[Spinal analgesia for labor]

Combined spinal epidural (CSE) analgesia for labour is usually performed with sufentanil (or fentanyl) which provides powerful and fast onset pain relief (< or = 5 min). Dose reduction of sufentanil from 10 to 5 micrograms may be recommended and has little influence on the 1.5-2 hours of analgesia usually obtained. This mean duration of action may be prolonged by half an hour with the addition of a low dose of bupivacaine (< or = 2.5 mg). CSE analgesia using this association has an elective indication when labour is advanced (cervical dilation > or = 6 cm) because intrathecal sufentanil alone becomes insufficient at this stage and standard epidural analgesia has the drawback of delayed onset. Motor blockade is also very uncommon during intrathecal analgesia and this benefit partly persists while using the epidural. In contrast, intrathecal analgesia and standard epidural analgesia carry a comparable risk of maternal hypotension. Mild pruritus is the sole side-effect often encountered. The only real concern during intrathecal analgesia is the reliability of the epidural location of the catheter when an emergency Ceasarean section is needed. Major improvement will be to prolong the excellent pain relief provided by intrathecal analgesia throughout the whole labour. This will require prolonging substantially the intrathecal analgesia duration and/ or influencing positively the epidural analgesia used afterwards. However, women prefer CSE technique to standard epidurals because of faster onset, less motor block, and feelings of greater self-control.