Zang et al. compared the quality of labour analgesia using dural puncture epidural (DPE) versus combined spinal–epidural (CSE) techniques [1]. In an accompanying editorial, George and Landau assert that the superior labour analgesia provided by the CSE over standard epidurals is undeniable [2]. They suggest that anaesthetists who do not universally adopt CSE are disadvantaging their patients [2]; we disagree.

George and Landau cited three trials to support their assertion, but only one directly compared CSE with standard epidurals for quality of analgesia [3]. This reported a statistically significant, yet clinically insignificant, mean pain score difference at 1 h and 5 h in favour of CSE over a 9-h period. A Cochrane review concluded that there was little basis for offering CSE over epidurals, as the only advantage was a slightly faster onset of analgesia [4]. A recent systematic review was unable to conclude that CSE provided better labour analgesia quality than standard epidurals [5].

Zang et al. reported no significant differences between DPE and CSE for a composite measure of quality of analgesia or for post-procedure pain scores, with 29% of all patients reporting poor block quality and 24% requiring a supplemental epidural bolus [1]. This small trial does not suggest that an intrathecal injection of bupivacaine and fentanyl in the CSE added any advantage to the dural puncture. The question remains whether the dural puncture adds any advantage to the quality of labour epidural analgesia. The dural puncture may provide faster onset initial analgesia, if the initial epidural loading volume of the low-dose local anaesthetic mixture is parsimonious, for example, 10 ml vs. 20 ml. With a 20-ml volume, there is minimal significant difference between a DPE and a standard epidural for onset of initial analgesia, and there is no difference in analgesia by 10 min [6, 7]. When compared with DPE or CSE, a standard epidural provides more prolonged initial analgesia if an adequate loading volume is used. Additionally, a smaller subsequent dose is necessary to maintain analgesia [8].

The benefit of the dural puncture is postulated to be the conduit it provides for translocation of epidural local anaesthetic into the cerebrospinal fluid. Conduits can be bidirectional with cerebrospinal fluid leakage causing intracranial hypotension and postdural puncture headache (PDPH), a significant inherent risk with DPE and CSE techniques. Zhang et al. reported a PDPH incidence of 1% [1]. The excess risk of PDPH with CSE has been estimated to be at least 0.3% [9]. Universal use of CSE for labour analgesia would likely increase the burden of PDPH morbidity, which has recognised long-term postpartum health implications. The intrathecal opioids given with a CSE increase the risk of fetal bradycardia and maternal pruritus significantly [10]. In the study of patient preferences for outcomes associated with labour epidural analgesia cited by George and Landau, faster labour analgesia onset was only ranked fourth in importance, while avoiding complications was ranked fifth [11].

Standard epidurals provide effective and satisfactory labour analgesia for many parturients without acceptance of the added risks of CSE and dural puncture. There is a role for the CSE in labour analgesia but on a selective basis, including those parturients too distressed to safely allow epidural cannulation; analgesia request in the second stage of labour; replacement epidural analgesia; or maternal request. That would be regarded as a patient-centric and patient-personalised approach to care and not the universal adoption of the CSE for labour analgesia advocated by George and Landau.

Zang 等人比较了使用硬膜穿刺硬膜外 （DPE） 与脊髓硬膜外联合 （CSE） 技术的分娩镇痛质量 [1]。在随附的社论中，George 和 Landau 断言，CSE 提供的分娩镇痛优于标准硬膜外麻醉是不可否认的 [2]。他们认为，不普遍采用 CSE 的麻醉师正在使他们的患者处于不利地位 [2];我们不同意。

George 和 Landau 引用了 3 项试验来支持他们的论断，但只有一项试验直接比较了 CSE 与标准硬膜外麻醉的镇痛质量 [3]。这报告了在 9 小时内 1 小时和 5 小时的平均疼痛评分差异具有统计学意义但临床上不显著，有利于 CSE。一项 Cochrane 评价得出结论，与硬膜外麻醉相比，提供 CSE 几乎没有依据，因为唯一的优点是镇痛起效略快 [4]。最近的一项系统评价无法得出结论，CSE 比标准硬膜外麻醉提供更好的分娩镇痛质量 [5]。

Zang 等人报道，DPE 和 CSE 在镇痛质量的综合测量或术后疼痛评分方面没有显著差异，29% 的患者报告阻滞质量差，24% 的患者需要补充硬膜外推注 [1]。这项小型试验并未表明在 CSE 中鞘内注射布比卡因和芬太尼为硬脑膜穿刺增加了任何优势。问题仍然存在，硬脑膜穿刺是否为分娩硬膜外镇痛的质量增加了任何优势。如果低剂量局部麻醉剂混合物的初始硬膜外负荷量是简洁的，例如，10 ml vs. 20 ml，则硬膜穿刺可以提供更快的初始镇痛。在 20 ml 体积下，DPE 和标准硬膜外麻醉在初始镇痛开始时的显着差异最小，并且在 10 分钟时镇痛没有差异 [6， 7]。与 DPE 或 CSE 相比，如果使用足够的负荷量，标准硬膜外麻醉可提供更持久的初始镇痛。此外，需要较小的后续剂量来维持镇痛 [8]。

硬脑膜穿刺的好处是它为硬膜外局部麻醉剂转移到脑脊液中提供了管道。导管可以是双向的，脑脊液渗漏会导致颅内低血压和硬膜穿刺后头痛 （PDPH），这是 DPE 和 CSE 技术的一个重要固有风险。Zhang 等人报道的 PDPH 发生率为 1% [1]。据估计，CSE 导致 PDPH 的额外风险至少为 0.3% [9]。普遍使用 CSE 进行分娩镇痛可能会增加 PDPH 发病率的负担，这已经认识到产后的长期健康影响。鞘内注射阿片类药物与 CSE 一起给药可显著增加胎儿心动过缓和产妇瘙痒的风险 [10]。在 George 和 Landau 引用的关于患者对分娩硬膜外镇痛相关结局偏好的研究中，更快的分娩镇痛发生的重要性仅排名第四，而避免并发症的重要性排名第五 [11]。

标准硬膜外麻醉为许多产妇提供有效且令人满意的分娩镇痛，而不接受 CSE 和硬脑膜穿刺的额外风险。CSE 在分娩镇痛中发挥作用，但有选择地发挥作用，包括那些因太痛苦而无法安全地进行硬膜外插管的产妇;第二产程中的镇痛请求;替代硬膜外镇痛;或产妇的要求。这将被视为一种以患者为中心和患者个性化的护理方法，而不是 George 和 Landau 倡导的普遍采用 CSE 进行分娩镇痛。