A 10-year update: national survey questionnaire of obstetric anesthesia units in Israel

Birthing consciousness and the flow experience during physiological childbirth

PROBLEM

It has been demonstrated that birth without medical intervention conveys significant physical and psychological benefits to the mother and her newborn baby. However, there is a need to include women's subjective experience of physiological birth to understand and promote it.

BACKGROUND

The theoretical concept of "birthing consciousness" hypothesizes that women during natural childbirth sometimes experience a specific altered state of consciousness, which is a positive peak experience that resembles "flow" in many aspects.

AIM

To investigate the underexplored connection between the physiological mode of childbirth and altered states of consciousness during childbirth.

METHODS

Israeli women with childbirth experience were recruited through social media (Facebook groups with a focus on childbirth and motherhood). Participants (n = 766) completed an online survey: the Flow State Scale (FSS) and a demographic questionnaire.

FINDINGS

Differences were found between modes of birth as to flow state, as women who experienced physiological childbirth (i.e., with no epidural anesthesia or instrumental interventions) had a higher flow state during birth.

DISCUSSION

This link empirically confirms the phenomenon of birthing consciousness. All nine dimensions of the mental state of flow apply to childbirth: challenge-skill balance, action-awareness merging, clear goals, unambiguous feedback, concentration on the task, sense of control, loss of self-consciousness, transformation of time, and autotelic experience.

CONCLUSION

Understanding a women's subjective experience during physiological birth can enhance clinical understanding of physiological birth thus promoting positive physiological birth experiences - which has crucial health benefits. We propose that more studies need to be done to promote experiencing flow during physiological birth.

A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor

INTRODUCTION

Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines.

METHODS

An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units.

RESULTS

Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices.

CONCLUSIONS

There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

The association between epidural analgesia during labor and mother-infant bonding

STUDY OBJECTIVE

This study was aimed to assess the association between the use of epidural analgesia during labor and mother-infant bonding.

DESIGN

A cross-sectional study.

SETTING

Maternity ward at Soroka University Medical Center during 2020.

PATIENTS

Women who delivered a singleton live-born infant vaginally in their immediate post-partum period.

INTERVENTIONS

Women completed questionnaires. 25 items post-partum bonding questionnaire (PBQ) to assess mother-infant bonding (A high score on the PBQ indicates impaired mother-infant bonding) and the Edinburgh postnatal depression scale (EPDS) questionnaire to assess risk for post-partum depression.

MEASUREMENTS

The study used PBQ questionnaire and four sub-scales to assess mother-infant bonding and the EPDS questionnaire to assess risk for post- partum depression. Generalized linear regression models (gamma) were constructed to examine the association between epidural analgesia and mother-infant bonding total score and impaired bonding sub- scale, while adjusting for confounders Additional information such as pregnancy complications and sociodemographic data was drawn from women's medical records.

MAIN RESULTS

A total of 234 women were included in the final analysis, of them 126 (53.8%) delivered with epidural analgesia. The total PBQ score was significantly lower among women who received epidural analgesia compared to women without epidural analgesia (7.6 vs. 10.2, p = 0.024), demonstrating a better mother -infant bonding. Using two multivariable linear regression models, controlling for confounders such as maternal age and educational status, epidural analgesia during labor was independently associated with a better mother -infant bonding total score and better impaired bonding sub-scale score (Beta coefficient-0.252, 95% CI -0.5; -0.006, p = 0.045 and Beta coefficient - 0.34, 95% CI -0.52; -0.08, p = 0.01 for mother-infant bonding total score and sub-scale score, respectively). No differences in post-partum depression risks were found between the groups (EDPS≥13, 5.7% vs. 13%, p = 0.058).

CONCLUSION

Our study demonstrated better mother -infant bonding among women delivering with epidural analgesia.

The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia

BACKGROUND

Pulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia.

METHODS

This survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers.

RESULTS

Four hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration.

CONCLUSIONS

More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

Update on Non-neuraxial Labor Analgesia

Purpose of Review

This review will present recent updates for the use of non-neuraxial analgesia for laboring women.

Recent Findings

Non-neuraxial labor analgesia by nitrous oxide and intravenous opioids are described, and safety concerns with regard to remifentanil administration have been a major focus of recent studies. Fentanyl and nitrous oxide offer some efficacy, albeit less than remifentanil, however with a greater safety margin.

Summary

Women may request or require alternatives to neuraxial labor analgesia, in some cases due to concurrent comorbidities. Remifentanil offers the most efficacious alternative analgesia option; however, safety concerns may preclude widespread use.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study

BACKGROUND

We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor.

METHODS

Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios.

RESULTS

There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group.

CONCLUSION

Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

Peripartum anesthetic management of women with SARS-CoV-2 infection in eight medical centers across three European countries: prospective cohort observation study

OBJECTIVE

Several reports of obstetric anesthesia management have been published since the onset of the COVID-19 pandemic. We aimed to collect high-quality broad and detailed data from different university medical centers in several European Society of Anesthesiologist countries.

METHODS

This prospective observational survey was performed in eight medical centers in Spain, Israel and Portugal from 1^st April to 31^st July 2020. Institutional review board approval was received at each participating center. Inclusion criteria: all women with a positive test for COVID-19. Retrieved data included maternal, delivery, anesthetic, postpartum details, and neonatal outcomes. Descriptive data are presented, and outcomes were compared for women with versus without respiratory signs and symptoms.

RESULTS

Women with respiratory symptoms (20/12.1%) had significantly higher mean (standard deviation) temperature (37.2 °C (0.8) versus 36.8 °C (0.6)), were older (34.1 (6.7) years versus 30.5 (6.6)) and had higher body mass index kg m^-2 - (29.5 (7.5) versus 28.2 (5.1)). Women with respiratory symptoms delivered at a significantly earlier gestational age (50% < 37 weeks) with a 65% cesarean delivery rate (versus 22.1% in the group without respiratory symptoms) and 5-fold increased rate of emergency cesarean delivery, 30% performed under general anesthesia. A higher rate of intrauterine fetal death (3%) was observed than expected from the literature (0.2-0.3%) in developed countries. There was no evidence of viral vertical transmission.

CONCLUSION

Well-functioning neuraxial analgesia should be available to manage laboring women with respiratory symptoms, as there is a higher frequency of emergency cesarean delivery. We report a higher rate of undiagnosed parturient and intrauterine fetal death.

Obstetric anesthesia services in Israel snapshot (OASIS) study: a 72 hour cross-sectional observational study of workforce supply and demand

Background

We planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care.

Methods

Observers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS.

Results

Data on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival.

Conclusions

Inadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00460-2.

Epidural augmentation for urgent Cesarean Section : a nationwide Israeli survey

Background : Epidural augmentation to convert analgesia to emergency cesarean delivery anesthesia is a common practice. In this survey we examined the common augmentation practices in different hospitals in Israel. We investigated whether practices vary by hospital size and if written protocols for conversion correlate with intra-hospital homogeneity. Methods : A questionnaire containing 39 questions was sent to obstetric anesthesia unit heads and to four additional anesthesiologists (attending and residents) in 24 obstetric anesthesia units nationwide. Answers were received online anonymously using web-based survey site. Results : 99/120 participants responded to the survey. 80% of large hospitals have a detailed epidural augmentation protocol. The existence of a written protocol does not affect intrahospital management variability. Overall, 18 different drug mixtures for epidural augmentation were reported, and the most used drug combination is lidocaine, fentanyl and bicarbonate. In large hospitals, 72% add epinephrine and 96% initiate augmentation before operating room arrival. Most respondents reported a final administered total volume of 15-20 ml. In most hospitals there is no maternal or fetal monitoring during patient transfer from delivery room to the operating room, lasting 3.68 minutes on average, with a relative low risk of significant complication as a result of augmentation. Conclusion : We report variations in common practices, depending on hospital size. We recognized low rate of intra-hospital concordance between centers with or without a written protocol of augmentation. Regarding points for improvement, we would recommend adhering to the accepted institutional protocol.

Outcome of Peripartum Anesthesia in Women with Valvular Disease

Objective

Maternal heart disease is one of the major causes for mortality among parturients. In our study, we surveyed 220 patients with different valvular disorders who gave birth in our medical center in the years 2012–2018. The aim of this study was to characterize various valvular pathologies and compare the results of different anesthetic approaches.

Methods

In this retrospective study, the computerized system and file archive were searched for maternal valvular pathologies according to the International Classification of Diseases, Ninth Revision (ICD-9). The women included in the study were defined as American Society of Anesthesiology (ASA)-II or more, who suffer from valvular heart disease.

Results

The most common pathology was mitral valve regurgitation (57.73% of all cardiac patients). Most women were defined as having mild insufficiency, and 82.68% had normal vaginal delivery. In 17.3% of patients who had cesarean section, the main type of anesthesia was neuraxial anesthesia (95.45%). The second most common pathology was tricuspid valve regurgitation (22.73%). Most patients (78%) had normal vaginal delivery, and epidural analgesia was used in 64.1%. A minority of cardiac patients in our study were patients with stenotic heart diseases, such as aortic stenosis, mitral stenosis and pulmonic stenosis (8.18%, 4.55%, and 1.36%, respectively). No complications were observed in the peripartum period.

Conclusion

The use of regional anesthesia is recommended for all valvular pathologies without exception, as we observed no cases in which the severity of cardiac condition had not allowed the use of various types of regional anesthesia, for surgery or vaginal delivery.

Cervical dilation at the time of epidural catheter insertion is not associated with the degree of prolongation of the first or second stages of labor, or the rate of instrumental vaginal delivery

INTRODUCTION

Epidural analgesia (EA) is an established option for efficient intrapartum analgesia. Meta-analyses have shown that EA differentially affects the first stage of labor but prolongs the second. The question of EA timing remains open. We aimed to investigate whether EA prolongs delivery in total and whether the EA administration timing vis-à-vis cervical dilation at catheter insertion is associated with a modulation of its effects on the duration of the first and second stages, as well as the rate of instrumental vaginal delivery in primiparas and multiparas.

MATERIAL AND METHODS

A retrospective electronic medical records-based study of 18 870 singleton term deliveries occurring in our institution from 2003 to 2015. Cervical dilation was determined within a half-hour of EA administration. We examined whether cervical dilation at EA administration correlated with the duration of the first and/or second stage, with the rate of prolonged second stage, and with the rate of interventional delivery. The study group was stratified to 10 subgroups defined by 1-cm intervals of cervical dilation at EA administration. Logistic regression modeling was applied to analyze the association between EA timing and rate of instrumental delivery while controlling for possible confounders.

RESULTS

In primiparas, receiving EA correlated with longer medians of active first stage (+51 minutes; P < .001) and second stage (+55 minutes; P < .001). In multiparas, median increases in active first stage (+43 minutes; P < .001) and second stage (+8 minutes; P < .001) were noted. The timing of EA, vis-à-vis cervical dilation (1-10 cm) was not associated with a substantial modulation of these effects. Logistic regression showed that cervical dilation at EA was not associated with a higher instrumental vaginal delivery rate.

CONCLUSIONS

Epidural analgesia prolonged the first and second stages of labor vs no epidural. Having EA was associated with a higher instrumental delivery rate but not with higher rates of maternal or neonatal complications, in primi- and multiparas. Importantly, the timing of EA, vis-à-vis cervical dilation, was not associated with substantial changes in the duration of labor stages or the instrumental delivery rate. Thus, EA may be offered early in the first stage of labor.