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VOLUME 10 , ISSUE 2 ( July-December, 2021 ) > List of Articles


Dural Puncture Epidural during Labor: A Perspective

Rani Ponnusamy, T Arun Thilak

Keywords : Bupivacaine, Dural puncture epidural, Obstetric analgesia, Ropivacaine

Citation Information : Ponnusamy R, Thilak TA. Dural Puncture Epidural during Labor: A Perspective. 2021; 10 (2):39-41.

DOI: 10.5005/jp-journals-10085-9109

License: CC BY-NC 4.0

Published Online: 04-03-2022

Copyright Statement:  Copyright © 2021; The Author(s).


Combined spinal epidural (CSE) and epidural (EPL) are the two commonly used neuraxial techniques for labor analgesia. CSE has faster onset but late recognition of epidural failure. EPL produces late onset of analgesia, and quality may not be reliable. Dural puncture epidural (DPE), a modification of the CSE, is a procedure in which the dura will be perforated using a spinal needle with no administration of intrathecal medication. This technique has a faster onset and improved block quality in terms of the caudal spread of analgesia that can be attributed due to the translocation of medication from epidural space into the dural sac. DPE is found to be more effective for labor analgesia with a low dose of local anesthetics with fewer maternal and fetal side effects than the other techniques.

  1. 2018. Labour analgesia. Available from:
  2. Cappiello E, O'Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg 2008;107(5):1646–1651. DOI: 10.1213/ane.0b013e318184ec14.
  3. Norris MC, Fogel ST, Conway-Long C. Combined spinal-epidural versus epidural labor analgesia. Anesthesiology 2001;95(4):913–920. DOI: 10.1097/00000542-200110000-00020.
  4. Cook TM. Combined spinal-epidural techniques. Anaesthesia 2000;55(1):42–64. DOI: 10.1046/j.1365-2044.2000.01157.x.
  5. Van de Velde M, Teunkens A, Hanssens M, Vandermeersch E, Verhaeghe J. Intrathecal sufentanil and fetal heart rate abnormalities: a double-blind, double placebo-controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor. AnesthAnalg 2004;98(4):1153–1159. DOI: 10.1213/01.ANE.0000101980.34587.66.
  6. Sykes MK. Delayed spinal analgesia: a complication of epidural analgesia. Anaesthesia 1958;13(1):78–83. DOI: 10.1111/j.1365-2044.1958.tb08028.x.
  7. Leach A, Smith GB. Subarachnoid spread of epidural local anaesthetic following dural puncture. Anaesthesia 1988;43(8):671–674. DOI: 10.1111/j.1365-2044.1988.tb04155.x.
  8. Bernards CM, Kopacz DJ, Michel MZ. Effect of needle puncture on morphine and lidocaine flux through the spinal meninges of the monkey in vitro. Implications for combined spinal-epidural anesthesia. Anesthesiology 1994;80(4):853–858. DOI: 10.1097/00000542-199404000-00019.
  9. Swenson JD, Wisniewski M, McJames S, Ashburn MA, Pace NL. The effect of prior dural puncture on cisternal cerebrospinal fluid morphine concentrations in sheep after administration of lumbar epidural morphine. Anesth Analg 1996;83(3):523–525. DOI: 10.1097/00000539-199609000-00014.
  10. Suzuki N, Koganemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia. Anesth Analg 1996;82:1040–1120. Available from:
  11. Toledano RD, Tsen LC. Epidural catheter design: history, innovations, and clinical implications. Anesthesiology 2014;121(1):9–17. DOI: 10.1097/ALN.0000000000000239.
  12. Gunaydin B, Erel S. How neuraxial labor analgesia differs by approach: dural puncture epidural as a novel option. J Anesth 2019;33(1):125–130. DOI: 10.1007/s00540-018-2564-y.
  13. Park WY. Factors influencing distribution of local anesthetics in the epidural space. Reg Anesth Pain Med 1988;13(2):49–57.
  14. Collis RE, Davies DW, Aveling W. Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. Lancet. 1995;345(8962):1413–1416. DOI: 10.1016/S0140-6736(95)92602-X.
  15. Chau A, Bibbo C, Huang CC, Elterman K, Cappiello EC, Robinson JN, et al. A prospective, randomized trial of standard epidural, dural puncture epidural and combined spinal epidural labor analgesia techniques on maternal and fetal outcomes. AnesthAnalg 2017;124(2):560–569. DOI: 10.1213/ANE.0000000000001798.
  16. Bonica JJ. Obstetric analgesia-anaesthesia. London: WB Saunders; 1975;48–72. DOI: 10.1007/978-3-642-49813-8_5.
  17. Gupta DE, Sri Raja kaliindi AR, Soskin VI. Dural puncture epidural analgesia is not superior to continuous labor epidural analgesia. Middle East J Anaesthesiol 2013;22(3):309–316.
  18. Chau A, Tsen LC. Dural puncture epidural technique: a novel method for labor analgesia. Curr Anesthesiol Rep 2017;7(1):49–54. DOI: 10.1007/s40140-017-0197-6.
  19. Wilson SH, Wolf BJ, Bingham K, Scotland QS, Fox JM, Woltz EM, et al. Labor analgesia onset with dural puncture epidural versus traditional epidural using a 26-gauge Whitacre needle and 0.125% bupivacaine bolus: a randomized clinical trial. Anesth Analg 2018; 126(2):545–551. DOI: 10.1213/ANE.0000000000002129.
  20. Yadav P, Kumari I, Narang A, Baser N, Bedi V, Dindor BK. Comparison of dural puncture epidural technique versus conventional epidural technique for labor analgesia in primigravida. J Obstet Anaesth Crit Care 2018;8(1):24–28 DOI: 10.4103/joacc.JOACC_32_17.
  21. Layera S, Bravo D, Aliste J, Tran DQ. A systematic review of dural puncture epidural analgesia for labor. J Clin Anesth 2019;53:5–10. DOI: 10.4103/joacc.JOACC_32_17.
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