Comparison of neuraxial anesthesia and analgesia strategies for obese parturients: a systematic review and network meta-analysis

Abstract Background Neuraxial block failure in obese parturients is a significant clinical challenge, leading to inadequate pain relief and increased maternal risk. Novel techniques such as the Combined Spinal-Epidural (CSE) and Dural Puncture Epidural (DPE) have emerged as promising alternatives to standard epidural, but their comparative efficacy and safety have not been systematically evaluated in a comprehensive network. This systematic review and network meta-analysis aimed to determine the optimal neuraxial technique for preventing analgesia and anesthesia failure in obese parturients, with specific attention to morbidly obese subgroups and procedural efficiency. Methods Following Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines, we systematically searched PubMed, Embase, the Cochrane Library, and Web of Science for relevant studies published up to October 2025. We included randomized controlled trials (RCTs) that evaluated different neuraxial techniques in adult obese parturients (Body Mass Index ≥ 30 kg/m²). The methodological quality was assessed using the Cochrane Risk of Bias 2 tool. A frequentist random-effects network meta-analysis was used to calculate pooled Odds Ratios (ORs) and their 95% Confidence Intervals (CIs). The hierarchy of interventions was determined by P-scores. Results Eleven RCTs comprising a total of 1,178 patients were included in the final analysis. For the primary outcome of preventing block failure, CSE ranked highest (P-score 0.88), followed by DPE (P-score 0.74). Compared with the standard epidural technique, both CSE (Odds Ratio [OR] 0.41; 95% CI 0.19–0.93) and DPE (OR 0.50; 95% CI 0.31–0.82) significantly reduced the risk of failure. In the subgroup analysis of morbidly obese parturients (BMI ≥ 40 kg/m²), DPE and CSE remained the top-ranked interventions. Regarding safety, CSE was associated with a higher risk of hypotension compared to standard epidural, while DPE showed a comparable safety profile. Procedure times were generally similar across techniques, though heterogeneity existed. Conclusion CSE and DPE appear to be the most effective neuraxial techniques for preventing block failure in obese parturients. While CSE ranks highest in efficacy, it carries an increased risk of hypotension. DPE offers a favorable balance of high efficacy and safety, particularly in morbidly obese populations. The choice of technique represents a clinical trade-off, where DPE may offer a more balanced efficacy and safety profile for labor analgesia. The optimal technique for cesarean delivery in this high-risk population remains uncertain due to a lack of direct comparative evidence, highlighting a critical area for future research. Trial registration The protocol for this systematic review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD420251244336.