Combined Spinal-Epidural (CSE) for labor and delivery

Labor analgesia has undergone dramatic changes over the last decade, with an improved understanding by anesthesiologists of the many disease entities seen in obstetric patients. In addition, the introduction of new techniques (pencil-point needles, CSE, dilute epidural infusions) that have permitted us to come closer to the realization of providing almost complete relief from the pain of labor while minimizing effects on the progress of labor. CSE provides an opportunity to take advantage of the major attributes of spinal (rapidity, density, and reliability) and epidural (flexibility and ability to extend for the duration of labor). Women in labor and their obstetricians are no longer seeking or expecting labor anesthesia, but rather analgesia, and more women are requesting to ambulate while in labor. As our labor analgesia practice has changed, the debate regarding the influence of epidural analgesia on the course of labor has also evolved, and many obstetricians now demand that neuraxial analgesia be without motor block. The tangible benefits of CSE in producing fast-acting and solid sensory analgesia without motor block, coupled with the growing reports of this technique in the lay press, have produced a near-exponential increase in the use of CSE. It is clearly not the only method of providing effective neuraxial analgesia for labor and delivery; however, as reviewed in this article, CSE may be particularly advantageous in many circumstances.