The Takeaway
Dural Puncture Epidural analgesia is associated with faster onset, fewer motor and unilateral block, and improved sacral sparing compared with epidural analgesia.
Study Design
- Identified randomised controlled trials comparing epidural analgesia with DPE analgesia in laboring parturients published up to October 2024
- The primary outcome was time to onset of analgesia
- Secondary outcomes were unilateral block, motor block, sacral sparing, adequate analgesia, Caesarean/operative vaginal delivery, additional doses, and hypotension
- 18 trials involving 2144 parturients were included
- Different dosing techniques included without restrictions on protocols
Physiology Refresh
In the realm of pain management during labor, epidural analgesia is one of the most common methods used to provide relief to women in active labor. It works by delivering anesthetic medications to the epidural space, numbing the lower body to alleviate the intense pain of contractions and delivery. However, a variation of this technique known as dural puncture epidural analgesia (DPEA) has gained attention in recent years. This method involves puncturing the dura mater, without intrathecal injection of medication, to provide pain relief more efficiently.
When a local anesthetics is administered into the epidural space, it diffuses through the epidural fat and reaches the nerve roots that emerge from the spinal cord. These nerve roots are responsible for transmitting sensory and motor signals, including the sensations of pain. The dural puncture provides faster onset and enhanced sensory block.
The mechanism of action at the cellular level begins when the anesthetic molecules bind to the sodium channels located on the neuronal cell membranes of these nerve fibers. Sodium channels are essential for the generation and propagation of action potentials, which are the electrical signals that carry pain sensations from the periphery to the brain.
Local anesthetics specifically bind to the voltage-gated sodium channels, blocking them from opening. This prevents sodium ions from entering the neuron, which is crucial for the initiation of an action potential. Without the influx of sodium, the neuron cannot reach the necessary depolarization threshold to transmit an electrical signal. As a result, the pain signal is effectively stopped at the nerve root, preventing it from traveling up the spinal cord to the brain.
This blockade of nerve conduction leads to loss of sensation, which is why patients experience pain relief during labor or surgery. The motor fibers are affected as well, leading to muscle weakness or paralysis depending on the concentration and spread of the anesthetic agent.
Abstract
Background: Epidural analgesia and dural puncture epidural (DPE) analgesia are widely used techniques for alleviating labour pain. This meta-analysis compared clinical outcomes between parturients receiving epidural analgesia vs DPE analgesia for labour pain.
Methods: Medical databases were searched to identify randomised controlled trials comparing epidural analgesia with DPE analgesia in labouring parturients published up to October 2024. Results were pooled using an inverse variance random-effects model, and 95% prediction intervals were calculated. Clinical outcomes were used as defined by individual trials. The primary outcome was time to onset of analgesia. Secondary outcomes were unilateral block, motor block, sacral sparing, adequate analgesia, Caesarean/operative vaginal delivery, additional doses, and hypotension. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation guidelines, and subgroup analyses were performed based on the types of local anaesthetics used.
Results: Eighteen trials involving 2144 parturients were included. DPE labour analgesia slightly reduced the time to onset (mean difference: 3.4 min, 95% confidence interval: 2.1-4.7, P<0.01, I2=97%; moderate certainty). All statistically significant results demonstrated clinical advantages for DPE analgesia, including fewer unilateral blocks, reduced motor block, improved sacral coverage, and higher rates of adequate analgesia. Substantial heterogeneity was observed in the outcome data for time to onset of analgesia, unilateral block, and sacral sparing. Pooled results for Caesarean/operative vaginal delivery, additional doses, and hypotension failed to achieve statistical significance.
Conclusions: DPE labour analgesia offers a slightly faster onset and reduced incidence of motor and unilateral blocks compared with traditional epidural analgesia. However, high heterogeneity in some outcomes, likely attributable to clinical and dosing variability, requires cautious interpretation. Although the clinical relevance of the faster onset with DPE analgesia might be modest, when considered alongside its benefits in secondary outcomes it supports the use of DPE analgesia over traditional epidural analgesia. Imputed prediction intervals cross zero for many outcomes, and further studies might alter these findings.
Excerpts
The proposed advantages of DPE analgesia over traditional epidural analgesia include a faster onset of analgesia and an enhanced sensory block for a given anaesthetic dose. However, uncertainty remains regarding these potential benefits, and some clinicians may be concerned by the potentially increased risk of post-dural puncture headache (PDPH) and increased theoretical risk of seeding infections into the cerebrospinal fluid (CSF) because of breach in the dura mater
We focus on clinically relevant outcomes and comparisons of these two techniques to help guide clinical decision-making
Rapid and sustained pain relief during labour is important for maternal satisfaction. Additionally, motor block may negatively impact labour duration (prolonged second stage) or can increase the rate of operative vaginal delivery
Our results provide valuable insights into how the DPE technique can enhance the patient experience during labour, suggesting that DPE analgesia may be preferred over traditional epidural analgesia for effective neuraxial labour pain relief. These findings include a small but statistically significant reduction in the time of onset of analgesia. Furthermore, we observed a significant reduction in the incidence of motor block associated with DPE, with an OR of 1.95 indicating that traditional epidural analgesia is associated with a 95% higher likelihood of motor block than the DPE. This advantage highlights the potential for DPE analgesia to reduce operative vaginal deliveries. Additionally, it is plausible that reduced motor block may be associated with a shorter duration of the second stage of labour.
Our meta-analysis is unique in that we were able to subdivide and analyse the results according to local anaesthetic, facilitating indirect comparison between bupivacaine and ropivacaine. Our analysis revealed comparable outcomes for both local anaesthetics when used at clinical concentrations, suggesting that the selection of either anaesthetic can be reasonably determined by institutional availability and cost.
The quicker onset of analgesia with DPE enhances patient comfort and may be advantageous in clinical settings requiring prompt pain management where CSE techniques are not routinely practiced or feasible. Our findings on sacral sparing further support DPE analgesia's role in offering a more complete sensory block, enhancing overall analgesic efficacy.
The shared mechanism of dural puncture with a spinal needle to confirm epidural access and facilitate intrathecal translocation of epidural drug logically supports the use of either technique to achieve timely and effective labour analgesia. Avoidance of hypotension and potentially compromised uteroplacental blood flow, however, remains an important clinical goal during the provision of neuraxial analgesia, and the omission of a spinal dose with the DPE technique likely reduces this risk.
One of the potential limitations of our study is the clinical relevance of the observed 2–3-min difference in the onset of analgesia with the DPE technique. Although this difference may not seem significant when considering the overall duration of labour, it is important to recognise that faster onset could contribute to an overall improved patient experience, particularly when viewed alongside other benefits observed in secondary outcomes. It may still offer an advantage in clinical scenarios where rapid pain relief is crucial.
An important consideration in the DPE technique is the gauge of the spinal needle used, as it may influence the clinical outcomes. In this analysis, ∼60% of the included trials (11/18) used a 25-G Whitacre needle (Table 1), and sensitivity analysis was performed based on spinal needle gauge for the statistically significant outcomes. Given the observed variation in needle gauge across studies, subgrouping by needle size did not reveal any substantial differences in the measured outcomes.
Citation
Singh PM, Monks DT, Bhat AD, Borle A, Kaur M, Yang P, Kanakaraj M. Epidural analgesia versus dural puncture epidural analgesia in labouring parturients: a meta-analysis of randomised controlled trials. Br J Anaesth. 2025 Mar 21:S0007-0912(25)00098-4. doi: 10.1016/j.bja.2025.01.033. Epub ahead of print. PMID: 40121178.
