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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 156-161

Is combined spinal-epidural more effective compared to epidural for labor analgesia?


1 Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Anaesthesia, Christian Medical College, Ludhiana, Punjab, India
3 Department of Anatomy, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission28-Jun-2018
Date of Decision04-Jul-2018
Date of Acceptance15-Aug-2018
Date of Web Publication13-Aug-2019

Correspondence Address:
Sunimal Bhaggien
Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_99_18

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  Abstract 


Aims and Objectives: This study aims to compare the effectiveness of combined spinal-epidural (CSE) analgesia and low-dose epidural analgesia in labor and study their effects on maternal and fetal well-being. Material and Methods: Sixty parturients classified as the American Society of Anesthesiologists I, in established labor and requesting epidural, were alternately divided into two groups (30 each). Group I received 0.125% bupivacaine with fentanyl 2 ug/ml epidural analgesia. Group II received CSE analgesia comprising of 25 μg fentanyl in the intrathecal space and 0.125% bupivacaine with fentanyl 2 ug/ml for epidural analgesia. Onset of analgesia, maternal hemodynamics, fetal heart rate, duration of labor, ambulation, incidence of cesarean section, instrumental delivery, side effects, and total dose of bupivacaine and fentanyl used were recorded. Results: Onset of analgesia in CSE group (1.48 ± 0.46 min) was significantly faster compared to the epidural group (3.87 ± 0.83 min). Duration of the first stage of labor was shorter in the CSE group (218.93 ± 78.15 min) compared to epidural group (308.03 ± 147). No significant difference between the groups was found in hemodynamic effects, duration of the second stage of labor, or in maternal and neonatal outcomes. Pruritus was seen in 50% of CSE patients. Mean total bupivacaine used in CSE group was significantly lesser than that used in Group I (56.750 ± 22.33 mg vs. 79.325 ± 28.81 mg). Conclusion: Both CSE and epidural analgesia provide comparable pain relief and maternal and fetal outcomes. CSE can be beneficial for parturients coming in advanced labor as its onset of action is faster.

Keywords: Combined spinal epidural, epidural, labor analgesia


How to cite this article:
Joel JJ, Osahan NK, Rai E, Daniel P, Bhaggien S. Is combined spinal-epidural more effective compared to epidural for labor analgesia?. CHRISMED J Health Res 2019;6:156-61

How to cite this URL:
Joel JJ, Osahan NK, Rai E, Daniel P, Bhaggien S. Is combined spinal-epidural more effective compared to epidural for labor analgesia?. CHRISMED J Health Res [serial online] 2019 [cited 2019 Oct 17];6:156-61. Available from: http://www.cjhr.org/text.asp?2019/6/3/156/264385




  Introduction Top


Labor is regarded as one of the most painful experiences in a woman's life. The primary aim of providing labor analgesia is to alleviate labor pain without interfering with the normal progression of labor. Epidural analgesia is widely considered the most effective method of providing pain relief during labor. Advantages of epidural analgesia include slower onset of hypotension compared to subarachnoid anesthesia, thereby avoiding decrease in utero placental circulation and fetal acidosis. Furthermore, it allows extension of anesthesia for episiotomy, forceps and cesarean delivery, and decreased maternal and fetal respiratory depression.[1],[2],[3] Although with epidural analgesia pain relief is excellent, it can produce substantial sensory and motor blockade. Consequently, women are unable to walk and are usually confined to bed.[4]

Recently combined spinal-epidural (CSE) analgesia is being widely used, where a lipid-soluble opioid is given as a single intrathecal injection with an epidural infusion of a low concentration local anesthetic and narcotic. This provides satisfactory analgesia without motor blockade preserving the full range of motion and ability to walk hence called “walking epidural.”[4]

Advantages of CSE analgesia over epidural alone are related to the additional use of spinal component which provides rapid onset of analgesia more reliable than epidural, producing excellent analgesia, lower dose requirements of local anesthetic, thus preventing toxic systemic effects.[5],[6] However, a few concerns regarding the CSE analgesia are risk of infectious complications and postdural puncture headache (PDPH). The most common complications of CSE analgesia technique include pruritis, maternal hypotension, urinary retention, fetal heart rate (FHR) changes, and increased rate of nausea and vomiting due to opioids.[3],[4],[5],[7]

Through this study, we aim to evaluate the effectiveness of CSE analgesia versus low-dose epidural analgesia in labor and to study the effects of these two techniques on maternal and fetal well-being.


  Materials and Methods Top


After obtaining approval from the institutional ethics committee, written informed consent was obtained from 60 parturients classified as the American Society of Anesthesiologists physical status I. Nulliparous or multiparous women who had delivered 5 years back, with singleton fetus in vertex position, in established labor with cervical dilatation of 3 cm and a reassuring FHR tracing and who requested epidural analgesia, were included in the study. Patients with the history of multiple pregnancies, premature labor, previous lower segment cesarean section (LSCS), women who had received opioid analgesia by another route during the previous 4 h, and patients with any contraindications to neuraxial blockade (e.g., skin infection, allergy to local anesthetics, pathology of lumbosacral spine, and patients on anticoagulant therapy) were excluded from the study.

After obtaining consent, an IV line was started and 500 ml of Ringer lactate was infused before the procedure. Patients were placed in either the left lateral or sitting position and a Tuohy's needle were inserted at intervertebral space L2–L3 or L3–L4. Loss of resistance to air was used to recognize epidural space after which an 18G epidural cannula was inserted 5 cm into the epidural space. Patients were divided into two groups of 30 each on alternate basis. Group I (E) patients received 6 ml of 0.125% bupivacaine with fentanyl 2 ug/ml as the loading dose in 3 ml increments after which infusion was started immediately at the rate of 6 ml/h and was increased up to a maximum of 10 ml/h. Group II (CSE) patients received CSE analgesia where the initial analgesia was established by an intrathecal injection of 25 μg fentanyl through 25G Whitacre needle in the L3–L4 intervertebral space (was diluted with saline up to a total volume of 2 ml). Subsequently, an epidural performed and catheter inserted by above technique and was activated on maternal request, where 6 ml of 0.125% bupivacaine with fentanyl 2 ug/ml was given in 3 ml increments following which an infusion was started immediately at the rate of 6 ml/h up to a max of 10 ml/h. After the procedure, patients were placed supine with left uterine displacement and head end elevated by 30°.

Maternal pulse, blood pressure (BP), visual analog scale (VAS) score, FHR, and motor blockade using modified Bromage score [Table 1][8] were monitored every 5 min for the first 30 min. Thereafter, all parameters were recorded at hourly intervals throughout labor. Ambulation was considered possible after three unassisted steps but always advised with an assistant. In case of breakthrough pain (VAS >5), 6–8 ml of 0.125% bupivacaine with fentanyl 2 ug/ml was given on maternal request but not more than hourly. Subsequent rescue analgesia after this was given according to the study protocol. After delivery, neonates were assessed using Apgar score at 1 and 5 min. Patients were interviewed a day after delivery for satisfaction level and willingness for labor epidural for subsequent deliveries.
Table 1: Modified Bromage Score

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The statistical analysis was done using Statistical Package for the Social Sciences version 15, (SPSS Inc., Chicago, Illinois, USA). All quantitative variables were estimated using means and standard deviation. Kolmogorov–Smirnov tests were used for normality of data. For normally distributed data, means were compared using Student's t-test for two groups. For skewed data or for scores (for VAS score, motor power), Mann–Whitney test was applied. Qualitative variables were described as frequencies and proportions. Proportions were compared using Chi-square or Fisher's exact test whichever was applicable. For time-related variables, two-way ANOVA was applied. One-way ANOVA was applied for within group comparison. For time-related scores, Wilcoxon signed-rank test was applied. All statistical tests were two-sided and performed at a significance level of α = 0.05.


  Results and Analysis Top


The mean age of patients in Group I was 26.73 ± 3.28 years and 26.07 ± 2.75 years in Group II. Number of patients monitored till they went into labor in both groups is listed in [Table 2]. In Group I, the mean baseline pulse rate was 97.70 ± 6.844. In Group II, the mean baseline pulse rate was 96.67 ± 8.934. In both the groups, there was a significant fall in pulse rate, but it was max in Group I at 15–20 min, whereas in Group II maximum fall was seen after intrathecal fentanyl injection at 5–10 min. On intergroup comparison, the fall in the pulse rate was significantly more in Group II at 10 min (P = 0.004). The difference was statistically insignificant at rest of the observed timings [Figure 1].
Table 2: Number of patients monitored in each group till labor

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Figure 1: Pulse rate group comparison between the two groups

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There was a fall in systolic BP after epidural injection within Group I, which was statistically significant from 5 min to 3 h (P < 0.001–0.004). In Group II also, there was a fall in systolic BP after subarachnoid opioid injection, which was statistically significant at 5–25 min (P < 0.001–0.005). However, the fall in systolic BP was comparable in both the groups [Figure 2].
Figure 2: Systolic blood pressure group comparison between the two groups

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In Group I, the mean time for onset of analgesia was 3.87 ± 0.83 min. In Group II, the mean time for onset of analgesia was 1.48 ± 0.46 min. Thus, the onset of analgesia in Group II was significantly faster when compared to Group I (P < 0.001) [Figure 3].
Figure 3: Onset of analgesia comparison between the two groups

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Soon after pain relief was provided, Group II (CSE) showed significantly lower VAS scores at 5 and 10 min than Group I (epidural), but from 15 to 30 min, it was significantly lower in Group I than Group II [Figure 4].
Figure 4: Visual analog scale score comparison between the two groups

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The mean total bupivacaine used in Group II (CSE) was significantly lesser than that used in Group I (56.750 ± 22.33 mg vs. 79.325 ± 28.81 mg) (P = 0.001), whereas total fentanyl used was not statistically significant between the groups (109 ± 43.55 ug vs. 113 ± 63.37 ug) (P = 0.77).

The duration of first stage of labor was significantly shorter in Group II (CSE) with a mean of 218.93 ± 78.15 min in Group II and 308.03 ± 147 min in Group I (P = 0.005). There was no statistically significant difference between the groups in duration of the second stage of labor (68.07 ± 39.84 min vs. 46.55 ± 34.01 min) (P = 0.031) [Figure 5].
Figure 5: Duration of labor comparison between the two groups

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The number of parturients requiring additional rescue analgesia (top ups) were more in the epidural group (30% [9/30]) compared to the CSE group (6.67% [2/30]); however, it was not found to be statistically significant.

In our study, the only side effect observed was pruritis which was significantly more in the CSE group (15/30) compared to epidural group (5/30) (P = 0.005).

Overall, only one patient in the epidural group had motor blockade (Modified Bromage Score Grade 2) at 15 and 20 min which resolved by 25 min, whereas no motor blockade was seen in the patients in CSE group.

In Group I, 20 (66.6%) patients had normal vaginal delivery, 9/30 (30%) had forceps delivery, and 1/30 (3.33%) had LSCS. In Group II, 23/30 patients (76.66%) had normal vaginal delivery, six patients (20%) had forceps delivery, and one patient (3.33%) had LSCS. We did not find significant difference in the level of maternal satisfaction between the CSE and epidural groups. All parturients included in the CSE and epidural groups were willing for further CSE analgesia (CSEA)/epidural in subsequent deliveries. There was no significant difference in the Apgar scores at 1 and 5 min between the CSE and epidural groups.

We did not have any reports of dural punctures or PDPH in our study. A few cases of blood coming in the epidural cannula after insertion were observed which was rectified by placing epidural one space above in the next attempt. These parameters had no residual effects thereafter and were not included in the study. The limitation we had was to make the parturients to ambulate as most of them were exhausted and wanted to rest and some had elderly attendants who could not assist them in ambulation. Hence, we could not study ambulation and had to exclude that parameter.


  Discussion Top


Ever since the introduction of labor analgesia, there has been a revolution in handling women during labor over the past decades. Mobile or ambulatory extradural labor analgesia is a novel approach to painless labor.[4] Advantages of CSE over an epidural alone are related to the additional use of spinal component which provides rapid onset of analgesia producing excellent analgesia, lower dose requirement of local anesthetic, thus preventing toxic systemic effects.[5],[6] Hence in our study, we tried to determine the effectiveness of both the techniques.

The hemodynamic parameters studied included maternal pulse rate and BP and FHR. We observed maximum fall in pulse rate at 20 min in the epidural group which coincided with peak action of the bolus dose. The maximum fall in the CSE group was observed at 10 min which could be possibly due to the rapid reduction in the maternal catecholamine levels secondary to immediate pain relief after CSE analgesia.[9]

A significant fall in systolic BP was observed in both the groups, but the difference in the fall of systolic BP was comparable (P > 0.05). None of the patients required treatment. The diastolic BP showed no significant changes from baseline in both the groups. Norris et al. in their study found both epidural and CSE to have similar effects on systolic BP and a very low incidence of significant hypotension after both epidural and CSE analgesia. They also suggested that intrathecal opioids may lower BP through an action on the opioid receptors located on the preganglionic sympathetic nerve fibers or by exerting a weak local anesthetic effect.[10] Collins et al. showed that fluid preloading significantly reduces maternal hypotension (34%–12%) during epidural analgesia.[11] The reduced incidence of hypotension in our study could be synchronous with the findings of Collins et al. as we had preloaded our patients.

We did not observe any significant change in the mean FHR from the baseline value within the groups after initiation of labor analgesia at any recorded timing. Similar results were observed by Frikha et al. in their study on CSE analgesia in labor. They studied 40 parturients and no patient in their study had a nonreassuring FHR tracing after initial analgesia.[12] Hepner et al. and Palmer et al. also showed no significant changes in FHR both in CSE and epidural group, but Collis et al. found the rate of fetal bradycardia to be 13% in the combined spinal-epidural group and 9% in the standard epidural group.[6],[13],[14] The cause of fetal bradycardia after CSE remains unclear, but it may be related to an acute reduction in circulating maternal catecholamine levels after the quick onset of analgesia. An imbalance between epinephrine and norepinephrine levels causes unopposed alpha-adrenoreceptor effects on uterine tone and decreases the uterine blood flow.[9] Hattler et al. in their systematic review and meta-analysis of 17 trials consisting of 3497 parturients studied the effects of CSE and epidural on nonreassuring FHR tracings and found CSE to be associated with higher risk of nonreassuring FHR tracings than epidural alone (P = 0.03).[15] Patel et al. in their randomized controlled trial (RCT) on changes in FHR between CSE and epidural found that CSE did not increase FHR abnormalities or had an adverse effect on neonatal or obstetric outcomes compared with epidural and suggested that oxytocin rather than hypotension may be an important associating factor.[16] Collins et al. and Kinsella et al. observed that fluid preloading significantly reduces the abnormalities in FHR during epidural analgesia.[11],[17] In our study, we had preloaded patients with 500 ml of crystalloid before the procedure and as seen in the aforementioned studies, we also did not observe much change in the FHR in both the groups, but nevertheless, vigilant monitoring of FHR is a prerequisite whenever opioid is being administered intrathecally as mentioned in aforementioned studies.

We observed that there was a significantly lower VAS score at 5 and 10 min in the CSE group. This was due to the intrathecal component which has a quick onset, whereas from 15 min onward, VAS was significantly lower in the epidural group, probably due to the weaning off of the spinal opioid in the CSE group and the peak action of the initial epidural bolus in the epidural group. Our results are close to the Comparative Obstetric Mobile Epidural Trial (COMET) study, who found significantly less median VAS scores at 5 min in the CSE group compared to traditional epidural group, and this difference was maintained up to 1 h. At 3 h, the median VAS scores were significantly higher in CSE group.[18] Hepner et al. found VAS scores were lower in CSE group up to 15 min. According to them, the proximity of the drug to the nerve in the CSE approach probably accounts for the difference in the pain scores. However, there were no significant differences in the VAS score after 15 min between the two groups.[13]

Our study showed significantly faster onset of analgesia in the CSE group than the epidural group, which is similar to the observation made by Simmons et al. They conducted a Cochrane database review and studied 27 RCT involving 3274 women. They found significantly faster onset with CSE group compared to the epidural group.[19] We did not observe any significant difference between the groups in the incidence of motor blockade. Only one patient in epidural group had motor blockade which resolved in 25 min.

The mean total dose of bupivacaine used in CSE group by us was significantly less than the epidural group but as far as the total dose of fentanyl was concerned, there was no significant difference between the groups. Gupta et al. also reported that lower total dosage of fentanyl and bupivacaine used in the CSE group compared to the epidural group.[5]

Although more number of parturients required rescue analgesia (top ups) in the epidural group, the difference was not statistically significant. Simmons et al. also showed that increased used of rescue interventions with traditional epidural favored use of CSE.[19]

In our study, we observed that the duration of the first stage of labor was significantly shorter in the CSE group. This could be because of preservation of motor power of the pelvic floor muscles due to the late initiation of bupivacaine infusion. The duration of the second stage was comparable in both the groups. Tsen et al. reported similar results. They proposed that CSE causes rapid cervical dilatation due to two mechanisms. First, it could be spinal analgesia in CSE allowing reduction in local anesthetic exposure compared with epidural analgesia causing a probable decrease in uterine activity. Second, the rapid onset of pain relief with CSE may allow equally rapid decrease in maternal catecholamines.[20] Rajappa et al. in their RCT on 120 parturients also found more rapid cervical dilatation in CSE with mean cervical dilatation of 2 cm/h compared to 1.16 cm/h in epidural group and shorter first stage of labor in CSE compared to epidural alone (P < 0.001).[21]

Miro et al. have reported high incidence of vaginal delivery in the CSE group. They also reported the high incidence of instrumental vaginal delivery and cesarean section in epidural group.[22] We did not find any difference between the two techniques as far as mode of delivery was concerned similar to Singh et al.[23]

Level of maternal satisfaction for CSE and epidural was similar as reported by Simmons et al.[19]

In our study, the only side effect observed was pruritis which was significantly more in the CSE group. The second side effect was sedation which was comparable in both groups. Similar observations have been reported by Simmons et al. and Nageotte et al.[19],[4]

Apgar scores were comparable in both the Groups at 1 and 5 min. Norris et al. and Collis et al. also did not observe any difference in the Apgar scores between the two groups.[6],[10]


  Conclusion Top


Both epidural and CSE techniques provide satisfactory labor analgesia and have similar maternal and fetal outcome. Since CSE produces the faster onset of analgesia, it can be beneficial for parturients in advanced labor where patient cooperation becomes difficult. Even though CSE had short duration of first stage of labor secondary to rapid cervical dilatation, there was no significant difference in outcomes and needs further larger trials to substantiate its effect on outcomes.

Acknowledgments

I thank my patients who consented being part of study. I am grateful to the Department of Anesthesia and Obstetrics and Gynecology, Christian medical college Ludhiana for their cooperation and support for this study.

Financial support and sponsorship

This study was financially supported by Christian Medical College, Ludhiana.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Lewis M, Calthorpe N. Combined spinal epidural analgesia in labour. Fetal Matern Med Rev 2005;16:29-50.  Back to cited text no. 1
    
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Nageotte MP, Larson D, Rumney PJ, Sidhu M, Hollenbach K. Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med 1997;337:1715-9.  Back to cited text no. 4
    
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Gupta S, Raiger LK, Raman V. Ambulatory labour analgesia – Comparison of two regional techniques. Indian J Anaesth 2002;46:44-8.  Back to cited text no. 5
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Kuczkowski KM. Ambulation with combined spinal-epidural labor analgesia: The technique. Acta Anaesthesiol Belg 2004;55:29-34.  Back to cited text no. 7
    
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Collins KM, Bevan DR, Beard RW. Fluid loading to reduce abnormalities of fetal heart rate and maternal hypotension during epidural analgesia in labour. Br Med J 1978;2:1460-1.  Back to cited text no. 11
    
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Frikha N, Ellachtar M, Mebazaa MS, Ben Ammar MS. Combined spinal-epidural analgesia in labor – Comparison of sufentanil vs. tramadol. Middle East J Anaesthesiol 2007;19:87-96.  Back to cited text no. 12
    
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Hepner DL, Gaiser RR, Cheek TG, Gutsche BB. Comparison of combined spinal-epidural and low dose epidural for labour analgesia. Can J Anaesth 2000;47:232-6.  Back to cited text no. 13
    
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Palmer CM, Maciulla JE, Cork RC, Nogami WM, Gossler K, Alves D, et al. The incidence of fetal heart rate changes after intrathecal fentanyl labor analgesia. Anesth Analg 1999;88:577-81.  Back to cited text no. 14
    
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Hattler J, Klimek M, Rossaint R, Heesen M. The effect of combined spinal-epidural versus epidural analgesia in laboring women on nonreassuring fetal heart rate tracings: Systematic review and meta-analysis. Anesth Analg 2016;123:955-64.  Back to cited text no. 15
    
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Patel NP, El-Wahab N, Fernando R, Wilson S, Robson SC, Columb MO, et al. Fetal effects of combined spinal-epidural vs. epidural labour analgesia: A prospective, randomised double-blind study. Anaesthesia 2014;69:458-67.  Back to cited text no. 16
    
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Kinsella SM, Pirlet M, Mills MS, Tuckey JP, Thomas TA. Randomized study of intravenous fluid preload before epidural analgesia during labour. Br J Anaesth 2000;85:311-3.  Back to cited text no. 17
    
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Simmons SW, Cyna AM, Dennis AT, Hughes D. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews 2007;(3):CD003401.  Back to cited text no. 19
    
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Tsen LC, Thue B, Datta S, Segal S. Is combined spinal-epidural analgesia associated with more rapid cervical dilation in nulliparous patients when compared with conventional epidural analgesia? Anesthesiology 1999;91:920-5.  Back to cited text no. 20
    
21.
Rajappa GC, Anandaswamy TC, Pattadi TJ, Swarup A. Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia. J Obstet Anaesth Crit Care 2017;7:43-6.  Back to cited text no. 21
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22.
Miro M, Guasch E, Gilsanz F. Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: A retrospective study of 6497 cases. Int J Obstet Anesth 2008;17:15-9.  Back to cited text no. 22
    
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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