Cokorda Gde Waesa Habisena, Ni Wayan Kartika Candra Kirana, I Made Agus Adi Widarma

Effectiveness and safety of dural-puncture epidural versus standard epidural for labor or cesarean analgesia: a systematic review

Introduction

Effectiveness and safety of dural-puncture epidural versus standard epidural for labor or cesarean analgesia: a systematic review. Systematic review compares dural-puncture epidural (DEP) and standard epidural for labor/cesarean analgesia. DEP offers faster onset, better pain relief, and fewer side effects.

Abstract

Background: Dural puncture epidural (DEP) is an evolving technique in labor analgesia that resembles combined spinal-epidural anesthesia without injecting drugs into the intrathecal space. By puncturing the dura mater with a spinal needle, DEP enhances catheter placement accuracy and promotes partial drug migration into the cerebrospinal fluid, potentially improving analgesic efficacy. Despite these advantages, concerns remain regarding its safety, cost, and clinical superiority over standard epidural anesthesia. This study compares the effectiveness and safety of DEP and standard epidural anesthesia for laboring women undergoing intrapartum cesarean sections. Methods: A systematic review was conducted using PubMed, Lippincott, and Elsevier databases, focusing on human studies published from 2015 to 2025. From 5,536 initial records, 4 randomized controlled trials were selected after applying inclusion criteria and full-text availability filters. Results: Across multiple studies, DEP consistently demonstrated faster onset of sensory block (median 422 vs. 655 seconds), earlier achievement of T5–T10 sensory levels, and reduced intraoperative pain compared to standard epidural anesthesia. DEP was associated with fewer required top-ups, more frequent bilateral sacral blockade, and a lower incidence of adverse postpartum effects. No significant difference was noted in intraoperative hypotension between groups. Conclusions: DEP offers significant clinical advantages over standard epidural anesthesia, including more rapid anesthesia onset and improved analgesia quality in cesarean delivery. These benefits, along with a lower need for supplemental dosing and fewer side effects, suggest DEP is a viable option for obstetric anesthesia. However, further studies are warranted to evaluate long-term safety, cost-effectiveness, and broader implementation.

Review

This systematic review provides a timely and pertinent evaluation of dural-puncture epidural (DEP) compared to standard epidural anesthesia for labor and cesarean section analgesia. The authors diligently searched major databases, ultimately synthesizing evidence from four randomized controlled trials published between 2015 and 2025. Their findings consistently demonstrate that DEP offers significant clinical advantages, including a notably faster onset of sensory block, earlier achievement of appropriate sensory levels, and reduced intraoperative pain. Critically, these benefits were observed without a significant increase in intraoperative hypotension, a common concern in obstetric anesthesia. The study's results are compelling and hold substantial implications for clinical practice. The reported improvements in analgesia quality, fewer required top-ups, and a lower incidence of adverse postpartum effects suggest that DEP could enhance both patient comfort and safety during delivery. The finding of more frequent bilateral sacral blockade also points towards a more comprehensive and effective analgesic spread, which is highly desirable in obstetric settings. By consolidating the current evidence, this review supports the adoption of DEP as a potentially superior technique for obstetric analgesia, offering tangible benefits over conventional methods. Despite its valuable contributions, the review's conclusions are based on a relatively small number of included studies, with only four randomized controlled trials identified from an initial pool of over 5,000 records. While these are high-quality studies, the limited volume necessitates cautious interpretation and highlights the nascent stage of research in this area. The authors appropriately acknowledge this by calling for further studies, particularly concerning long-term safety, cost-effectiveness, and broader implementation across diverse clinical settings. Future research should prioritize larger, multicenter trials to robustly confirm these promising findings and address the remaining unknowns before widespread clinical recommendations can be made.

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