Abstract

Effective management of labor pain is a cornerstone of modern obstetric anesthesia, with neuraxial techniques representing the gold standard. This narrative review explores current strategies for initiation and maintenance of neuraxial labor analgesia, focusing on the classic epidural (EPL), combined spinal–epidural (CSE), and dural puncture epidural (DPE), as well as maintenance methods including continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), and patient-controlled epidural analgesia (PCEA).

A comprehensive literature search was performed across major databases, emphasizing prospective trials, systematic reviews, and meta-analyses.

Evidence suggests that while EPL remains widely used and reliable, it is associated with slower onset and risk of patchy block. CSE provides the fastest onset and reliable analgesia but carries a slightly higher risk of maternal hypotension, pruritus, and fetal bradycardia. DPE offers marginal improvements in onset and block quality compared to EPL, with fewer side effects than CSE, although its clinical advantages remain limited. For maintenance, PIEB has demonstrated superiority over CEI in terms of analgesic quality, motor block reduction, and maternal satisfaction. PCEA, whether alone or in combination, increases maternal autonomy, reduces physician interventions, and lowers local anesthetic consumption.

Overall, neuraxial techniques should be tailored to maternal and fetal needs, balancing rapid onset and reliable analgesia against potential side effects. CSE and PIEB emerge as strong candidates for initiation and maintenance respectively, while ongoing research is required to refine the role of DPE and high-volume PCEA in modern practice.