European Journal of Cardiovascular Medicine

Labour pain is one of the most intense forms of pain experienced in a woman’s lifetime. It arises from uterine contractions, cervical dilatation, and stretching of the pelvic floor and perineum. The severity often exceeds maternal expectations and contributes to anxiety, fear, and reluctance toward natural childbirth. Beyond its psychological impact, unrelieved pain activates the sympathetic nervous system, causing maternal tachycardia, hypertension, and hyperventilation. These changes increase catecholamine release, reduce uteroplacental perfusion, and may compromise fetal oxygenation. Thus, effective labour analgesia improves both maternal well-being and perinatal safety.^[1]

Non-pharmacological methods such as relaxation, hydrotherapy, acupuncture, and TENS provide partial relief but are insufficient during active labour. Systemic agents including opioids, nitrous oxide, and sedatives yield moderate analgesia but carry limitations such as maternal sedation, nausea, and risk of neonatal respiratory depression. Regional analgesia, particularly epidural analgesia, is the most effective and widely accepted technique.

Conventional epidural analgesia (CEA), achieved by threading a catheter into the epidural space and administering local anaesthetic with or without opioids, remains the gold standard. It provides titratable, long-lasting pain relief and can be extended for operative delivery. However, its drawbacks include slower onset (15–20 minutes), incomplete sacral coverage, occasional patchy or unilateral blocks, and potential motor weakness that may hinder expulsive efforts in the second stage of labour. These shortcomings reduce efficiency and maternal satisfaction in some cases.^[2]

To address these limitations, modified neuraxial techniques have been introduced. Combined spinal–epidural (CSE) offers rapid onset from the spinal component with prolonged duration from the epidural catheter. While effective, it may lead to intrathecal opioid side effects such as pruritus and transient fetal heart rate changes. A more recent alternative is the dural puncture epidural (DPE) technique. In DPE, a fine-gauge spinal needle punctures the dura after epidural space identification, but no drug is injected intrathecally. The epidural catheter is then placed as in the conventional technique. The dural puncture is believed to facilitate translocation of epidural medication into the cerebrospinal fluid, enhancing spread, reducing segmental sparing, and accelerating onset of analgesia.

Evidence from randomized controlled trials suggests that DPE provides faster onset, better sacral coverage, and more symmetric analgesia compared to CEA, while avoiding the fetal bradycardia sometimes associated with CSE. Meta-analyses (e.g., Heesen et al., 2019) have confirmed improved block quality with DPE without increasing adverse events. Although the theoretical risk of post-dural puncture headache (PDPH) exists, its incidence is minimal when small-gauge needles are used. Despite promising results, DPE is not yet universally adopted, and further clinical trials are warranted to establish its advantages in routine practice.

In India, where awareness and uptake of labour analgesia remain limited, ensuring rapid, effective, and safe pain relief is critical to improving maternal satisfaction and acceptance. This study was therefore conducted to compare the quality of labour analgesia between conventional epidural and dural puncture epidural techniques, with particular focus on onset, distribution, motor block, and overall maternal satisfaction.

Study Design

Prospective, randomized, double-blind trial.

Setting

Department of Anaesthesiology and Obstetrics, D.Y. Patil Hospital, Kolhapur (April 2023–2025).

Sample Size

46 (23 per group, power 80%, effect size 0.7565, α=0.05).

Inclusion Criteria

All consenting parturients requesting labour analgesia.

Exclusion Criteria

Refusal, coagulopathy, anticoagulant therapy, severe systemic illness.

Randomization

Computer-generated; allocation into Group A (CEA) or Group B (DPE).

Technique:

Group A: 18G Tuohy → epidural catheter (4 cm into space).

Group B: 18G Tuohy + 26G Whitacre dural puncture → epidural catheter.

Test dose: 10 ml 0.125% bupivacaine + fentanyl 2 μg/ml over 3 min.

Maintenance: Intermittent boluses 8–10 ml as per demand (lockout 20 min).

Assessment

Onset: Time to achieve VAS <3.

Distribution: Sacral analgesia (yes/no).

Motor block: Bromage scale at 20 min.

Maternal satisfaction: 5-point Likert scale at 2 h postpartum.

Statistics: SPSS, p<0.05 significant.

Groups were demographically comparable.

DPE achieved faster onset of analgesia (10 vs. 16 min; p < 0.001).

Duration before top-up was significantly longer with DPE (105 vs. 83 min; p < 0.001).

Pain relief at 60 minutes was superior with DPE (100% pain-free vs. 47.8%; p < 0.001).

Motor block incidence was minimal in both groups.

Maternal satisfaction was high in both groups, with a trend favoring DPE.

No major adverse events were recorded.

In group A, 52.17% patients are of age between 21 to 25 yrs, followed by 34.78% patients are of age 26 to 30 yrs. In group B, 47.83% patients are of age between 21 to 25 yrs, followed by 30.43% patients are of age 26 to 30 yrs. Fisher exact test is used to check the association between two variables as some observations count is less than 5. As we can see p-value > 0.05 i.e. level of significance for our test. So, we accept our hypothesis and conclude that there is no statistical significance between groups and age of patients.

Gravida with Primi for group A and group B are 60.87% each and Gravida with Multi for group A and group B are 39.13% each. Chi square test is used to check the association between of two variables. As we can see p-value > 0.05 i.e. level of significance for our test. So, we accept our hypothesis and conclude that there is no statistical significance between groups and gravida.

At baseline, 8.70% patients from Group A and 21.74% of patients from Group B are with the same VAS score of 6. For a VAS score of 7, 56.52% of patients in Group A and 26.09% in Group B. At a VAS score of 8, 34.78% of patients belonged to Group A, whereas 43.48% were from Group B. Lastly, for a VAS score of 9, 0% of patients from Group A, while 8.70% from Group B.

Fisher exact test is used to check the association between two variables as some observations count is less than 5. As we can see p-value > 0.05 i.e. level of significance for our test. So, we accept our hypothesis and conclude that there is no statistical significance between groups and VAS at baseline.

This randomized double-blind study compared conventional epidural analgesia (CEA) with dural puncture epidural (DPE) in labouring women. The principal findings were that DPE provided a significantly faster onset of analgesia, longer duration before the first top-up, and superior pain control at 60 minutes, while maintaining comparable motor block and safety profiles. Maternal satisfaction was higher in the DPE group.

The quicker onset of analgesia observed with DPE (10 ± 1.3 minutes vs. 16.3 ± 1.7 minutes for CEA) is consistent with earlier studies. Cappiello et al.^[3] demonstrated that dural puncture facilitated spread of local anaesthetics into the subarachnoid space, resulting in more rapid and reliable block onset compared with CEA. The improved sacral coverage and symmetric analgesia reported here also mirror findings from Chau and Tsen,^[4] who described DPE as a hybrid technique bridging the advantages of CEA and combined spinal–epidural (CSE).

An important observation was the prolonged time to first top-up in the DPE group, suggesting a more durable effect. Similar results were noted in meta-analyses by Heesen et al,^[5] which concluded that DPE reduced the incidence of patchy blocks and supplemental dosing requirements. The improved analgesic distribution likely arises from enhanced translocation of epidural solution into the cerebrospinal fluid through the dural puncture, without direct intrathecal administration.

Maternal satisfaction, a critical endpoint in obstetric anaesthesia, was higher with DPE in our study (69.6% very satisfied vs. 60.9% in CEA). This reflects both the faster onset and the sustained analgesic effect. High satisfaction aligns with contemporary priorities in labour care, where patient-centred outcomes are as important as technical efficacy.

Motor blockade was minimal and not statistically different between the two groups. This is reassuring, as excessive motor weakness can prolong the second stage of labour and increase the risk of instrumental delivery. Our findings suggest that the dural puncture itself does not exacerbate motor block when low-concentration local anaesthetics are used. Importantly, no cases of post-dural puncture headache (PDPH) or other major complications were encountered, supporting the safety of using fine-gauge spinal needles in the DPE technique.

These results have significant clinical implications. By offering rapid, reliable, and long-lasting analgesia without increasing motor impairment or adverse effects, DPE may represent a superior modification of standard epidural analgesia. Its potential advantages are particularly relevant in busy obstetric units and in populations with limited awareness or uptake of labour analgesia, such as in India, where a technique that ensures consistent efficacy could improve acceptance rates.

Nonetheless, some limitations must be acknowledged. This was a single-centre study with a relatively small sample size, which may limit generalizability. Neonatal outcomes in detail and long-term maternal outcomes, including incidence of PDPH, were also not systematically evaluated. Future multicentric trials with larger cohorts and inclusion of neonatal endpoints would strengthen the evidence base.

In conclusion, our findings reinforce growing evidence that dural puncture epidural offers faster onset, more effective, and longer-lasting labour analgesia than conventional epidural, with higher maternal satisfaction and no increase in adverse effects. DPE can therefore be considered a valuable modification to standard neuraxial analgesia in obstetric practice.

Clinical Significance

Better analgesia without higher motor block, important for maternal mobility and active participation.

Safety

PDPH not observed in this cohort, though remains a theoretical risk.

Limitations

Single-centre, small sample size.

Future Scope

Larger multicentric trials, neonatal outcome assessment

Dural puncture epidural provides faster, more effective, and longer-lasting labour analgesia with higher maternal satisfaction compared to conventional epidural. It may be considered a preferred modification in modern obstetric anaesthesia practice.

1. Melzack R. The myth of painless childbirth (the John J. Bonica lecture). Pain 1984;19(4):321-37.
2. Gambling DR, Sharma SK, Ramin SM, et al. A randomized study of combined spinal–epidural analgesia versus conventional epidural analgesia in labour. Anesthesiology 1998;89(6):1336-44.
3. Cappiello E, O’Rourke N, Segal S, et al. A randomized trial of dural puncture epidural versus conventional epidural analgesia for labor. Anesth Analg 2008;107(5):1646-51.
4. Chau A, Tsen LC. Dural puncture epidural technique: a novel modification of labour analgesia. Anesth Analg 2017;124(2):560-2.
5. Heesen M, Rijs K, Rossaint R, et al. Dural puncture epidural versus conventional epidural block for labor analgesia: systematic review and meta-analysis. Anesth Analg 2019;129(2):399-412.