potential for increased foetal heart rate abnormalities.[2,3] Since Cappiello et al.[4] proposed that dural puncture epidural (DPE) could be utilised for labour analgesia, studies comparing DPE with either EA or CSE have gradually increased. While meta-analyses comparing DPE and EA exist, none specifically address DPE versus CSE. Therefore, a meta-analysis comparing DPE with CSE is warranted.

Existing literature has evaluated the clinical application of DPE in labour analgesia. Multiple independent studies have demonstrated the efficacy of DPE for labour analgesia.[1,5,6] Yin et al.’s[7] meta-analysis of 10 RCTs (n = 1099 parturients) demonstrated that DPE achieves effective analgesia significantly faster than epidural analgesia (EA). In primiparous women, Kang et al.[6] found that DPE provided analgesic efficacy comparable to combined spinal-epidural analgesia (CSE), but with reduced incidence of lower limb motor block (LLMB), pruritus, hypotension, and postpartum headache, while maintaining normal labour progression and neonatal Apgar scores. Nevertheless, DPE and CSE demonstrated similar analgesic quality, as reported by Zang et al.[8] These contradictory findings necessitate a systematic evidence synthesis to resolve the discrepancies. We, therefore, performed a comprehensive literature search of all relevant RCTs in obstetric populations and performed a meta-analysis on the pooled data.

This study aims to systematically analyse existing randomised controlled trials (RCTs) to evaluate DPE against CSE regarding clinical efficacy in labour analgesia. The visual analogue scale (VAS) score at 10 min post-administration was designated as the primary outcome measure, while a comprehensive evaluation of adverse reaction profiles associated with both analgesic techniques was undertaken to support clinical decision-making with rigorously validated evidence.

METHODS

The protocol for this systematic review and meta-analysis was listed on the International Prospective Register of Systematic Reviews (PROSPERO) database (ID: CRD42023455822). This study was conducted and documented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).[9]

Search strategy and study selection

Before starting their literature search, a strategy was set. Following this strategy, two independent authors searched through databases such as PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), WanFang Database, Chinese Scientific Journals Database (VIP), and Chinese Biomedical Literature Database (CBM) (PubMed search strategy, Supplementary Table 1). A strategy utilising both subject headings and free terms was implemented. The following English search terms were employed: “Labor, Obstetric,” “Labor,” “Obstetric Labor,” “Childbirth,” “dural puncture epidural,” “DPE,” “Anesthesia, Spinal,” “spinal anesthesia,” “Anesthesias, Spinal,” “Spinal Anesthesias,” “combined spinal - epidural,” “combined spinal epidural,” “CSE,” “Neuraxial Anesthesia,” and “Neuraxial Anesthesia.” The corresponding Chinese translations were subsequently queried across four principal Chinese academic databases: CNKI, WanFang, VIP, and CBM. An advanced search was conducted, with retrieval time spanning from the inception of various databases to 16 June 2025. The retrieved documents underwent a comprehensive screening process where their titles and abstracts were carefully evaluated. Two authors independently conducted the screening procedure, and EndNote 21 software (version 21; Clarivate Analytics, Philadelphia, PA, USA) was employed to eliminate duplicate manuscripts. The remaining manuscripts were then manually checked to ensure that no duplicates remained. Subsequently, the authors referenced earlier conducted a comprehensive review of all the papers. When disagreements arose during the article selection process, a third author arbitrated disagreements during article selection. We included RCT articles written in both English and Chinese.

Supplementary Table 1.

PubMed search strategy

Search number	Query
#7	Search: ((“Labor, Obstetric”[Mesh]) OR ((Obstetric Labor[Title/Abstract]) OR (Childbirth[Title/Abstract]))) AND ((“Anesthesia, Spinal”[Mesh]) OR ((((((((Anesthesias, Spinal[Title/Abstract]) OR (Spinal Anesthesia[Title/Abstract])) OR (Spinal Anesthesias[Title/Abstract])) OR (dural puncture epidural[Title/Abstract])) OR (combined spinal-epidural[Title/Abstract])) OR (Neuraxial Anesthesia[Title/Abstract])) OR (CSE[Title/Abstract])) OR (DPE[Title/Abstract])))
#6	Search: (“Anesthesia, Spinal”[Mesh]) OR ((((((((Anesthesias, Spinal[Title/Abstract]) OR (Spinal Anesthesia[Title/Abstract])) OR (Spinal Anesthesias[Title/Abstract])) OR (dural puncture epidural[Title/Abstract])) OR (combined spinal-epidural[Title/Abstract])) OR (Neuraxial Anesthesia[Title/Abstract])) OR (CSE[Title/Abstract])) OR (DPE[Title/Abstract]))
#5	Search: (((((((Anesthesias, Spinal [Title/Abstract]) OR (Spinal Anesthesia [Title/Abstract])) OR (Spinal Anesthesias[Title/Abstract])) OR (dural puncture epidural[Title/Abstract])) OR (combined spinal-epidural[Title/Abstract])) OR (Neuraxial Anesthesia[Title/Abstract])) OR (CSE[Title/Abstract])) OR (DPE[Title/Abstract])
#4	Search: “Anesthesia, Spinal”[Mesh] Sort by: Most Recent
#3	Search: (“Labor, Obstetric”[Mesh]) OR ((Obstetric Labor [Title/Abstract]) OR (Childbirth [Title/Abstract]))
#2	Search: (Obstetric Labor [Title/Abstract]) OR (Childbirth [Title/Abstract])
#1	Search: “Labor, Obstetric”[Mesh] Sort by: Most Recent

Eligibility criteria

For the meta-analysis, studies meeting the PICO criteria were included: Population: Pregnant women receiving labour analgesia; Intervention: Labour analgesia using the DPE technique; Comparison: Labour analgesia using the CSE technique; Outcomes: The primary outcome was the VAS pain score 10 min after administering analgesic method; Secondary outcomes included motor blockade, pruritus, nausea and vomiting, hypotension, post-dural puncture headaches (PDPH), intrapartum fever, uterine tachysystole, the duration of the first stage of labour, abnormal foetal heart rates, the proportion of non-operative delivery (using forceps or caesarean delivery), and the newborn’s Apgar scores at 1 min after birth. Studies excluded comprised systematic reviews/meta-analyses, retrospective investigations, practice guidelines, opinion pieces, case reports, protocols, conference abstracts, duplicate publications, and any study lacking primary data.

Data extraction and quality assessment

Data were extracted independently from the publications by two authors according to a pre-specified review form. Any disagreements were addressed via discussion among all authors. Extracted information included participant characteristics (e.g., age, parity, and body mass index), intervention details (e.g., type and dose of analgesics, size of the dural puncture needle, use of a bolus pump, and mode of administration), study design, sample size, funding sources, maternal and neonatal outcome measures, patient-controlled epidural analgesia (PCEA) activation frequency, parturients necessitating provider top-ups, and information for evaluating the risk of bias. The lead author and year of publication were also recorded. Data were primarily sourced from tables and text within the included studies. The Evidence-Based Medicine Data Processing Tool converted median-interquartile range data to mean-standard deviation values (https://ebm-helper.cn/index.php).[10] Corresponding authors were approached to resolve incomplete or unclear information. If no response was received, and the missing data were deemed crucial for analysis, the publication was excluded.

The Randomised Trial Bias Risk Assessment Tool was applied to assess methodological quality of randomised controlled trials (RCTs). Evaluated domains encompassed: randomisation implementation, allocation concealment, blinding (participants, personnel, outcome assessors), incomplete outcome data, selective reporting, and other biases. Overall bias risk was designated as low, unclear, or high.[11]

Statistical analyses

Quantitative synthesis was conducted employing Review Manager 5.4 (The Cochrane Collaboration, Copenhagen, Denmark) and Stata 17.0 (StataCorp LLC, College Station, TX, USA). Continuous outcomes were expressed as mean [standard deviation (SD)], whereas dichotomous variables were analysed using risk ratios (RR) with 95% confidence intervals (CI). VAS or numeric rating scale (NRS) pain scores ranging from 0 to 100 were divided by 10 to convert them into a 0–10 scale. A P value threshold of <0.05 defined statistical significance. I² statistic served to evaluate heterogeneity among studies. I² <50% indicated low heterogeneity, while I² ≥50% signified substantial heterogeneity warranting a random-effects model. To further explore heterogeneity, we conducted subgroup analyses stratified by maternal VAS pain scores at 10 min (categorised by spinal needle gauge) and opioid-induced pruritus (stratified by opioid type). Leave-one-out sensitivity analyses assessed robustness by sequentially excluding individual studies. Publication bias was assessed with funnel plots. Methodological quality was rigorously appraised using the grades of recommendation, assessment, development and evaluation (GRADE) framework.

To bridge the remaining evidence gaps and reinforce the validity of our findings, we employed trial sequential analysis (TSA). This method assessed whether the current data sufficiently support clinical decisions or necessitate additional research. We performed the analyses in TSA version 0.9 beta, configuring variance-based heterogeneity correction and using a fixed-effects model (http://www.ctu.dk/tsa).

RESULTS

Study selection

Applying the established search strategy, we retrieved 1313 citations. Among them, there are 327 duplicate articles. Following title/abstract screening, 938 articles were removed as irrelevant. From the remaining 48 articles, a further 19 concerning caesarean delivery were excluded, along with 15 non-prospective articles and three duplicate reports. Ultimately, 11 trials[6,8,12,13,14,15,16,17,18,19,20] were incorporated into this systematic review [Figure 1]. Bias risk evaluation of the enroled trials is summarised in Figure 2.

Figure 1.

PRISMA flow chart of included randomised controlled trials. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Figure 2.

Risk-of-bias assessment of randomised controlled trials by using the Cochrane risk of bias tool. a Risk of bias graph. b Risk of bias summary.

Study characteristics

We have summarised the characteristics of these 11 studies in Table 1, encompassing a total of 1461 parturients. Of these, 731 utilised the DPE technique for labour analgesia while 730 utilised the CSE technique. Seven trials[6,12,13,14,17,18,19] explicitly stated that only primiparous women were included. One trial[16] specified that primiparous women comprised only 45% of the study group, while the other three trials[8,15,20] did not mention the inclusion of multiparous women. Only two[6,13] studies did not specify whether the parturients had a singleton pregnancy, while all parturients in the other nine studies had singleton pregnancies. There were no differences in age and general physical characteristics among the parturients included in all studies. All trials used a combination of one local anaesthetic and one opioid for epidural administration. Eight trials[6,12,13,14,15,18,19,20] used ropivacaine as the local anaesthetic, two trials[16,17] used bupivacaine, and in one study,[8] Group DPE used ropivacaine while Group CSE used bupivacaine. Six trials[6,12,13,14,15,19] used sufentanil as the opioid, four trials[8,16,17,18] used fentanyl, and the remaining trial[20] used hydromorphone.

Table 1.

Characteristics of included studies

Study	Sample size	Pregnancy	Primary outcome	Interspace	Spinal needle		Loading dose	Spinal drugs	Background dose	PCEA	Lockout time
					DPE	CSE
Kang 2024[6]	136	nulliparous	VAS pain scores at different time points and time to NPRS ≤1	L2-3/L3-4	25 G	25 G	9 mL of 0.1% ropivacaine with sufentanyl 0.4 μg/mL	3 μg sufentanyl	NA	NA	NA
Zang 2024[8]	100	Singleton	VAS pain scores at different time points	L3-4/L4-5	25 G	25 G	20 mL of 0.1% ropivacaine with fentanyl 2 μg/mL	1 mL of 2 mg bupivacaine with 10 μg fentanyl	8 mL/45 min (PIEB)	10 mL	10 min
Lao 2012[12]	120	Singleton/nulliparous	VAS pain scores at different time points	L3-4	26 G	26 G	DPE: 10 mL of 0.0625% ropivacaine with sufentanyl 0.2 μg/mL CSE: 5 mL of 0.125% ropivacaine with sufentanyl 0.4 μg/mL	3 μg sufentanyl	DPE: 14 mL/h (CEI) CSE: 7 mL/h (CEI)	CSE: 2 mL DPE: 4 mL	15 min
Bai 2022[13]	119	nulliparous	Effective onset time of analgesia	DPE: L2-3/L3-4 CSE: L3-4	25 G	25 G	10–15 mL of 0.15% ropivacaine with sufentanyl 0.4 μg/mL	1.5 mL of 2.5 mg ropivacaine with sufentanil 2.5 μg	10 mL/h (PIEB)	5 mL	20 min
Ying 2021[14]	86	Singleton/nulliparous	VAS pain scores at different time points	L2-3	27 G	27 G	10 mL of 0.1% ropivacaine with sufentanyl 2 μg/mL	25 μg fentanyl	8 mL/h (PIEB)	5 mL	15 min
Hu 2020[15]	80	Singleton	Not mentioned	L2-3/L3-4	25 G	25 G	8–12 mL of 0.1% ropivacaine with sufentanyl 0.5 μg/mL	2.5 mg ropivacaine	6–8 mL/h (CEI)	5 mL	NA
Chau 2017[16]	80	Singleton	The mean hourly consumption of epidural bupivacaine and fentanyl	L2-3/L3-4	25 G	25 G	20 mL of 0.125% bupivacaine with fentanyl 2 μg/mL	1.7 mg bupivacaine and 17 μg fentanyl	6 mL/h (CEI)	6 mL	15 min
Bakhet 2017[17]	80	Singleton/nulliparous	Time to NPRS≤1	L3-4/L4-5	25 G	25 G	10 mL of 0.1% bupivacaine with fentanyl 2 μg/mL	2.5 mg bupivacaine	8 mL/h (CEI)	5 mL	15 min
Yan 2020[18]	430	Singleton/nulliparous	Time to NPRS ≤1	L2-3/L3-4	25 G	25 G	10 mL of 0.1% ropivacaine with fentanyl 2 μg/mL	2.5 mg ropivacaine and 12.5 μg fentanyl	10 mL/h (PIEB)	6 mL	15 min
Zhu 2021[19]	150	Singleton/nulliparous	Not mentioned	L2-3/L3-4	25 G	25 G	8 mL of 0.1% ropivacaine with sufentanyl 0.4 μg/ml	2.5–4 μg sufentanyl	4 mL/h (PIEB)	6 mL	NA
Chen 2021[20]	80	Singleton	Not mentioned	L3-4	25 G	25 G	8 mL of 0.1% ropivacaine with hydromorphone 20 μg/mL	3 mL of 0.1% ropivacaine with hydromorphone 20 μg/mL	8 mL/h (CEI)	8 mL	20 min

VAS=visual analogue scale; CEI=continuous epidural infusion; PIEB=programmed intermittent epidural bolus; NPRS=numeric pain rating scale; NA=Data not available; DPE = dural puncture epidural; CSE = combined spinal epidural

Outcomes

The quality of analgesia

Six studies,[6,12,13,14,19,20] encompassing a total of 691 parturients, documented the VAS pain scores at 10 min following the initiation of labour analgesia. Meta-analysis indicates that analgesia onset is significantly slower with the DPE technique compared with CSE (SMD = 0.60; 95% CI: 0.24, 0.95; P = 0.001; I² = 76%) [Figure 3a]. Subgroup analysis by spinal needle size (25 G vs 26/27 G) was employed to assess potential causes of heterogeneity. However, this analysis indicated that the difference in onset time was not related to needle gauge [Figure 4] (funnel plot shown in Figure 5). While all other studies employed sufentanil, Chen et al.[20] administered hydromorphone for opioid analgesia. Sensitivity analysis suggested that this variation in opioid agents may represent a potential source of heterogeneity. Subsequent exclusion of this study was associated with a significant reduction in heterogeneity [Figure 6]. Another five studies[8,15,16,17,18] defined the onset time based on the time taken for the parturients’ pain VAS or NRS scores to reach a specific value; pooled analysis was precluded by heterogeneous endpoints and partial data availability across these studies. Furthermore, five studies[8,13,16,17,18] reported the number of parturients in each group requiring physician top-up boluses. Meta-analysis showed that the proportion requiring top-up boluses was significantly lower in the DPE group than in the CSE group (RR = 0.64; 95% CI: 0.46, 0.88; P = 0.006; I² = 11%) [Figure 3b]. Motor blockade occurrence did not differ significantly between the two groups [Figure 3c].

Figure 3.

The quality of blocks. a VAS pain score of the parturient at 10 min. b Incidence of physician top-up boluses. c Incidence of motor blockade. DPE = dural puncture epidural; CSE = combined spinal epidural; CI = confidence interval; SD = standard deviation; VAS = visual analogue scale

Figure 4.

Subgroup analysis of VAS pain score of the parturient at 10 min by different sizes of spinal needle. DPE = dural puncture epidural; CSE = combined spinal epidural; CI = confidence interval; SD = standard deviation; VAS = visual analogue scale

Figure 5.

Funnel plot of the VAS pain score of the parturient at 10 min. CI = confidence interval; MD = Mean Difference; se (MD) = Standard Error of Mean Difference; VAS = visual analogue scale

Figure 6.

VAS pain score of the parturient at 10 min excluding study without sufentanil use. DPE = dural puncture epidural; CSE = combined spinal epidural; CI = confidence interval; SD = standard deviation; VAS = visual analogue scale

Maternal outcomes

The DPE analgesia technique might be better in reducing the occurrence of anaesthesia-related adverse reactions. In nine studies[8,12,13,15,16,17,18,19,20] involving 1239 parturients, pruritus incidence was significantly elevated in the CSE cohort relative to the DPE group. Quantitative assessment confirmed substantial heterogeneity (P = 0.004, I² = 81%). Zang et al.[8] delivered fentanyl-supplemented bupivacaine intrathecally in their CSE cohort, whereas the DPE group received epidural ropivacaine with fentanyl as the background medication. Sensitivity analysis identified this disparity in the local anaesthetic regimens (bupivacaine vs ropivacaine) as a potential source of confounding. The removal of this study significantly attenuated heterogeneity metrics (RR = 0.27; 95% CI: 0.14, 0.53; P < 0.001; I² = 54%) [Figure 7a]. To reduce heterogeneity, we performed subgroup analyses based on different opioids. Subgroup analysis of sufentanil recipients showed substantially reduced pruritus frequency with DPE versus CSE anaesthesia [Figure 8]. Pooled analysis of eight trials[8,13,15,16,17,18,19,20] (n = 1119 parturients) indicated numerically lower nausea/vomiting incidence with DPE versus CSE, though intergroup differences lacked statistical significance (RR = 0.67; 95% CI: 0.43, 1.04; P = 0.070; I² = 0%) [Figure 7b]. The CSE analgesia technique appears to have a more pronounced effect on maternal haemodynamics. Analysis of eight studies[8,13,15,16,17,18,19,20] involving 1119 parturients revealed that hypotension occurred in up to 19.3% of the CSE group, a rate significantly exceeding that observed in the DPE group. The analysis indicated substantial heterogeneity, with an I² statistic of 74% (P < 0.001). In the study by Yan et al.,[18] which utilised the programmed intermittent epidural bolus (PIEB) technique, the bolus dose of ropivacaine administered was relatively large, which led to a higher rate of motor block. Sensitivity analysis indicated that this specific regimen (large bolus dose of ropivacaine via PIEB) could be a potential source of confounding. Following the exclusion of this study, within-group heterogeneity was significantly reduced; hypotension occurred significantly less often in the DPE group versus the CSE group (RR = 0.52; 95% CI: 0.33, 0.80; P = 0.003; I² = 37%) [Figure 7c]. Across six studies assessing PDPH in 889 parturients,[6,13,15,16,18,20] Hu et al.[15] and Chau et al.[16] reported no PDPH cases. The pooled analysis indicated comparable PDPH rates in the DPE and CSE groups (RR = 0.99; 95% CI: 0.27, 3.62; P = 0.990; I² = 0%) [Figure 7d]. Only three studies[12,13,15] involving a total of 319 parturients focused on the occurrence of antepartum fever. Despite a higher proportion of febrile parturients in the CSE group, this difference lacked statistical significance (RR = 0.56; 95% CI: 0.27, 1.17; P = 0.120; I² = 0%) [Figure 7e].

Figure 7.

The maternal outcomes. (a) Incidence of pruritus in parturients. (b) Incidence of nausea and vomiting in parturients. (c) Incidence of hypotension in parturients. (d) Incidence of post-dural puncture headache in parturients. (e) Incidence of antepartum fever in parturients. (f) Incidence of uterine tachysystole in parturients. (g) Duration of the first stage of labour in parturients. DPE = dural puncture epidural; CSE = combined spinal epidural; CI = confidence interval; M-H = Mantel-Haenszel; SD = standard deviation

Figure 8.

Subgroup analysis of pruritus induced by different opioids. DPE = dural puncture epidural; CSE = combined spinal epidural; CI = confidence interval; M-H = Mantel-Haenszel

While adverse outcomes occur more frequently with CSE analgesia, only two trials[16,18] documented the incidence of uterine tachysystole in parturients. No elevated uterine tachysystole risk is substantiated by contemporary evidence for CSE analgesia (RR = 0.09; 95% CI: 0.00, 1.86; P = 0.120; I² = 72%) [Figure 7f]. Analysis of 1125 parturients across eight studies[6,13,14,15,16,18,19,20] detected no significant intergroup difference in first-stage labour duration (SMD = −0.05; 95% CI: −0.28, 0.18; P = 0.690; I² = 69%) [Figure 7g].

Foetal outcomes

Eight studies[8,12,13,14,16,18,19,20] reported the number of cases with foetal heart rate abnormalities during labour. The meta-analysis reveals a significantly smaller effect of the DPE group on foetal heart rate (RR = 0.27; 95% CI: 0.16, 0.44; P < 0.001; I² = 0%) [Figure 9a]. No comparable variations were identified in later assessments regarding how the two labour analgesia techniques affected the spontaneous delivery rate [Figure 9b] and the neonate’s 1 min Apgar scores [Figure 9c].

Figure 9.

The foetal outcomes. (a) Incidence of foetal heart abnormalities. (b) Rate of non-spontaneous delivery. (c) Apgar scores at 1 min after delivery. DPE = dural puncture epidural; CSE = combined spinal epidural; CI = confidence interval; M-H = Mantel-Haenszel

Sensitivity analysis

Where substantial heterogeneity was present (I² >50%), a leave-one-out sensitivity analysis approach was employed. In the analysis of VAS pain scores at 10 min, the exclusion of Chen’s study[20] reduced the I² statistic for the between-group comparison to 50%. In comparing the duration of the first stage of labour between the two groups, excluding the study by Hu et al.[15] brought the I² down to 20%. In the comparison regarding the occurrence of hypotension between both groups, when the study by Yan et al.[18] was removed, I² decreased to 37%. Following the omission of Zang et al.’s study,[8] the assessment of pruritus incidence between groups yielded an I² value of 54%. However, none of the aforementioned results showed significant changes after the exclusion of studies with notable heterogeneity.

Publication bias

Funnel plots were constructed for the following parameters: VAS pain scores at 10 min, incidence of top-up boluses, incidence of pruritus in parturients, incidence of hypotension in parturients, and incidence of foetal heart rate abnormalities. Significant asymmetry was observed solely for VAS pain scores at 10 min [Figure 5], while all other parameters demonstrated symmetrical distributions [Supplementary Figure 1 ^{(1.2MB, tif)} ].

Quality of evidence

The GRADE framework was used to appraise evidence quality for all outcomes; results are detailed in Supplementary Table 2. The primary reasons for downgrading the quality rating stem from the failure of included studies to employ allocation concealment or implement blinding, inconsistency, and the small sample sizes of included studies.

Supplementary Table 2.

Summary of findings (SOF)

Patient or population: parturients undergoing labour analgesia Intervention: dural puncture epidural analgesia Comparison: combined spinal-epidural analgesia
Outcomes	Anticipated absolute effects (95% CI)		Relative effect (95% CI)	Number of participants (studies)	Certainty of the evidence (GRADE)
	Risk with CSE	Risk with DPE
VAS pain score at 10 min	-	SMD 0.6 higher (0.24 higher to 0.95 higher)	-	691 (6 RCTs)	⨁⨁◯◯Low
Duration of the first stage of labour	-	SMD 0.05 lower (0.28 lower to 0.18 higher)	-	1125 (8 RCTs)	⨁◯◯◯Very low
Top-up intervention	193 per 1,000	123 per 1,000 (89 to 169)	RR 0.64 (0.46 to 0.88)	809 (5 RCTs)	⨁⨁⨁◯Moderate
Hypotension	193 per 1,000	69 per 1000 (29 to 172)	RR 0.36 (0.15 to 0.89)	1119 (8 RCTs)	⨁⨁⨁◯Moderate
Pruritus	240 per 1,000	75 per 1,000 (34 to 163)	RR 0.31 (0.14 to 0.68)	1239 (9 RCTs)	⨁⨁⨁⨁ High
Motor blockade	123 per 1,000	91 per 1,000 (36 to 230)	RR 0.74 (0.29 to 1.86)	809 (5 RCTs)	⨁⨁⨁◯Moderate
Foetal heart abnormalities	119 per 1,000	32 per 1,000 (19 to 52)	RR 0.27 (0.16 to 0.44)	1165 (8 RCTs)	⨁⨁⨁◯Moderate
Apgar scores at 1 min	27 per 1,000	17 per 1,000 (6 to 51)	RR 0.63 (0.21 to 1.89)	590 (3 RCTs)	⨁◯◯◯Very low
Non-spontaneous delivery	172 per 1,000	170 per 1,000 (134 to 217)	RR 0.99 (0.78 to 1.26)	1245 (9 RCTs)	⨁⨁⨁◯Moderate
Antepartum fever	113 per 1,000	63 per 1,000 (30 to 132)	RR 0.56 (0.27 to 1.17)	319 (3 RCTs)	⨁⨁◯◯Low
Uterine hyperstimulation	121 per 1,000	11 per 1,000 (0 to 224)	RR 0.09 (0.00 to 1.86)	510 (2 RCTs)	⨁⨁◯◯Low
Nausea and vomiting	75 per 1,000	50 per 1,000 (32 to 78)	RR 0.67 (0.43 to 1.04)	1119 (8 RCTs)	⨁⨁◯◯Low
PDPH	8 per 1,000	8 per 1,000 (2 to 30)	RR 0.99 (0.27 to 3.62)	729 (4 RCTs)	⨁⨁⨁◯Moderate

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). DPE=dural puncture epidural; CSE=combined spinal epidural; CI=confidence interval; RR=risk ratio; SMD=standardised mean difference; VAS=visual analogue scale; RCTs=randomised controlled trials; PDPH=post-dural puncture headaches. GRADE Working Group grades of evidence. High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

Trial sequential analysis

Four outcomes underwent TSA: VAS pain scores at 10 min, pruritus, hypotension, and foetal heart rate abnormalities during labour. As shown in Supplementary Figure 2 ^{(1.2MB, tif)} a, the cumulative Z-curve crosses the conventional boundary, favouring CSE but not the TSA monitoring boundary. This indicates that, due to the required information size (RIS) not being met, the current evidence is insufficient to confirm or refute a difference between groups definitively. Regarding pruritus and hypotension incidence, TSA suggested a lower occurrence rate with DPE, as evidenced by the alpha boundary crossings [Supplementary Figure 2 ^{(1.2MB, tif)} b and c]. For foetal outcomes, the accrued sample size (n = 1165) surpassed the required information size, demonstrating that DPE had a significantly lesser impact on foetal heart rate [Supplementary Figure 2 ^{(1.2MB, tif)} d].

DISCUSSION

This systematic review and meta-analysis incorporating TSA included 11 studies comparing DPE with CSE for labour analgesia. Results demonstrated that CSE provided a shorter analgesia onset time. Conversely, the DPE group exhibited a lower incidence of physician-administered top-up boluses, suggesting potentially more reliable analgesic efficacy with this technique. Furthermore, parturients receiving DPE experienced significantly lower rates of adverse effects (notably pruritus and hypotension) and foetal heart rate abnormalities. The two techniques demonstrated comparable effects on other maternal and neonatal outcomes. TSA substantiated that DPE’s advantages in reducing pruritus, hypotension, and foetal heart rate abnormalities were statistically significant, with the current evidence base deemed sufficient to confirm these findings. While previous literature reported inconsistent conclusions regarding DPE’s efficacy for labour analgesia, this synthesis strengthens the evidence supporting DPE as a viable alternative to CSE. Although CSE offers faster onset, DPE may provide superior analgesic reliability with fewer adverse effects, meriting consideration in clinical practice. These findings align with prior studies reporting neutral or inconclusive outcomes.

Due to inconsistencies across studies regarding definitions of “effective onset time,” the 10-min VAS score, which was reported most consistently, was selected as the primary measure. Results demonstrated significantly lower 10-min VAS scores in the CSE group compared to the DPE group. Needle gauge notably influenced analgesic onset, as smaller needles (e.g. 27 G) delayed onset and increased the risk of incomplete blockade.[21] One study employing a 27-G needle[14] implemented a modified DPE technique (involving four sequential dural punctures) to mitigate this limitation, reporting onset times intermediate between epidural and CSE techniques. However, the safety profile of this method remains unclear due to the absence of data on PDPH incidence. Despite statistical significance, considerable heterogeneity (I² = 76%) existed between studies, likely influenced by needle gauge variation, and TSA further indicated that the RIS was not attained. Consequently, current evidence remains insufficient to confirm or refute intergroup differences definitively.

Five studies[8,13,16,17,18] reported physician top-up boluses as an indirect measure of analgesic efficacy, revealing a significantly higher rescue analgesia rate in the CSE group (19.3%) compared to the DPE group (12.4%). Supporting this, Chau et al.[16] found that the mean time to first rescue analgesia was significantly longer with DPE (250 min) than CSE (132 min) (P < 0.05). A large retrospective cohort study involving 18,726 parturients similarly indicated prolonged analgesic duration with DPE compared to the epidural puncture technique.[22] Additionally, two articles[15,18] noted similarly low and statistically non-significant incidences of unilateral block and inadequate sacral block between groups. Collectively, current evidence suggests that while the DPE technique may offer slower onset than CSE, it potentially provides more robust and sustained analgesia. Future studies should directly compare analgesic quality between the two techniques through outcome measures such as breakthrough pain incidence and patient satisfaction scores.

The nine trials[8,12,13,15,16,17,18,19,20] included in this study that reported pruritus incidence demonstrated that all groups employing the CSE technique received opioids via the intrathecal route, exhibiting a pruritus incidence approximately 4.4-fold higher than that observed in the DPE groups. This finding closely aligns with the results of the large-scale meta-analysis by Grangier et al.,[23] which encompassed 41 trials involving 7984 parturients. Their analysis found that compared to epidural analgesia alone, the CSE technique utilising intrathecal administration of the lipophilic opioids fentanyl or sufentanil was associated with a 4.26-fold increase in the risk of pruritus. The significant difference observed between the groups (4.4-fold vs 4.26-fold) is highly consistent with the established mechanism of opioid-induced pruritus (OIP). It is currently understood that the central μ-opioid receptor constitutes the primary mechanism mediating OIP[24] and that there appears to be a specific dose threshold required to elicit OIP.[25,26,27] Crucially, the intrathecal route of administration is the most likely to attain and exceed this threshold.[23] Consequently, although the DPE technique permits some diffusion of opioids into the intrathecal space, the diffused dose is typically limited and insufficient to reach the specific threshold necessary to trigger OIP. This clearly explains why the incidence of pruritus was significantly lower in the DPE groups compared to the CSE groups within this study.

In our study, the incidence of foetal heart abnormalities in the DPE and CSE groups was 3.1% and 11.9%, respectively. This aligns closely with the findings of Okahara et al.[3] in a pilot study involving 302 parturient women. Hattler et al.[2] suggested that the circulatory disturbances induced by CSE in parturient women are a significant cause of foetal heart abnormalities. The TSA also states that the DPE demonstrates substantial benefits in reducing the incidence of foetal heart rate abnormalities during labour. A possible mechanism is the rapid action of CSE on the spinal cord, which may lead to a decrease in the plasma concentration of adrenaline that inhibits uterine contractions. This may result in excessive uterine contractions, increasing uterine vascular resistance, and subsequently reducing foetal oxygenation and increasing the likelihood of foetal heart abnormalities.[28,29] It is worth noting that seven trials[6,12,13,14,16,18,20] also had an EP group, defined as parturients who received epidural anaesthesia alone for labour analgesia. In these trials, there was no significant difference between the DPE and EP groups in terms of the incidence of foetal heart abnormalities. Future research might consider focusing on the plasma epinephrine levels in parturient women at a certain time after labour analgesia and the pH of umbilical cord blood, which could help elucidate the mechanisms behind the observed differences.

Our study demonstrated that the incidence of maternal hypotension was significantly higher in the CSE group compared to the DPE group. This finding aligns with Rao et al.,[30] who reported in women undergoing caesarean delivery that CSE was associated with increased hypotension and vasoactive agent requirements versus DPE, a phenomenon potentially explained by reduced plasma adrenaline levels in the CSE group.[30] Hypotension itself contributes to nausea and vomiting through mechanisms such as cerebral hypoperfusion, which activates the vomiting centre; splanchnic hypoperfusion, resulting in the release of emetic factors such as serotonin; and unopposed vagal activity, which leads to gastrointestinal hyperactivity.[31] Irrespective of the underlying aetiology, these factors are associated with maternal hypotension. However, in contrast to these CSE-specific observations, Singh et al.’s[32] meta-analysis comparing epidural and DPE techniques found no statistically significant difference in hypotension incidence between these groups. Furthermore, our findings regarding nausea and vomiting did not reach statistical significance, as only five of the included RCTs provided relevant data, and the analysed data exhibited considerable heterogeneity (I² = 69%), indicating that larger trials may be required to establish whether one technique is superior to the other.

This study found no statistically significant difference between DPE and CSE in preventing motor block (DPE 7.2% vs CSE 12.3%, P = 0.520). This finding aligns with the progression of neuraxial analgesia techniques towards preserving motor function. Notably, the meta-analysis by Singh et al.[32] indicated that traditional epidural analgesia (EP) carries a 95% greater risk of motor block compared to DPE. Within this context, the present study suggests that DPE, potentially through technical refinements such as dural puncture needle guidance for precise drug administration, may achieve comparable levels of motor function preservation to CSE. Concurrently, no significant differences were observed between the two groups for the following adverse reactions/outcomes in both parturients and foetuses: antepartum fever, duration of the first stage of labour, uterine tachysystole, Apgar scores at 1 min, and non-spontaneous delivery rates. This indicates that DPE optimises neural selectivity without significantly compromising critical obstetric outcomes. Given that the spinal component of CSE may introduce additional risks, DPE presents a potentially ideal alternative to mitigate such risks whilst maintaining comparable clinical outcomes.

The majority of studies included in this meta-analysis exhibited significant risks of bias (e.g., lack of blinding and unclear allocation concealment). These methodological shortcomings, particularly for subjective outcomes such as VAS, may have led to an overestimation of effect sizes. Given the prevalence of such bias within the included studies, the certainty of the synthesised results is limited. Future research should implement rigorous blinding and allocation concealment procedures to mitigate bias risks and enhance the reliability of findings.

This study has several limitations. Firstly, significant heterogeneity was observed in outcomes such as VAS pain scores and the incidence of pruritus and hypotension, likely due to varied intervention details, populations, or measurement methods, reducing the generalisability of findings. Inconsistent definitions of “effective onset time” across studies required using the 10-min VAS score as a surrogate, but limited available data restricted accurate assessment of DPE onset speed. Reliance on indirect proxies such as supplemental analgesia requirements rather than direct measures (e.g., breakthrough pain or satisfaction scores) may also misrepresent true analgesic efficacy. Secondly, GRADE assessments showed reduced evidence quality due to inadequate blinding, inconsistent results, and small sample sizes. Thirdly, the applicability to other populations may be limited due to potential variations in drug response, labour management, and patient expectations, as the evidence primarily derives from Chinese cohorts. Thus, caution is needed when interpreting these results, and future multi-centre studies with diverse populations are warranted.

CONCLUSION

Based on the currently limited evidence, compared to the combined spinal-epidural analgesia technique, the dural puncture epidural technique appears to have a slower onset but may provide more consistent pain relief. Furthermore, it may be associated with fewer maternal and foetal adverse reactions. However, the accuracy and reliability of this conclusion await further validation from more high-quality studies.

Conflicts of interest

There are no conflicts of interest.

Data availability

The data for this systematic review and meta-analysis may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared upon request.

Presentation at conferences/CMEs and abstract publication

None.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI.

Declaration of use of permitted tools

The figures and tables are freely available and not copyrighted.

Authors contributions

JJQ and JSM designed the meta-analysis and independently evaluated the methodological quality of included studies. JJQ and CLH performed the screening process for titles and abstracts, while JJQ and WLZ performed the screening process for full texts. JSM and ZWC supervised the acquisition and extracted data. JJQ and JSM conducted the statistical analysis of data. JJQ and WLZ wrote the manuscript. All authors contributed to the article and approved the submitted manuscript.

Supplementary material:

This article has supplementary material and can be accessed at this link. Supplementary Material at http://links.lww.com/IJOA/A39.

Supplementary Figure 1

Funnel plots for: (a) incidence of top-up boluses administered; (b) incidence of pruritus in parturients; (c) incidence of hypotension in parturients; (d) incidence of foetal heart rate abnormalities. CI = confidence interval

Supplementary Figure 2

Trial sequential analysis (TSA) for maternal outcomes: (a) VAS pain scores at the 10th minute; (b) pruritus; (c) hypotension; (d) foetal outcomes and foetal heart rate abnormalities during labour

Funding Statement

Nil.