Maternal satisfaction

Failure rate of labor epidural: An observational study among different levels of trainee anesthesiologists in a university hospital of a developing country

Context:

Frequent use of labor epidural has also led to a corresponding increase in failed epidural analgesia (FEA).

Aims:

This study aims to identify the overall rate of FEA and evaluate its association with trainee anesthesiologist at different years/levels of anesthesia residency training.

Settings and Design:

Prospective observational study was conducted for one year in the labor room suit of a university hospital.

Methods and Material:

After university ethics committee approval, full-term parturient receiving labor epidurals and consenting for the study were included. FEA was identified by the presence of one or more set criteria of failure including; pain of numeric rating scale of >4 at 45 minutes after epidural placement, accidental dural puncture, need to re-site the epidural, abandoning the procedure, and maternal dissatisfaction with labor pain relief.

Statistical Analysis Used:

A binary logistic regression was used to assess the association between failure rate of labor epidural and grades of anesthesiologists. Odds ratio (OR) and 95% confidence interval (CI) were reported. P value ≤0.05 was considered significant.

Results:

Out of 500 women included, 76 (15.2%) had FEA, which was significantly high in 2^nd and 3^rd year residents compared to 5^th year and above level anesthesiologists [OR = 2.08; 95% CI: 1.17 to 3.67; P = 0.012]. Failure rate was also high but insignificant in 4^th year residents compared to senior level anesthesiologists [OR = 1.78; 95%CI: 0.89 to 3.53; P = 0.098].

Conclusions:

The incidence of FEA is comparable to those quoted in literature from developed countries and shows association to experience and year of training of anesthesia residents.

Validierung der deutschen Übersetzung des Childbirth Experience Questionnaire (CEQ2)

Zusammenfassung. Der Childbirth Experience Questionnaire (CEQ; Dencker, Taft, Bergqvist, Lilja & Berg, 2010 ) ist ein reliables und valides Instrument zur Erfassung der Geburtserfahrung. Ziel der Studie war, die revidierte Fassung des CEQ (CEQ2) ins Deutsche zu übersetzen und an einer Stichprobe aus 295 Wöchnerinnen zu validieren. In einer konfirmatorischen Faktorenanalyse konnte die 4-faktorielle Struktur der Originalversion nicht repliziert werden. Stattdessen wurden in einer explorativen Faktorenanalyse vier neue Faktoren gewonnen, die ähnlichen übergeordneten Facetten des Geburtserlebens zugeordnet wurden. Für die neu gewonnenen Skalen erwiesen sich die internen Konsistenzen als überwiegend zufriedenstellend bis gut. Der Zusammenhang zwischen dem CEQ2 und der konstruktnahen Salmon′s Item List ( Stadlmayr et al., 2001 ) spricht zudem für die konvergente Validität. Ebenso zeigten sich auch die erwarteten Zusammenhänge mit relevanten Außenkriterien. Die Ergebnisse dieser ersten Validierungsstudie sind somit vielversprechend, wobei weitere Studien in anderen Settings sowie im Längsschnitt wünschenswert sind.

Social ties between team members affect patient satisfaction: a data-driven approach to handling complex network analyses

Research from outside the medical field suggests that social ties between team-members influence knowledge sharing, improve coordination, and facilitate task completion. However, the relative importance of social ties among team-members for patient satisfaction remains unknown. In this study, we explored the association between social ties within emergency teams performing simulated caesarean sections (CS) and patient-actor satisfaction. Two hundred seventy-two participants were allocated to 33 teams performing two emergency CSs in a simulated setting. We collected data on social ties between team-members, measured as affective, personal and professional ties. Ties were rated on 5-point Likert scales. In addition, participants' clinical experience, demographic data and their knowledge about team members' roles were surveyed. Perceived patient satisfaction was measured on a 5-point Likert scale. Data was analysed with a linear regression model using elastic net regularization. In total, 109 predictor variables were analysed including 84 related to social ties and 25 related to clinical experience, demographics and knowledge test scores. Of the 84 variables reflecting social ties, 34 (41%) had significant association with patient satisfaction, p < 0.01. By contrast, a significant association with patient satisfaction was found for only one (4%) of the 25 variables reflecting clinical experience, demographics and knowledge of team roles. Affective ties and personal ties were found to be far more important predictors in the statistical model than professional ties and predictors relating to clinical experience. Social ties between emergency team members may be important predictors of patient satisfaction. The results from this study help to enhance our conceptual understanding of social ties and their implications for team-dynamics. Our study challenges existing views of team-performance by placing emphasis on achieving collective competence through affective and personal social ties, rather than focusing on traditional measures of expertise.

A specially designed medical screen for children suffering from burns: A randomized trial of a distraction-type therapy

•

The current study is the first to explore the medical screen as a treatment to control the pain and its related psychological symptoms on children suffering from burns;.

•

Compared with conventional dressing methods, the medical screen can be used as a novel way to decrease the negative experience of burn patients -ages 1–3 who require dressing changes.

;•

The medical screen is likely a feasible, acceptable and potentially efficacious treatment option for burns medical workers.

Objective

To evaluate the impact of the specially designed medical dressing screen during wound dressing changes of children who suffered burns to their hand or foot.

Design

Randomized controlled trial.

Setting

Burns and Plastic Reconstruction Unit.

Participants

Children (NN = 120) with burns on up to 1%-–5% of the total body surface area.

Interventions

The patients were selected and randomly allocated to 3 equal-sized groups as follows:control group (N control group (N = 40): the children received only regular dressing changes; computer group (NN = 40): a touch-screen computer was used for children during dressing changes; medical screen group (NN = 40): a medical screen combined with the touch-screen computer were used for children during dressing changes. All patients underwent a dressing change once per day for four days. Data were distributed four times: immediately after the initial dressing change (T1); and immediately after each times at next three consecutive days (T2-T4).Main Outcome M–T4).

Main outcome measures

The Pain level of the children evaluated by medical staffs was the primary outcome, the Pain level of the children evaluated by children's parents and the satisfaction of wound therapist were used as second outcomes.

Results

The mean scores related to pain level at the medical screen group displayed significantly better results than those of control group and those of the computer group. Additionally, the results of the pain evaluated by parents and satisfaction score of the wound therapist at the medical screen group was also better than other groups.

Conclusions

This study demonstrated “that the” application of the medical screen for burns can relieve the pain of 1-–3 years old children suffering from a burns during dressing changes. Additionally, the application of the medical screen also increased the satisfaction of the parents and the wound therapist performing the dressing changes.

Making the best of the worst: Care quality during emergency cesarean sections

Objective

This study aimed to identify factors influencing mothers’ and their partners’ perceptions of care quality, and to identify associated clinical factors.

Methods

Questionnaires were developed based on eight interviews with couples after emergency Cesarean Sections (ECS). The internal structure of the questionnaires was examined using Rasch analysis. Cronbach’s alpha was calculated to evaluate internal consistency of questionnaire items. Finally, associations between questionnaire scores and ECS characteristics were determined.

Results

Thematic analysis of interview data demonstrated that team-dynamics, professionalism, information, safety, leadership and mother-child continuity of care are important to patient- perceived quality of care. Questionnaire responses from 119 women and 95 partners were included in the validation and demonstrated satisfying fit to the Rasch model. The questionnaires had acceptable internal consistency with Cronbach’s alpha 0.8 and 0.7 for mothers and partners, respectively. Perceived quality of care was negatively associated with increasing urgency of the CS. Spearman rank correlation coefficients were -0.34 (p <0.001) and -0.32 (p = 0.004) for mothers and partners, respectively. Perceived quality of care differed significantly across CS indications for both mothers (p = 0.0006) and their partners (p<0.0001).

Conclusion

Team-dynamics, professionalism, information, safety, leadership and mother-child-continuity affect patients’ perceptions of care. Perceptions of care were highly influenced by CS indications and urgency.

A randomized double-blind comparison of the double-space technique versus the single-space technique in combined spinal-epidural anesthesia for cesarean section

BACKGROUND

Combined spinal-epidural anesthesia (CSEA) can be performed with either a single-space technique or a double-space technique for cesarean section. We performed a double-blind randomized controlled study to compare the effect of the double-space technique with that of the single-space technique on sensory block level and side effects.

METHODS

Parturients undergoing elective cesarean section under regional anesthesia were randomized to receive CSEA with either the double-space technique (double group, n = 20) or the single-space technique (single group, n = 20). In the double group, an epidural catheter was inserted at the L1-2 interspace, and dural puncture was performed at the L3-4 interspace. In the single group, the procedure was performed at the L3-4 interspace using the needle-through-needle technique.

RESULTS

There were no differences in time to readiness or intraoperative level of sensory block between the two groups. The postoperative sensory level was maintained at a higher level in the double group than in the single group (1 h postoperatively, P = 0.029; 6 h postoperatively, P = 0.016). There was no difference between the two groups in terms of side effects. The parturient satisfaction scores 48 h postoperatively were significantly different between groups (9.5 in the double group vs. 8 in the single group, P = 0.004).

CONCLUSIONS

We conclude that there were no differences in intraoperative variables between the double-space technique and the single-space technique for CSEA. However, double-space CSEA for cesarean section may be beneficial for controlling postoperative pain and improving parturient satisfaction.

TRIAL REGISTRATION

The study was retrospectively registered at https://cris.nih.go.kr under the trial ID KCT0002514. Date of registration: October 27, 2017.

Patient choice compared with no choice of intrathecal morphine dose for caesarean analgesia: a randomized clinical trial

Background

The study aimed to determine whether a patient's choice for their intrathecal morphine (ITM) dose reflects their opioid requirements and pain after caesarean delivery and if giving women a choice of ITM dose would reduce opioid use and improve pain scores compared with women who did not have a choice.

Methods

A total of 120 women undergoing caesarean delivery with spinal anaesthesia were enrolled in this randomized, double-blind study. Patients were randomly assigned to a choice of 100 or 200 μg ITM or no choice. The study involved deception, such that all participants were still randomly assigned 100 or 200 μg ITM regardless of choice. Rescue opioid use over the 48-h study period was the primary outcome measure. Pain at rest and movement and side effect (pruritus, nausea, and vomiting) data were collected 3, 6, 12, 24, 36 and 48 h postoperatively. Data are presented as median [95% confidence interval (CI)].

Results

Women who requested the larger ITM dose required more supplemental opioid [median 0.8 (95% CI 0.4-1.3)] mg morphine equivalents at each assessment interval; P  < 0.001] and reported more pain with movement [median 1.2 (95% CI 0.5-1.9)] verbal numerical rating score of 0-10 points] than patients who requested the smaller ITM dose ( P  = 0.0008), regardless of the ITM dose given. There was no difference in opioid use whether the patient was offered a perceived choice or not.

Conclusions

Women who were given a choice and chose the larger ITM dose correctly anticipated a greater postoperative opioid requirement and more pain compared with women who chose the smaller dose. Simply being offered a choice did not impact opioid use or pain scores after caesarean delivery.

Trial Registration

ClinicalTrials.gov (NCT01425762).

Investigating determinants for patient satisfaction in women receiving epidural analgesia for labour pain: a retrospective cohort study

BACKGROUND

Epidural analgesia is a popular choice for labour pain relief. Patient satisfaction is an important patient-centric outcome because it can significantly influence both mother and child. However, there is limited evidence in the correlations between clinical determinants and patient satisfaction. We aim to investigate clinical covariates that are associated with low patient satisfaction in parturients receiving labour neuraxial analgesia.

METHODS

After institutional ethics approval was obtained, we conducted a retrospective cohort study using electronic and corresponding hardcopy records from 10,170 parturients receiving neuraxial analgesia between the periods of January 2012 to December 2013 in KK Women's and Children's Hospital in Singapore. Demographic, obstetric and anesthetic data were collected. The patient satisfaction scores on the neuraxial labour analgesia was reported by the parturient at 24 to 48 h post-delivery during the post-epidural round conducted by the resident and pain nurse. Parturients were stratified into one of three categories based on their satisfaction scores. Ordinal logistic regression models were used to identify potential covariates of patient dissatisfaction.

RESULTS

10,146 parturients were included into the study, of which 3230 (31.8%) were 'not satisfied', 3646 (35.9%) were 'satisfied', and 3270 (32.2%) were 'very satisfied'. Multivariable ordinal logistic regression analysis showed that instrument-assisted vaginal delivery (p = 0.0007), higher post-epidural pain score (p = 0.0016), receiving epidural catheter resiting (p <  0.0001), receiving neuraxial analgesia at a more advanced cervical dilation (p = 0.0443), multiparity (p = 0.0039), and post-procedure complications headache (p = 0.0006), backache (p <  0.0001), urinary retention (p = 0.0002) and neural deficit (p = 0.0297) were associated with patient dissatisfaction. Chinese, compared with other ethnicities (p = 0.0104), were more likely to be dissatisfied.

CONCLUSIONS

Our study has identified several clinical determinants that were independent associated factors for low patient satisfaction. These covariates could be useful in developing a predictive model to detect at-risk parturients and undertake time-sensitive precautionary measures for better patient satisfaction.

Premedication with midazolam prior to cesarean delivery in preeclamptic parturients: A randomized controlled trial

Background:

Anxiety is a concern in obstetrics, especially in preeclamptic mothers. Sedation is not commonly used in parturients for fear of adverse neonatal effect. We investigated maternal and neonatal outcome of midazolam as an adjuvant to spinal anesthesia for elective cesarean delivery.

Methods:

A prospective randomized controlled trial, in which eighty preeclamptic parturients received either an intravenous dose of 0.035 mg/kg of midazolam or an equal volume of normal saline, 30 min before spinal anesthesia. Maternal anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS); postoperative maternal satisfaction was assessed using Maternal Satisfaction Scale for Cesarean Section (MSSCS). Newborns were assessed using Apgar score, Neonatal Neurologic and Adaptive Capacity Score (NACS), and umbilical artery blood gases.

Results:

Mothers premedicated with midazolam showed a lower level of preoperative anxiety and a higher degree of postoperative satisfaction than the control group. There were no between-group differences regarding the neonatal outcome.

Conclusion:

Preeclamptic parturients premedicated with midazolam (0.035 mg/kg) before spinal anesthesia have lower anxiety and higher postoperative satisfaction levels, with no adverse effects on the newborns.

[Labor pain worries future fathers more than the mothers]

OBJECTIVE

To evaluate the concerns of the future father about labor pain and another 9 items which could be important to the well-being of the mother during delivery. To investigate any possible differences in opinion between the future father and mother.

PATIENTS AND METHODS

An anonymous and voluntary questionnaire was offered to the father and the pregnant patient during the last month of pregnancy. They had to answer the questionnaire separately, scoring 10 items in a 0-10 point ordinal scale, according to their concerns and the importance for the good development of the delivery (0= not concerned about/insignificant to 10=concerned about/great importance). The items included were: 1) esthetic aftermath, 2) embarassment, 3) continous information, 4) walking during labor, 5) drinking during labor, 6) companionship, 7) labor pain, 8) keeping composure, 9) kindness, 10) room comfortability. Data on age, education, parity and nationality were recorded.

RESULTS

A total of 147 questionnaires were completed, 99 by mothers, and 48 by fathers. Pain was the most important concern for the future fathers scoring a mean (SD) of 8.15 (2), while continuous information 7.71 (2.5), kindness 7.9 (2.1), and companionship 8.21 (2.3) were more important than pain for mothers. A statistically significant difference was found between fathers and mothers regarding labor pain (P=.001), walking during labor (P=.003), and drinking during labor (P=.009).

CONCLUSIONS

The result of our study suggests that increasing the presence of the father during the delivery process, and taking care of the emotional aspects and the quality of the information given could be very important for the perception of satisfaction.

Maternal expectations and experiences of labor analgesia with nitrous oxide

BACKGROUND

Although there are various methods for painless delivery such as using entonox gas, most of the people are unfamiliar or concerned about it yet.

OBJECTIVES

The purpose of this study was to assess maternal expectations and experience of labor analgesia with nitrous oxide.

PATIENTS AND METHODS

In a clinical trial study, 98 pregnant women in active phase of delivery were studied randomly in two groups (intervention group = 49, control group = 49) after obtaining written consent. Efficacy, experience satisfaction, and also expectation of pregnant women about entonox gas in two groups were compared, likewise in intervention group before and after using entonox gas.

RESULTS

Most of the pregnant women receiving entonox gas had less labor pain (91.8%), and were satisfied with it (98%). The severity of pain in the most of entonox user was moderate level (46.94%), while for the control group it was severe (55.10%) which was significant, 40.82% of the mother in entonox group had a severe pain and 10.20% had a very severe pain, whereas in the control group (55.10%) of the mother had a severe pain and 26.53% of the had very severe pain (P = 0.004). efficacy of labor pain was in moderate level in most cases. 49% of pregnant women receiving gas described their experience as a good and excellent. 80.9% indicated that they will request the mentioned painless method in the future. The amount of suffering from gas side effects was mild in most patients of intervention group (63%). Expectations of the majority of pregnant women in intervention group (before receiving gas) and control group for painless delivery were weak (65.3%, 40.9%). The percentage of positive expectations had increased after receiving entonox gas (P = 0.01). There was a difference between the expectations of intervention group receiving entonox gas and control group (P = 0.001). Positive expectations were more in intervention group than the control group. Most differences of expectations in intervention group before and after receiving the gas were about higher efficacy (P = 0.001), more satisfaction (P = 0.001), fewer complications (P = 0.001), information about gas as painless delivery method (P = 0.02), and also previous experience of intolerable labor pain (P = 0.04).

CONCLUSIONS

This study has shown that using entonox gas caused less labor pain, favorable expectations and experiences and also more maternal satisfaction.

Phase 1 development of an index to measure the quality of neuraxial labour analgesia: exploring the perspectives of childbearing women

PURPOSE

Modern neuraxial labour analgesia reflects a shift in obstetrical anesthesia thinking - away from a simple focus on pain relief towards a focus on the overall quality of analgesia. However, advances in the methods used to measure outcomes have not kept pace with clinical progress, and these approaches must evolve to facilitate meaningful assessment of the advances provided towards the quality of analgesia. Developing a tool to measure the quality of neuraxial labour analgesia that research has achieved is best guided by women's perspectives. As the initial step in developing an instrument to quantitatively measure quality neuraxial labour analgesia, this qualitative descriptive study explored childbearing women's experiences and perspectives regarding this subject.

METHODS

Twenty-eight postpartum women, all delivering with neuraxial labour analgesia, were recruited from three hospitals in the greater Toronto area. Twenty-five women described a priori plans to use neuraxial labour analgesia, or they described themselves as having been open to the idea. Women's experiences and perspectives of neuraxial labour analgesia were explored in focus groups and in-depth interviews < or =72 hr following childbirth.

RESULTS

Four major themes emerged: 1)The Enormity of Labour Pain; 2) Fear and Anxiety Related to Epidural Pain Relief; 3) What Women Value about Epidural Pain Relief; and 4) The Relative Value of Achieving Epidural Pain Relief vs Avoidance of Epidural Drug Side Effects. Participants broadly described quality neuraxial labour analgesia as pain relief without side effects. Responses affirmed the importance of traditionally measured outcomes as attributes of quality neuraxial labour analgesia, e.g., pain relief and side effects, as well as the overall importance of pain control during labour and delivery. For research to capture the experience of quality neuraxial labour analgesia, findings suggest that this outcome involves physical, cognitive, and emotional dimensions that must be measured. The findings further suggest an important relationship between each of these dimensions and perceptions of control.

CONCLUSIONS

Women's perspectives must be incorporated into the assessment of quality neuraxial labour analgesia in order for research to measure this outcome in a meaningful manner. Study findings have important implications for scale development, interpretation of existing research, and antenatal education.

[Maternal satisfaction with the quality of epidural analgesia for pain relief in labor]

OBJECTIVE

To measure patient satisfaction with epidural analgesia in labor and to analyze the sociodemographic characteristics of the obstetric population treated in our hospital.

MATERIAL AND METHODS

We administered an anonymous questionnaire in July and December 2003 to all patients who received epidural analgesia during labor to obtain information on the intensity of pain before analgesia and the efficacy of this procedure.

RESULTS

A total of 1067 questionnaires were returned. Of the patients who responded to the questionnaire, 91.3% were satisfied with the process of epidural anesthesia, 93.8% stated that they would recommend the technique used in our hospital, and 94% responded that they would request the technique again in our hospital. Spanish nationals accounted for 74.8% of the surveyed patients; the remaining 25.2% were from other countries-mainly from Central and South America (18% of the total). Before administration of epidural analgesia, 23.3% of Spanish primiparas defined labor pain as severe compared to 40.7% of foreign primiparas (P<.001). Of the multiparas, 212% of Spanish patients described the pain as severe compared to 40.4% of foreign women (P<.001).

CONCLUSIONS

The overall level of satisfaction with the process of epidural analgesia is very high and was not influenced by sociodemographic factors. Labor pain is perceived as being more intense by non-Spanish women.

The use of remifentanil in obstetrics

Remifentanil has been proposed as the most suitable systemic opioid for use in obstetrics. Although the onset and offset are rapid, it cannot achieve maximum effect within the time period of a single uterine contraction. Nevertheless, it provides worthwhile analgesia mainly for the first stage of labor with consistently high maternal satisfaction. Maternal oxygen desaturation limits the dose and suitable monitoring during use is advised. As an adjunct to general anesthesia, it is successful in blunting responses to airway manipulation and providing hemodynamic stability in high-risk women. Neonatal effects when used in labor are minimal, but when combined with general anesthesia neonatal depression is unpredictable and more likely with an infusion dose greater than 0.1 microg/kg/min.

Memory of childbirth in the second year: the long-term effect of a negative birth experience and its modulation by the perceived intranatal relationship with caregivers

OBJECTIVE

To assess the memory of various subdimensions of the birth experience in the second year postpartum, and to identify women in the first weeks postpartum at risk of developing a long-term negative memory. DESIGN, METHOD, OUTCOME MEASURES: New mothers' birth experience (BE) was assessed 48-96 hours postpartum (T1) by means of the SIL-Ger and the BBCI (perception of intranatal relationships); early postnatal adjustment (week 3 pp: T1(bis)) was also assessed. Then, four subgroups of women were defined by means of a cluster-analysis, integrating the T1/T1(bis) variables. To evaluate the memory of the BE, the SIL-Ger was again applied in the second year after childbirth (T2). First, the ratings of the SIL-Ger dimensions of T1 were compared to those at T2 in the whole sample. Then, the four subgroups were compared with respect to their ratings of the birth experience at T2 (correlations, ANOVAs and t-tests).

RESULTS

In general, fulfillment, emotional adaptation, physical discomfort, and anxiety improve spontaneously over the first year postpartum, whereas in negative emotional experience, control, and time-going-slowly no shift over time is observed. However, women with a negative overall birth experience and a low level of perceived intranatal relationship at T1 run a high risk of retaining a negative memory in all of the seven subdimensions of the birth experience.

CONCLUSIONS

Women at risk of developing a negative long-term memory of the BE can be identified at the time of early postpartum, when the overall birth experience and the perceived intranatal relationship are taken into account.

Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard

BACKGROUND

This double-blind randomised controlled trial investigated the most appropriate dose of intrathecal diamorphine to use with high-dose diclofenac as part of a multimodal analgesic regimen for caesarean section under subarachnoid block. We also wished to establish whether it was possible to satisfy the Royal College of Anaesthetists postoperative pain audit recommendation for this patient group.

METHODS

One hundred and twenty patients presenting for elective caesarean section under subarachnoid block were recruited and divided into four groups. Treatment was standard except that patients were given either placebo or one of three different doses of intrathecal diamorphine (100 microg, 200 microg or 300 microg). All patients were given regular paracetamol, high-dose diclofenac and an hourly subcutaneous diamorphine regimen for breakthrough pain.

RESULTS

There was a dose-dependent improvement in analgesia with intrathecal diamorphine. Only 37.9% of patients given 300 microg of intrathecal diamorphine had a visual analogue pain score of 3/10 or less throughout the study. There was a dose-dependent increase in the incidence of itching with intrathecal diamorphine although the incidence of nausea and vomiting was similar between groups.

CONCLUSIONS

We found that for elective caesarean section under subarachnoid block with high dose diclofenac, analgesia was optimal with 300 microg of intrathecal diamorphine. Even the highest dose of intrathecal diamorphine did not achieve the Royal College of Anaesthetists postoperative audit target that 90% of patients should have a pain score of no more than 3/10. We believe that this target is too arduous.

Obstetric pain relief and its association with remembrance of labor pain at two months and one year after birth

The association between obstetric pain relief and long-term memory of pain is poorly researched in spite of the fact that a woman's memory of childbirth may affect her emotional wellbeing and future reproduction. The aim of this study was to investigate the association between epidural analgesia and other forms of pain relief, and memory of pain at two months and one year after birth. A national sample of 2482 Swedish speaking women with vaginal delivery or emergency cesarean section preceded by labor were followed from early pregnancy to one year after birth. Data were collected by three postal questionnaires: in early pregnancy, and two months and one year after the birth. Recollection of intense pain at two months and one year was associated with high rates of pain relief, and this was most obvious regarding epidural analgesia in first-time mothers. When comparing women with the same pain score at two months postpartum who had and who did not have an epidural, the first group seemed to have greater difficulty forgetting pain 10 months later. Possible explanations of these findings are discussed.

A randomised controlled trial to evaluate the effect of self-administered analgesia on women's experience of outpatient treatment at colposcopy

OBJECTIVE

To evaluate the effect of self-administered isoflurane and desflurane on women's experience of outpatient treatment at colposcopy.

DESIGN

A prospective double-blinded randomised controlled trial.

SETTING

A colposcopy clinic serving a regional population.

POPULATION

Three hundred and ninety-six women scheduled for treatment of cervical intraepithelial neoplasia (CIN) by large loop excision of the transformation zone (LLETZ).

METHODS

Self-administration of trial gas during a LLETZ procedure. One hundred and ninety-eight women were randomised to use isoflurane and desflurane and 198 to use placebo.

MAIN OUTCOME MEASURES

Patient satisfaction, pain and anxiety.

RESULTS

The mean pain score for cervical surgery was significantly lower for women using isoflurane and desflurane (22.4) than the placebo arm (29.6) (P= 0.003). There was no significant difference between arms in anxiety levels before or after treatment. More women using isoflurane and desflurane (78%) reported 'total helpfulness' of the trial gas than those using placebo (67%) (P= 0.012). A subgroup analysis of trial participants classified as anxious by Hospital Anxiety and Depression Scale (HADS) score at recruitment showed that using isoflurane and desflurane significantly increased total treatment acceptability, helpfulness of the gas and willingness to undergo a similar procedure at six-month follow up.

CONCLUSION

Satisfaction with outpatient treatment at colposcopy is generally high. The main effect of isoflurane and desflurane evaluated in this trial was to reduce pain. It appeared to be effective for women with clinically significant anxiety and could be offered as an alternative to general anaesthesia.

Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty †

BACKGROUND

Peripheral neural blockade appears to provide effective analgesia with potentially less morbidity than central neuraxial techniques. We compared the relative benefits of combined femoral (3-in-1) and sciatic nerve block with epidural blockade for postoperative knee arthroplasty analgesia.

METHODS

Sixty patients, ASA I-III, undergoing unilateral knee replacement were prospectively randomized to receive either a lumbar epidural infusion or combined single-shot femoral (3-in-1) and sciatic blocks (combined blocks). All patients received standard general anaesthesia. Visual analogue pain scores and rescue opioid requirements were recorded at four time points postoperatively. Patient satisfaction, morbidity, block insertion time, perioperative blood loss and rehabilitation indices were also assessed.

RESULTS

In both groups, pain on movement was well controlled at discharge from recovery and 6 h postoperatively but increased at 24 and 48 h. Median (95% CI) analogue scale scores were 0 (0-0), 15 (0-30), 55 (38-75) and 54 (30-67) mm for epidural block and 0.5 (0-22), 21.5 (10-28), 40 (20-50) and 34.5 (21-55) mm for combined block. VAS pain scores with the combined blocks were significantly lower at 24 h (P=0.004). Total morphine usage was low in both groups: median epidural group 17 mg (8-32) versus combined blocks 13 mg (7.8-27.5). Patient satisfaction was high in both groups with median (95% CI) scores of 100 (85-100), 83 (70-100) and 82 (57-90) mm for epidural and 90 (73-100), 100 (77-100) and 97 (80-100) mm for combined blocks (not significant). Perioperative blood loss and rehabilitation indices were also similar.

CONCLUSIONS

Combined femoral (3-in-1) and sciatic blocks offer a practical alternative to epidural analgesia for unilateral knee replacements.

A prospective observational study of the subjective experience of caesarean section under regional anaesthesia

The aim of our study was to determine the subjective sensation of caesarean section under regional anaesthesia. We performed a prospective, observational study of 205 patients undergoing caesarean section under regional anaesthesia in a UK district general hospital. Patients were asked open and closed questions relating to their physical and emotional experience during the operation. Seventy-three percent of patients chose the phrase "pulling and pushing" to describe the physical sensation of the operation, 75% described the experience as pleasant, and only 4% described it as unpleasant, the rest saying it was neither pleasant nor unpleasant. Ninety-six percent said they would by choice have any future caesarean section under regional anaesthesia, 3% were undecided and 1% said they would prefer a general anaesthetic next time. This study provides important precise information that may be given to patients before caesarean section under regional anaesthesia. We believe it will help minimise preoperative fears and increase patients' ability to make informed decisions about their care.

Audit of an early feeding program after Cesarean delivery: patient wellbeing is increased

PURPOSE

Early feeding is well tolerated after Cesarean delivery. However, patient wellbeing and nurses' attitudes toward implementation of early feeding have rarely been investigated.

METHODS

A quality-assurance program of 18 months duration was implemented because evaluation of traditional practice demonstrated significant deficiencies (phase I). Drinking was then allowed within one hour and feeding within six to eight hours after delivery. Gradual dietary expansion followed according to a detailed program. Three consecutive evaluations (phase II-IV) were performed: 1) to measure implementation by the ward nurses; 2) to record the type of food and the volume of water effectively received; 3) to evaluate patients' gastrointestinal tolerance and patients' levels of hunger and thirst and patients' overall satisfaction.

RESULTS

In phase I, 60% of patients received nothing by mouth and 28% received only water on the day of surgery (D0). Moderate or severe hunger and thirst were seen in a large portion of these patients (D0, hunger: 38%, thirst: 63%, D1, hunger: 40%, thirst: 28%). Introduction of the program significantly improved patient wellbeing as well as patient satisfaction. No side effects were encountered.

CONCLUSION

Hunger and thirst are frequently encountered after Cesarean delivery when patients are allowed to eat only after return of the first flatus. By using a quality-assurance program, it was possible to reduce the incidence and the severity of these distressing symptoms and to improve patients' satisfaction while no side effects were encountered. These beneficial effects were maintained in phase IV suggesting a high acceptance rate from the nursing staff.

Birth as a multidimensional experience: comparison of the English- and German-language versions of Salmon's Item List

Results concerning satisfaction with the birth experience in different trials are difficult to compare, owing to a lack of internationally used research scales. Salmon's Item List (SIL) is easy-to-handle and would therefore be very helpful for research as well as for obstetric clinic quality control. Two hundred and fifty-one patients were investigated using a German-language version of SIL (SIL-ger); the statistical evaluation was carried out by means of a principal components analysis. Principal components analysis revealed two major findings: (1) as stated by other authors the birth experience is multidimensional, each aspect influencing the others in a non-linear way; (2) in addition to Salmon's dimensions (i.e. postnatal 'fulfillment', intranatal 'physical discomfort' and intranatal 'emotional distress') another postnatal dimension labeled 'negative emotional experience' was detected. Not only are intranatal experiences multidimensional, but so too are evaluative feelings afterwards. In addition to fulfillment, as developed by Salmon, a dimension of negative emotional experience needs to be taken into account. This dimension does not correlate in a linear way with fulfillment. It is appropriate to use SIL in research. Before using it for purposes of clinical quality control, however, larger samples need to be evaluated in order to prove the stability of the factor structure.

Choice of opioid for initiation of combined spinal epidural analgesia in labour--fentanyl or diamorphine

Sixty-two women requesting regional analgesia in labour were allocated to receive a 1.5 ml intrathecal injection as part of a combined spinal-epidural (CSE) analgesic technique. This contained either bupivacaine 2.5 mg plus fentanyl 25 microg (group F) or bupivacaine 2.5 mg plus diamorphine 250 microg (group D). Times of analgesic onset and offset were recorded, motor and proprioceptive assessments made and side-effects noted. Analgesic onset was not significantly different between the groups (group F, 8.0 min; group D, 9.5 min; P = 0.3) but time to first top-up request was significantly longer in the diamorphine group (group F, 73 min; group D, 101 min; P = 0.003). Motor loss, assessed by the modified Bromage score, was statistically but not clinically greater in the fentanyl group (P = 0.01). Maternal hypotension, pruritus, proprioceptive loss, nausea and fetal bradycardia were rare and not severe, and their incidences did not differ between groups. No respiratory depression was observed after CSE. This use of diamorphine was not associated with increased side-effects compared with fentanyl/bupivacaine, and it has a longer duration of action.

Comparison of maternal satisfaction between epidural and spinal anesthesia for elective Cesarean section

PURPOSE

Epidural anesthesia was a commonly used technique for elective Cesarean section. Recently, because of the availability of non-cutting spinal needles, many institutions have changed from epidural to spinal anesthesia. The purpose of this study was to compare maternal satisfaction between epidural and spinal anesthesia for elective Cesarean section with a new satisfaction tool.

METHODS

We studied healthy parturients in a randomized, double-blinded pilot study in which patients were assigned to receive either epidural (n = 13) or spinal (n = 14) anesthesia for elective Cesarean section. Two and 24 hr postoperatively, patients completed a validated 22-point maternal satisfaction questionnaire and a 10-cm visual analog score (VAS) for satisfaction. Maternal satisfaction scores were compared between groups.

RESULTS

There was no difference in demographics, complications or technical failures between groups. Mean satisfaction scores on the questionnaire (0-154) at two and 24 hr were 130.23 +/- 11.36 and 129.54 +/- 16.70 for the epidural group and 116.92 +/- 18.47 and 115.92 +/- 15.71 for the spinal group (P = 0.04 and P = 0.03 respectively). No difference in VAS scores was noted. The presence of minor side effects including pruritus contributed to the lower satisfaction in the spinal group at 24 hr.

CONCLUSION

This pilot study demonstrated higher maternal satisfaction with epidural than with spinal anesthesia for elective Cesarean section. This may be related to the increased side effects caused by neuraxial morphine. The satisfaction questionnaire was able to elucidate differences not detected with a global VAS for satisfaction. Further study with a larger patient population is required to confirm these data.

The development of a maternal satisfaction scale for caesarean section

Satisfaction has become an important outcome measure. The purpose of this study was to develop a valid, reliable maternal satisfaction scale for women undergoing caesarean section. After Research Ethics Board approval, each patient gave verbal consent. To ensure face validity, patients were interviewed before and after caesarean section. Interviewing until no new items were generated ensured content validity. A draft scale using a 7 point Likert scale was given to 115 patients. Items endorsed by less than 15% of patients were deleted. Item-total correlations, principal component and factor analysis were performed and items in factors with less than three items or complex loadings excluded. Correlating the new scale to a Visual Analogue Scale (VAS) for satisfaction assessed construct validity. Reliability, as measured by internal consistency, was tested using Cronbach's alpha. Twenty-five women were interviewed for item generation. Patients were both nulliparous and multiparous and all received regional anaesthesia for elective or non-emergent caesarean section. Six items of the 33 on the draft scale were excluded because of lack of endorsement. Five items were excluded after principal component and factor analysis and two after item-total correlations. The correlation between the scale total and the VAS was 0.48. Cronbach's alpha was 0.82 for the total scale. Maternal sense of control was the item most related to satisfaction. This scale provides more detailed information than a simple VAS. In the population studied, this tool was found to be a valid and reliable method for assessing maternal satisfaction in women undergoing non-emergent caesarean section.

Towards effective obstetric anaesthetic audit in the UK

Obstetric audit is multidisciplinary, but maternal mortality data represent the only national obstetric anaesthetic audit currently available in the UK. Maternity and neonatal audit is progressing towards the collection of both numerator and denominator data in order to compare local, regional and national figures. Obstetric anaesthetists as a professional group play a significant role in maternity care and have in the past developed a minimum data set. Such a set now requires revision of items, agreement on definitions and integration with national projects. Since local and regional obstetric anaesthesia data collection systems are available, albeit in various manual or computerized forms, this is an achievable target. A standard maternity and neonatal data set which incorporates obstetric anaesthetic clinical items could offer a qualitative comparison of process variables and outcome, but should be under professional anaesthetic control. In addition, the process may enable professional standards to be defined and tested so that high quality obstetric anaesthetic care can be maintained.