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Combined spinal–epidural (CSE) analgesia is an ideal analgesic technique for use during labor. CSEA combines both the rapid onset of the spinal analgesia and the flexibility of the epidural catheter. It combines the rapid, reliable onset of profound analgesia resulting from spinal injection with the flexibility and longer duration of epidural techniques. The most common side effects of intrathecal opioids are pruritus, nausea, vomiting, and urinary retention. Transient nonreassuring fetal heart rate patterns may occur because of uterine hyperstimulation, presumably as a result of a rapid decrease in maternal catecholamines resulting in the unopposed effects of oxytocin.
Incidence of puncture headache emergency and cesarean section delivery is no greater with CSE analgesia than after conventional epidural analgesia. An opioid alone may provide sufficient relief for the early latent phase, but the addition of bupivacaine is almost always necessary for satisfactory analgesia during advanced labor. Intrathecal injection of fentanyl 10–25 mcg or sufentanil 2.5–5 mcg, alone or in combination with up to 1 mL of isobaric bupivacaine 0.25%, produces profound analgesia lasting for 60–120 minutes with minimal motor block.
Theoretically the technique combines the advantages of the speed of onset and the reliability of block achieved by subarachnoid anaesthesia with the flexibility provided by the presence of an epidural catheter and avoids their individual disadvantages. The complications that may be encountered are those attributable to subarachnoid and epidural anaesthesia individually but some are unique to the CSE technique. This review examines the current literature on common techniques, drugs used, adverse effects and role of CSE analgesia on labour outcome in practice of labour pain management.
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