Combined spinal‐epidural versus epidural analgesia in labour

Damien Hughes; Scott W Simmons; Jane Brown; Allan M Cyna

doi:10.1002/14651858.CD003401

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Analysis 1.1

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 1 Time from first injection to effective analgesia (minutes).

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Analysis 1.2

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 2 Need for rescue analgesia.

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Analysis 1.3

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 3 Number of women satisfied with analgesia.

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Analysis 1.4

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 4 Number of women who mobilise.

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Analysis 1.5

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 5 Post dural puncture headache.

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Analysis 1.6

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 6 Known dural tap.

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Analysis 1.7

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 7 Number of women requiring blood patch for PDPH.

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Analysis 1.8

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 8 Pruritus.

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Analysis 1.9

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 9 Urinary retention.

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Analysis 1.10

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 10 Nausea/vomiting.

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Analysis 1.11

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 11 Hypotension.

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Analysis 1.12

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 12 Respiratory depression.

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Analysis 1.13

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 13 Headache (any).

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Analysis 1.14

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 14 Sedation.

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Analysis 1.15

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 15 Labour augmentation required.

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Analysis 1.16

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 16 Augmentation after analgesia.

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Analysis 1.17

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 17 Normal delivery.

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Analysis 1.18

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 18 Instrumental delivery.

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Analysis 1.19

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 19 Caesarean section.

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Analysis 1.20

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 20 Umbilical arterial pH.

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Analysis 1.21

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 21 Umbilical venous pH.

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Analysis 1.22

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 22 Umbilical cord pH.

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Analysis 1.23

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 23 Apgar score < 7 at 5 minutes.

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Analysis 1.24

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 24 Apgar score < 8 at 5 minutes.

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Analysis 1.25

Comparison 1 Combined spinal epidural (CSE) versus (vs) epidural, Outcome 25 Number admitted to neonatal unit.

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Table 1. Epidural techniques used ‐ initial dose and subsequent maintenance

	Nil maintenance	Immediate infusion	Repeat boluses	Repeat boluses	Bolus/infusion	Repeat boluses	PCEA
		LA + OPIOID	HIGH DOSE LA	LOW DOSE LA	LOW DOSE LA/OPIOID	LOW DOSE LA/OPIOID
INITIAL DOSE
Low‐dose bupivacaine < 0.25%				Abouliesh
Traditional dose bupivacaine = 0.25%		Tsen, Gomez	COMET
Low‐dose bupivacaine < 0.25% + opioid	Parry	COMET			Hepner	Kartawiadi, Nickells	Price, Van de Velde
Traditional dose bupivacaine + opioid		Caldwell	Roux
Test lignocaine + opioid	Dunn, Breen

Table 1. Epidural techniques used ‐ initial dose and subsequent maintenance

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Table 2. CSE techniques used ‐ initial IT injection and subsequent epidural


	NIL EPIDURAL	IMMEDIATE INFUSION	IMMEDIATE BOLUS/INFUSION	IMMEDIATE BOLUS/BOLUSES	DELAY BOLUS/INFUSION	DELAYED BOLUSES	PCEA
IT INJECTION
IT opioid only	Breen, Dunn			Abouliesh, Roux	Caldwell	Abouliesh
IT LA + opioid	Parry				Gomez, Hepner, Tsen	COMET, Kartawiadi, Nickells	Price, Van de Velde

Table 2. CSE techniques used ‐ initial IT injection and subsequent epidural

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Comparison 1. Combined spinal epidural (CSE) versus (vs) epidural

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Time from first injection to effective analgesia (minutes) Show forest plot	4	364	Mean Difference (IV, Fixed, 95% CI)	‐5.50 [‐6.47, ‐4.52]

1.1 CSE vs traditional epidural	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 CSE vs low dose epidural	3	285	Mean Difference (IV, Fixed, 95% CI)	‐5.59 [‐6.59, ‐4.58]
1.3 Opioid CSE vs traditional epidural	1	79	Mean Difference (IV, Fixed, 95% CI)	‐4.0 [‐8.08, 0.08]
1.4 Opioid CSE vs test LA/opioid epidural	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Need for rescue analgesia Show forest plot	6	1097	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.60, 1.08]

2.1 CSE vs low dose epidural	4	986	Odds Ratio (M‐H, Fixed, 95% CI)	0.91 [0.67, 1.24]
2.2 CSE vs traditional epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	0.10 [0.02, 0.40]
2.3 Opioid CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.31 [0.01, 7.99]
2.5 Opioid CSE vs low dose epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of women satisfied with analgesia Show forest plot	3	223	Odds Ratio (M‐H, Fixed, 95% CI)	4.69 [1.27, 17.29]

3.1 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 CSE vs low dose epidural	3	223	Odds Ratio (M‐H, Fixed, 95% CI)	4.69 [1.27, 17.29]
4 Number of women who mobilise Show forest plot	5	963	Odds Ratio (M‐H, Fixed, 95% CI)	1.07 [0.82, 1.39]

4.1 CSE vs low dose epidural	3	854	Odds Ratio (M‐H, Fixed, 95% CI)	0.99 [0.75, 1.32]
4.2 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 Opioid CSE vs test LA/opioid epidural	2	109	Odds Ratio (M‐H, Fixed, 95% CI)	1.99 [0.87, 4.59]
5 Post dural puncture headache Show forest plot	9		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 CSE vs low dose epidural	6	418	Odds Ratio (M‐H, Fixed, 95% CI)	2.46 [0.35, 17.29]
5.2 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	3.94 [0.15, 100.81]
5.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.31 [0.01, 7.99]
5.5 Opioid CSE vs low dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.6 CSE vs epidural: overall	9	645	Odds Ratio (M‐H, Fixed, 95% CI)	1.46 [0.37, 5.71]
6 Known dural tap Show forest plot	6		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 CSE vs traditional epidural	1	704	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.23]
6.2 CSE vs low dose epidural	3	893	Odds Ratio (M‐H, Fixed, 95% CI)	0.14 [0.01, 2.74]
6.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	7.18 [0.84, 61.72]
6.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.5 CSE vs epidural: overall	6	1453	Odds Ratio (M‐H, Fixed, 95% CI)	1.77 [0.53, 5.94]
7 Number of women requiring blood patch for PDPH Show forest plot	6		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 CSE vs low dose epidural	3	198	Odds Ratio (M‐H, Fixed, 95% CI)	5.16 [0.24, 112.01]
7.2 Opioid CSE vs low dose epidural	2	92	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.31 [0.01, 7.99]
7.4 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.5 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.6 CSE vs epidural: overall	6	416	Odds Ratio (M‐H, Fixed, 95% CI)	1.47 [0.24, 8.98]
8 Pruritus Show forest plot	9		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 CSE vs low dose epidural	5	358	Odds Ratio (M‐H, Fixed, 95% CI)	1.87 [1.19, 2.94]
8.2 CSE vs traditional epidural	2	142	Odds Ratio (M‐H, Fixed, 95% CI)	10.45 [1.93, 56.64]
8.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	22.15 [3.87, 126.79]
8.4 Opioid CSE vs low dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	9.0 [0.98, 83.06]
8.5 CSE vs epidural: overall	9	658	Odds Ratio (M‐H, Fixed, 95% CI)	2.79 [1.87, 4.18]
9 Urinary retention Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 CSE vs low dose epidural	2	126	Odds Ratio (M‐H, Fixed, 95% CI)	0.71 [0.29, 1.73]
9.3 Opioid CSE vs low dose epidural	1	34	Odds Ratio (M‐H, Fixed, 95% CI)	2.02 [0.51, 7.94]
9.4 CSE vs epidural: overall	2	142	Odds Ratio (M‐H, Fixed, 95% CI)	0.89 [0.39, 2.00]
10 Nausea/vomiting Show forest plot	8		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10.1 CSE vs traditional epidural	2	142	Odds Ratio (M‐H, Fixed, 95% CI)	0.21 [0.02, 2.09]
10.2 CSE vs low dose epidural	3	202	Odds Ratio (M‐H, Fixed, 95% CI)	1.16 [0.54, 2.46]
10.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	2.10 [1.03, 4.29]
10.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.96 [0.30, 3.12]
10.5 Opioid CSE vs low dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	12.27 [0.62, 244.05]
10.6 CSE vs epidural: overall	8	571	Odds Ratio (M‐H, Fixed, 95% CI)	1.36 [0.87, 2.14]
11 Hypotension Show forest plot	10	791	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.39, 2.44]

11.1 CSE vs traditional epidural	2	142	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 CSE vs low dose epidural	6	501	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.46, 3.44]
11.3 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	0.19 [0.01, 4.19]
11.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Respiratory depression Show forest plot	5		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

12.1 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.2 CSE vs low dose epidural	2	92	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.5 Opioid CSE vs low dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Headache (any) Show forest plot	2	189	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.05, 2.11]

13.1 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.06, 17.01]
13.2 CSE vs low dose epidural	1	110	Odds Ratio (M‐H, Fixed, 95% CI)	0.14 [0.01, 2.68]
14 Sedation Show forest plot	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.36, 2.96]

14.1 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.36, 2.96]
14.2 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Labour augmentation required Show forest plot	6		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

15.1 CSE vs traditional epidural	2	804	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.66, 1.21]
15.2 CSE vs low dose epidural	3	885	Odds Ratio (M‐H, Fixed, 95% CI)	0.89 [0.66, 1.20]
15.3 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	1.72 [0.50, 5.90]
15.5 Opioid CSE vs low dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	0.53 [0.04, 6.29]
15.6 CSE vs epidural: overall	6	1506	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.70, 1.16]
16 Augmentation after analgesia Show forest plot	1	100	Odds Ratio (M‐H, Fixed, 95% CI)	0.40 [0.15, 1.06]

16.1 CSE vs traditional epidural	1	100	Odds Ratio (M‐H, Fixed, 95% CI)	0.40 [0.15, 1.06]
16.2 CSE vs low‐dose epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.3 Opioid CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Normal delivery Show forest plot	12		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

17.1 CSE vs low dose epidural	7	1119	Odds Ratio (M‐H, Fixed, 95% CI)	0.96 [0.75, 1.23]
17.2 CSE vs traditional epidural	3	846	Odds Ratio (M‐H, Fixed, 95% CI)	1.31 [0.99, 1.73]
17.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	0.56 [0.26, 1.20]
17.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.26, 2.87]
17.5 Opioid CSE vs low‐dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	0.89 [0.19, 4.15]
17.6 CSE vs epidural: overall	12	1841	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.84, 1.25]
18 Instrumental delivery Show forest plot	10		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

18.1 CSE vs low‐dose epidural	6	1059	Odds Ratio (M‐H, Fixed, 95% CI)	1.07 [0.80, 1.43]
18.2 CSE vs traditional epidural	3	846	Odds Ratio (M‐H, Fixed, 95% CI)	0.72 [0.54, 0.97]
18.3 Opioid CSE vs low‐dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.4 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	1.53 [0.44, 5.31]
18.5 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	0.97 [0.13, 7.31]
18.6 CSE vs epidural: overall	10	1722	Odds Ratio (M‐H, Fixed, 95% CI)	0.91 [0.72, 1.15]
19 Caesarean section Show forest plot	10		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

19.1 CSE vs low‐dose epidural	6	1059	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.74, 1.31]
19.2 CSE vs traditional epidural	3	846	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.76, 1.41]
19.3 Opioid CSE vs traditional epidural	1	79	Odds Ratio (M‐H, Fixed, 95% CI)	1.58 [0.25, 10.03]
19.4 Opioid CSE vs test LA/opioid epidural	1	69	Odds Ratio (M‐H, Fixed, 95% CI)	1.25 [0.31, 5.11]
19.5 Opioid CSE vs low‐dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	1.13 [0.24, 5.25]
19.6 CSE vs epidural: overall	10	1722	Odds Ratio (M‐H, Fixed, 95% CI)	1.02 [0.81, 1.30]
20 Umbilical arterial pH Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

20.1 CSE versus traditional epidural	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.2 CSE versus low dose epidural	3	191	Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.02, 0.03]
20.3 Opioid CSE versus traditional epidural	1	55	Mean Difference (IV, Fixed, 95% CI)	‐0.02 [‐0.06, 0.02]
20.4 Opioid CSE versus low dose epidural	1	42	Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.03, 0.11]
20.5 CSE versus epidural: overall	4	266	Mean Difference (IV, Fixed, 95% CI)	‐0.00 [‐0.03, 0.02]
21 Umbilical venous pH Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

21.1 CSE versus traditional epidural	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.2 CSE versus low dose epidural	2	85	Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.00, 0.07]
21.3 Opioid CSE versus traditional epidural	1	55	Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.06, ‐0.00]
21.4 Opioid CSE versus low dose epidural	1	42	Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.00, 0.08]
21.5 CSE versus epidural: overall	3	160	Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.03, 0.02]
22 Umbilical cord pH Show forest plot	1	110	Mean Difference (IV, Fixed, 95% CI)	‐0.02 [‐0.05, 0.01]

22.1 CSE versus low dose epidural	1	110	Mean Difference (IV, Fixed, 95% CI)	‐0.02 [‐0.05, 0.01]
23 Apgar score < 7 at 5 minutes Show forest plot	5	391	Odds Ratio (M‐H, Fixed, 95% CI)	0.53 [0.10, 2.95]

23.1 CSE vs low‐dose epidural	3	253	Odds Ratio (M‐H, Fixed, 95% CI)	0.32 [0.03, 3.17]
23.2 CSE vs traditional epidural	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.3 Opioid CSE vs traditional epidural	2	138	Odds Ratio (M‐H, Fixed, 95% CI)	1.28 [0.08, 21.49]
24 Apgar score < 8 at 5 minutes Show forest plot	4		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

24.1 CSE vs traditional epidural	1	704	Odds Ratio (M‐H, Fixed, 95% CI)	2.37 [0.61, 9.26]
24.2 CSE vs low‐dose epidural	4	866	Odds Ratio (M‐H, Fixed, 95% CI)	0.80 [0.32, 2.00]
24.3 Opioid CSE vs low‐dose epidural	1	42	Odds Ratio (M‐H, Fixed, 95% CI)	3.46 [0.13, 89.95]
24.4 CSE vs epidural: overall	4	1239	Odds Ratio (M‐H, Fixed, 95% CI)	1.22 [0.52, 2.83]
25 Number admitted to neonatal unit Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

25.1 CSE vs traditional epidural	1	704	Odds Ratio (M‐H, Fixed, 95% CI)	0.62 [0.28, 1.38]
25.2 CSE vs low‐dose epidural	2	751	Odds Ratio (M‐H, Fixed, 95% CI)	0.76 [0.33, 1.76]
25.3 CSE vs epidural: overall	2	1104	Odds Ratio (M‐H, Fixed, 95% CI)	0.68 [0.33, 1.41]

Comparison 1. Combined spinal epidural (CSE) versus (vs) epidural

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