Maternal satisfaction with labour analgesia

The Association of Maternal Satisfaction with Childbirth by Length of Second Stage

OBJECTIVE

 The aim of this study was to quantify patient satisfaction by hour of second stage of labor and subsequent delivery mode.

STUDY DESIGN

 Pilot cross-sectional study of nulliparous women delivered at George Washington University Hospital between April 2018 and March 2019. Patients completed three survey questionnaires in the immediate postpartum period: Patient Perception Score (PPS), Consumer Satisfaction Questionnaire (CSQ), and Six Simple Questions (SSQ). Length of second stage was divided into 2 groups (≤3 hours and >3 hours). Data on maternal characteristics, maternal outcomes, and neonatal outcomes were collected in REDCap and statistical analysis was performed using SAS version 9.4.

RESULTS

 Survey response rate was 100% (n = 100). Seventy-one patients had a normal second stage and 29 patients had a prolonged second stage. Prolonged second stage was significantly associated with a lower proportion of NSVD (65.5 vs. 90.1%; p <0.01) and a higher proportion of epidural (82.8 vs. 60.6%; p = 0.03) in comparison to a normal second stage. Length of second stage had a statistically significant negative correlation with overall PPS scores (ρ =  - 0.25, p ≤0.01). Length of second stage was not correlated with the SSQ (ρ = 0.05, p = 0.25) or CSQ (ρ =  - 0.18, p = 0.11) surveys. CSQ scores were statistically significantly lower in women who underwent second stage cesarean delivery.

CONCLUSION

 Maternal satisfaction with childbirth and health care experience was high regardless of length of second stage. Only the PSS survey showed that shorter length of second stage was correlated with higher satisfaction. Cesarean delivery in the second stage was significantly associated with decreased maternal satisfaction. Future studies with larger cohorts are needed to confirm our findings.

KEY POINTS

· There is limited data on maternal satisfaction with childbirth.. · Mode of delivery may affect maternal satisfaction.. · Shared decision-making about delivery mode and timing is crucial..

Survey of nulliparous parturients' attitudes regarding timing of epidural analgesia initiation

STUDY OBJECTIVE

At our hospital, although >90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia.

DESIGN

Single-center, nonrandomized quantitative survey.

SETTING

Labor and delivery suite in a large tertiary academic medical center.

PATIENTS

Two hundred laboring nulliparous women admitted to the labor and delivery suite.

INTERVENTIONS

After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia.

MEASUREMENTS

A variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor.

MAIN RESULTS

Analysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p<0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR=1.8; 95%CI:1.1-3.1; p=0.04). The most common views affecting decision-making were that epidural analgesia should not be administered "too early" (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR=2.0 (95%CI:1.1-3.8; p=0.03) and OR=2.0 (95% CI: 1.1 to 3.7; p=0.03), respectively.

CONCLUSIONS

We found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions.

Prescribing intramuscular opioids for labour analgesia in consultant-led maternity units: a survey of UK practice

BACKGROUND

Intramuscular opioids are widely used for analgesia in labour. We conducted a postal survey to establish current prescribing and monitoring guidelines for intramuscular opioids in consultant-led obstetric units in the UK.

METHODS

A postal questionnaire was sent between December 2005 and January 2006 to the lead obstetric anaesthetist of all 234 consultant-led obstetric units in the UK. We enquired about dose regimens of intramuscular opioids in labour and monitoring of mother, fetus and neonate.

RESULTS

The response rate was 71%; 84.4% of responding units used pethidine and 34.1% diamorphine. Meptazinol and morphine were available in 13.8% and 13.2% of units respectively. Some units used more than one opioid. The choice of opioid was dictated mainly by tradition (65.3%) and familiarity (40.7%). Prophylactic antiemetics were co-administered in 73.7% of units, the most commonly used being prochlorperazine (30.5%). Vital signs were monitored in 91.6% of units: in total 10.2% measured haemoglobin oxygen saturations and 4.8% respiratory rate. Pain scores were recorded in 13.7% of units.

CONCLUSIONS

When compared with previous studies the use of intramuscular diamorphine is increasing in UK consultant-led obstetric units, although pethidine remains the widely used opioid. At present this change cannot be justified by a suitably powered, randomised study comparing intramuscular pethidine with diamorphine.

Diamorphine for pain relief in labour : a randomised controlled trial comparing intramuscular injection and patient-controlled analgesia

OBJECTIVES

To compare the efficacy of diamorphine administered by a patient-controlled pump (patient-controlled analgesia) with intramuscular administration for pain relief in labour.

DESIGN

Randomised controlled trial.

SETTING

The South Glasgow University Hospitals NHS Trust.

SAMPLE

Primigravidae and multigravidae in labour at term (37-42 weeks).

METHODS

Women were randomised in labour to the study (patient-controlled analgesia) or control group (intramuscular). Randomisation was achieved through a random permuted block design stratified by parity. Study group women were given a loading dose of 1.2 mg diamorphine intravenously and then attached to the pump. Control group women received intramuscular diamorphine as per hospital protocol. Participants were also given 3 mg of buccal Stemetil. Data were collected throughout labour and at six postnatal weeks.

MAIN OUTCOME MEASURES

Analgesia requirements during labour and women's satisfaction with the method of pain relief.

RESULTS

Women in the study group (patient-controlled analgesia) used significantly less diamorphine than women in the control group (intramuscular) but were significantly more likely to state that they were very dissatisfied with their use of diamorphine and were significantly more likely to opt out of the trial before the birth of the baby. The majority of women in both groups used other analgesia concurrent with diamorphine such as Entonox, aromatherapy or TENS.

CONCLUSIONS

Patient-controlled analgesia administration of diamorphine for the relief of pain in labour offers no significant advantages over intramuscular administration. The results also suggest that diamorphine is a poor analgesic for labour pain irrespective of the mode of administration.

Intrapartum pain management at the Royal Hospital for Women

AIMS

To explore use of, and women's satisfaction with, intrapartum pain management at Royal Hospital for Women (RHW), Sydney, Australia.

METHODS

From October 2002 to January 2003 women aged over 16 who had been in labour at RHW were given a questionnaire to complete in the first week post-partum regarding their intrapartum pain management. Supplementary information was obtained from patient records.

RESULTS

A total of 496 women participated (69% response rate), including 95 birth centre clients. The mean age was 32 years and 73% percent had a normal vaginal delivery. At least one form of pain management ('natural', nitrous oxide, pethidine, epidural, local infiltration of the perineum) was used by 463 (93%) women, with 74% using two or more methods. Labour pain was 'worse' or 'much worse' than expected for 55%. Seventy-two percent were 'very' or 'quite' satisfied with overall pain management. Epidural analgesia had the highest utility scores (89%'very useful') and likelihood of use in subsequent labours (67%), and pethidine the lowest. Factors affecting analgesic use included cervical dilation on admission, labour length, English-speaking background, delivery suite versus birth centre care, parity, and syntocinon use.

CONCLUSIONS

Women at RHW use a variety of pain management methods in labour and most use multiple methods. Labour was rated more painful than expected by a majority; however, most were satisfied with their pain management. Labour length and cervical dilation on admission were most predictive of pain management use.

Patient-controlled epidural technique improves analgesia for labor but increases cesarean delivery rate compared with the intermittent bolus technique

BACKGROUND

We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery.

METHODS

We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume.

RESULTS

Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups.

CONCLUSION

The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section.

Analgésie péridurale de travail en Martinique : évaluation de la qualité et de l’accessibilité à l’analgésie péridurale par les parturientes dans une clinique obstétricale de niveau 1

OBJECTIVES

The main aim of this study was to evaluate real-life experience and the quality of labor epidural analgesia (LEA) by the patients, from the anaesthesia consultation to leaving the clinic after childbirth.

STUDY DESIGN

Descriptive study.

PATIENTS AND METHODS

This study took place over a period of 8 weeks, at the level I obstetric clinic in Martinique. One hundred and thirty-four successive patients completed an anonymous questionnaire following childbirth.

RESULTS

During the study period (134 patients completed the questionnaire, corresponding to 100% return) 127 women had asked for LEA (94%), which was possible in 94%, with a patient satisfaction level of 94% and an average mark for quality at 18/20. The quality of information given at the anaesthesia consultation was judged excellent for 97%, and 91% were reassured by the consultation. The delay between the demand and the LEA procedure was less than 15 min in 63%, and in 39% the procedure was done during the night. The procedure was painless in 63%, and 97% of women were ready to begin the same procedure again.

CONCLUSION

This study seems to underline the fact that the needs and the acceptability of LEA are the same in Martinique as in mainland France. This study does not support the hypothesis of the cultural barrier to justify the low level of LEA in the Overseas Departments. An obvious result seems to be that good organization of anaesthesia and obstetric services results in a natural increase in LEA demand.

[Evaluation of the demand for access to peridural obstetrical anesthesia in maternity units]

OBJECTIVES

This prospective study was initiated by a multicentric work. Each participating hospital, was asked to give data about 20 patients. Because of the importance of these informations for our practice, we decided to continue the evaluation, using the same inquiry, until 200 patients were enrolled.

PATIENTS AND METHODS

An independent student (resident pharmacist), using a preprinted inquiry from interviewed two hundred consecutive in the, 48 hours after delivery in order to evaluate the following aspects: reasons to wish an epidural analgesia (EA) or not, modalities of achievement of EA. Statistical study: Chi-square and logistic regression.

RESULTS

Among 199 analyzable files, 137 women wished for an EA (68.5%) but in only 90 the procedure was performed. Reasons for non-achievement of EA were the following: labour too advanced (43/47), obstetrical contraindication (2/47), anaesthesiologist non available (2/47). Delay between arrival at hospital and EA performance was 5 h 30 during daytime and 4 h 40 during nighttime. Delay and rate of EA achievement were not different between day and night time. Logistic regression analysis found following criteria related to: Wish for an EA analgesia: anaesthesiology consultation (OR = 193, p < 0.001), nulliparity (OR = 4, p < 0.002) and satisfactory information about EA (OR 35, p = 0.051). Achievement of EA: nulliparity (OR 38, p < 0.002), length of labour (OR = 1.01/min, p < 0.001).

CONCLUSION

This study underlined the fact that one third of parturients do not wish for an epidural analgesia, mainly out of fear for neurological complications. When the obstetrician indicated an EA, our organisation allowed its achievement in 98% of cases. The latency between arrival and EA should be shortened.