A Cochrane review [Abstract] 1 included 27studies with a total of 3 274 subjects. Combined spinal-epidural (CSE) compared with traditional epidural was more favourable in relation to need for rescue analgesia and urinary retention, and rate of instrumental delivery (RR 0.81; 95% CI 0.67 to 0.97; 6 trials, n=1015), but associated with more pruritus. For CSE versus low-dose epidurals, CSE had a faster onset of effective analgesia from time of injection but was associated with more pruritus. CSE was also associated with a clinically non-significant lower umbilical arterial pH. No differences between CSE and epidural were seen for maternal satisfaction, mobilisation in labour, modes of birth, incidence of post dural puncture headache or blood patch and maternal hypotension. It was not possible to draw any conclusions with respect to maternal respiratory depression, maternal sedation and need for labour augmentation.
Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes).
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