Association of dural-puncture epidural with conversion of labor analgesia to cesarean delivery anesthesia: a propensity score-weighted retrospective cohort study

Abstract

Extension of labor epidural analgesia to cesarean delivery anesthesia may fail, requiring a repeat neuraxial procedure or general anesthesia. Trials in elective cesarean delivery suggest that dural-puncture epidural (DPE) can accelerate epidural extension, but evidence after established labor analgesia remains limited. This single-center retrospective cohort study included singleton parturients who underwent intrapartum cesarean delivery after labor analgesia between September 2023 and April 2026. Patients were classified according to labor analgesia technique: DPE or conventional epidural. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to balance baseline covariates. The primary outcome was conversion failure, defined as the requirement for a repeat neuraxial procedure or conversion to general anesthesia. Secondary outcomes included anesthesia onset time, intraoperative pain, block characteristics, hemodynamic events, and satisfaction scores. A total of 521 parturients were analyzed, including 133 in the DPE group and 388 in the conventional epidural group. After IPTW adjustment, covariates in the propensity score model were balanced. Conversion failure occurred in 3 patients (2.3%) in the DPE group and 22 patients (5.7%) in the conventional epidural group (IPTW-weighted OR, 0.36; 95% CI, 0.11–1.22; P  = 0.101). In a secondary analysis, anesthesia onset time was shorter in the DPE group (15.05 ± 1.47 min vs. 15.80 ± 1.55 min; IPTW-weighted β, -0.77 min; 95% CI, -1.07 to -0.47; P  < 0.001). Estimates for other perioperative outcomes were imprecise and their confidence intervals included the null. Sensitivity analyses for conversion failure produced similar point estimates, with all confidence intervals crossing unity. In this retrospective cohort of parturients undergoing intrapartum cesarean delivery after labor analgesia, DPE was not associated with a statistically significant difference in the primary outcome of conversion failure. A secondary analysis found an approximately 0.8-minute shorter onset of surgical anesthesia with DPE, although the clinical importance of this small difference remains uncertain. These findings provide real-world observational evidence on epidural conversion performance after established labor analgesia and can inform both clinical practice and the design of future prospective studies. Not applicable.