Combo treatment might beat epidural to ease labor, study says

The research included 800 healthy women who required pain relief during childbirth, and who were divided into two groups. One group received standard epidural pain relief, which involves injections of local anesthetic and pain medications into the epidural space, inside the membranes covering the spinal cord.

The other group received the combination approach, which starts with medications injected into the intrathecal space, the deeper space directly around the spinal cord, before using an epidural injection.

After the initial epidural or intrathecal injections, both groups received patient-controlled epidural analgesia. The effectiveness of pain relief, rated on a 0-to-10 scale, was compared at different times during labor and delivery.

During the first state of labor, the typical pain score was 1.4 (out of 10) for women receiving the combo therapy and 1.9 for those receiving standard epidural analgesia. This difference was statistically significant, according to a team led by Dr. David Gambling of Sharp Mary Birch Hospital for Women and Newborns in San Diego.

The study also found that complete pain relief was achieved an average of 11 minutes faster among women in the combo therapy group than those in the standard epidural group. Women who got the combination of pain relievers were also less likely to require additional epidural "top-up" doses to maintain good pain control.

Side effects were similar in both groups and there was no significant difference in the type of delivery, with cesarean section rates of 14 percent to 16 percent, concluded the study, which is published in the March issue of the journal Anesthesia & Analgesia.

Experts agreed, however, that pain relief during labor is often a case-by-case decision, and the combination approach might have its own drawbacks.

"The study confirms what we know previously—namely, that the [combination approach] provides faster onset pain relief [by a few minutes] but is associated with a greater incidence of side effects including itching and low fetal heart rates," said Dr. Grant Gilbert, an obstetrician/gynecologist at NYU Langone Medical Center in New York City.

He added, however, that even though the rate of low fetal heart rate was a bit higher among women in the study who got the combination pain relief, "no patient required emergency cesarean for this fetal heart rate problem."

Gilbert also added that some doctors avoid the intrathecal approach due to a higher risk for meningitis, although this is an "admittedly rare complication" and there were no such incidents in the study.

"The bottom line is that both epidural and [the combination] techniques may be used to provide profound pain relief during labor," said Gilbert, who is also associate professor in the department of anesthesiology at NYU Langone. "Ultimately, each practitioner administers the type of analgesia that s/he considers to be best for their patient."

Another expert said the combination approach might have an edge in many cases.

"Combined spinal epidural anesthesia offers significantly better and faster relief for patients in labor, [and] there was no increase in side effects or cesarean sections, either," said Dr. Jennifer Wu, ob/gyn at Lenox Hill Hospital in New York City. "For patients who desire pain relief in labor, this is good information."

More information: The American Society of Anesthesiologists has more about pain management during childbirth.

Journal reference: Anesthesia & Analgesia

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