Clinical Concepts and Commentary  |   March 2000
Combined Spinal–Epidural Analgesia in Labor
Author Notes
  • F. M. James III Professor of Anesthesiology
  • Wake Forest University School of Medicine
  • Winston-Salem, North Carolina 27157-1009
Article Information
Clinical Concepts and Commentary
Clinical Concepts and Commentary   |   March 2000
Combined Spinal–Epidural Analgesia in Labor
Anesthesiology 3 2000, Vol.92, 869. doi:
Anesthesiology 3 2000, Vol.92, 869. doi:
In Reply:—
Dr. Van de Velde raises several issues that were briefly discussed in the obligatorily short review style of the Clinical Concepts and Commentary format. First, as remarked to me in several email messages and as corrected in a published erratum, the doses of fentanyl and sufentanil are of course in micrograms, not milligrams. The issue with hypotension is not that it is more common with the combined spinal–epidural (CSE) technique than with epidural analgesia, but that it does occur and necessitates monitoring by the practitioner. With regard to fetal bradycardia after CSE, it has been associated with an increased risk of urgent cesarean section, although its cause remains obscure. My estimate of 0.1% of respiratory depression incidence comes from large series in postoperative patients as well as a series of > 5,000 patients in labor at Thomas Jefferson University as reported at various national meetings by Dr. Mark Norris. Given the low incidence and few large series, the incidence could be threefold to 10-fold less or more than this. As with hypotension, the issue is that it can occur, even with small doses of spinal opioids in the absence of systemic opioids, and it necessitates monitoring. Finally, the risk/benefit ratio for routine use of CSE in all parturients requesting intraspinal analgesia is far from clear and will only be adequately addressed by large-scale randomized trials.
In response to Dr. Balestrieri, the use of CSE in the case he describes has advantages, but also disadvantages. Despite retrospective reviews and abstract presentations, there are no clear data suggesting that the incidence of unilateral, patchy, intravenous, or failed epidural catheters differs between CSE and standard epidural techniques. Given the scenario of a decreasing platelet count in a patient at high risk for cesarean section and possible difficult airway, many would prefer a standard epidural technique with early detection and replacement of an inadequate catheter rather than delaying identification of such a problem. The case described would be managed by most perinatologists by delivery within 24 h and active management of labor, and there is no convincing evidence that dosing an epidural catheter early in such cases alters the incidence of cesarean section or neonatal outcome. Thus, at our institution, we would prefer a standard epidural to CSE technique in this patient. The question Dr. Balestrieri addresses is important, and we have begun a large randomized trial of standard epidural versus  epidural plus needle-through-needle dural puncture without intrathecal injection to examine differences in the incidence of malpositioned or failed epidural catheters.