REVIEW Southern African Journal of Anaesthesia & Analgesia- July 2004 15 Advances in obstetric anesthesia:

ambulation during labor with combined spinal-epidural analgesia Epidural analgesia is widely considered as the most effective method of providing pain relief in labor. However, epidural labor analgesia is not a generic procedure and many technical modifi-cations have been invented over time. Continuous search for a balanced labor analgesia, which provides relief of pain of con-tractions while preserving motor function, has led to the devel-opment of the ambulatory labor analgesia. The combined spinal-epidural analgesia (CSEA) performed with subarachnoid opio-ids (with or without local anesthetics) causes minimal motor block and is particularly applicable to ambulatory labor analgesia. While there still remains some concern about dural puncture, the CSEA technique offers many advantages to the parturient, and has gained wide spread popularity in obstetric anesthesia worldwide. The advantages of CSEA The combined spinal-epidural labor analgesia technique (CSEA) has attained wide spread popularity in obstetric anesthesia. In many centers it has begun to replace or has replaced traditional epidural techniques. While there still remains some concern about dural puncture, the CSEA technique offers many advan-tages to the parturient. Several authors have reported a very low incidence of post dural puncture headache (PDPH) associated with CSEA, which may reflect the fact that the epidural needle, which must be correctly placed first, serves as the introducer for the spinal needle, which then results in a one-time very small gauge dural puncture by the spinal needle. The low incidence of PDPH may be particularly advantageous in patients with a his-tory of PDPH. It is known that symptoms of PDPH are more likely if there has been a preceding PDPH. Additionally, the appearance of the CSF in the hub of the spinal needle may indi