A survey of epidural analgesia for labour in the United Kingdom

Satisfaction as a Mediator and Its Interaction With Adherence to Labor Analgesia Protocols: A Cross-Sectional Survey of Chinese Medical Personnel

Background

Although the Chinese promotion of labor analgesia began in 2018 to improve maternal health, high-quality medical care is difficult to provide to pregnant women when medical staff cannot implement standard labor analgesia procedures. This study aims to examine medical personnel's adherence to labor analgesia protocols and to explore the relationships among adherence, satisfaction, and other factors.

Methods

The data were from a national cross-sectional dataset (N = 13,944) of the 2020 Chinese Labor Analgesia Pilot Evaluation Project. Mediating and moderating effects analyses were used to examine the role of satisfaction as a mediator between support measures and adherence.

Results

There were differences in adherence between different types of medical personnel. Support measures and satisfaction had a positive association with adherence to labor analgesia protocols. Satisfaction had a significant mediating and moderating effect on the relationship between support measures and adherence to labor analgesia standards. Moderating effects of professional titles and attitudes were also observed.

Conclusion

Primary health care policies worth considering include comprehensive incentives for medical institutions to improve the use of labor analgesia by medical personnel. It is also worth considering providing more training opportunities for the staff in anesthesiology departments.

Predictors of incomplete maternal satisfaction with neuraxial labor analgesia: A nationwide study

PURPOSE

Neuraxial analgesia is effective and widely used during labour, but little is known about maternal satisfaction with its use. Our objectives were to assess the frequency of incomplete maternal satisfaction with neuraxial labour analgesia and its predictors.

METHODS

We extracted data from the 2016 National Perinatal Survey, a cross-sectional population-based study including all births during one week in all French maternity units. This analysis included all women who attempted vaginal delivery with neuraxial analgesia. Maternal satisfaction with analgesia was assessed by a 4-point Likert scale during a postpartum interview. Incomplete satisfaction grouped together women who were fairly, not sufficiently and not at all satisfied. We performed generalised estimating equations analyses adjusted for sociodemographic, obstetric, anaesthetic, and organisational characteristics to compare women with incomplete satisfaction to those completely satisfied.

RESULTS

Among the 8538 women included, 35.2% were incompletely satisfied with their neuraxial analgesia. The odds of incomplete satisfaction were higher among women who reported a prenatal preference not to use neuraxial analgesia but subsequently did (adjusted odds ratio 1.21; 95% confidence interval 1.05-1.39) and among those who did not use patient-controlled neuraxial analgesia (1.20; 1.07-1.34); the odds were lower among women who used combined spinal epidural analgesia (0.53; 0.28-0.99) than among those with epidural analgesia.

CONCLUSION

Incomplete maternal satisfaction with neuraxial analgesia is a frequent concern in France. Increasing the use of patient-controlled neuraxial analgesia and combined spinal-epidural analgesia, as well as consistency between prenatal preference and actual use of neuraxial analgesia may improve maternal satisfaction.

An evaluation of the different types of labor pain relief, preferred methods of pain relief, and effects of social media on awareness and knowledge among pregnant women. A cross-sectional study in the Kingdom of Saudi Arabia

Objectives:

To evaluate the attitudes of pregnant women towards different forms of labor pain relief, preferred methods of pain relief, and the effects of social media on their awareness and knowledge.

Methods:

This was a cross-sectional study conducted between April and August 2017 in the Maternity and Children’s Hospital, Najran, Saudi Arabia. A total of 416 pregnant women were interviewed and analyzed using IBM Statistical Package for Social Sciences version 20 (IBM Corp, Armonk, NY, USA).

Results:

A total of 62.7% were aware of labor pain. However, 58.7% of the total sample group was unaware of labor pain relief, and 79.8% of the total sample group was unaware of the different forms of labor pain relief available. Educational level was significantly associated with awareness and knowledge of labor pain relief (p=0.001). The majority of pregnant women obtained information from friends (57.5%); and only 16.1% of women received information from their health care providers.

Conclusion:

Most of the pregnant women recruited into this study had insufficient awareness of labor pain and methods of pain relief. They acquired their information from their friends and families rather than from their health care providers.

A multicentre, randomised controlled trial of position during the late stages of labour in nulliparous women with an epidural: clinical effectiveness and an economic evaluation (BUMPES)

BACKGROUND

Epidural analgesia leads to increased risk of instrumental vaginal delivery (IVD). There is debate about whether or not posture in second-stage labour influences the incidence of spontaneous vaginal birth (SVB).

OBJECTIVES

In nulliparous women with epidural analgesia, does a policy of adopting an 'upright position' throughout second-stage labour increase the incidence of SVB compared with a policy of adopting a 'lying-down' position?

DESIGN

Two-arm randomised controlled trial.

SETTING

Maternity units in England and Wales.

PARTICIPANTS

Nulliparous women aged ≥ 16 years, at ≥ 37 weeks' gestation with singleton cephalic presentation and intended SVB, in second-stage labour with an epidural providing effective pain relief.

INTERVENTIONS

(1) Upright position to maintain the pelvis in as vertical a plane as possible; and (2) lying-down position to maintain the pelvis in as horizontal a plane as possible.

MAIN OUTCOME MEASURES

The primary outcome measure was incidence of SVB. Secondary outcomes included augmentation, interventions to maintain blood pressure, duration of labour, episiotomy, genital tract trauma, post-partum haemorrhage, maternal satisfaction, neonatal metabolic acidosis, 5-minute Apgar score of < 4, resuscitation at birth and admission to neonatal unit. At 1 year for (1) women: urinary or faecal incontinence, dyspareunia and health-related quality of life; (2) for infants: major morbidity. A cost-consequences analysis with a time horizon of 1 year after the birth from a NHS perspective.

RESULTS

Between October 2010 and January 2014, 3236 women were randomised from 41 centres in England and Wales. There was a statistically significant difference in the incidence of SVB between groups, with 35.2% of women achieving a SVB in the upright group, compared with 41.1% in the lying-down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). There was no evidence of differences in most of the secondary maternal or neonatal outcomes, or in long-term outcomes at the 12-month follow-up. No significant overall cost differences were observed between upright and lying-down positions for mothers or their babies.

LIMITATIONS

Measurement of adherence was challenging in this unmasked trial, and adherence could be influenced by midwives' beliefs about the allocated positions. If adherence was poor, this would have diluted the difference between the two groups.

CONCLUSIONS

There is clear evidence of the benefit of adopting a lying-down position in second-stage labour in nulliparous women with epidural analgesia, with no apparent disadvantages in either short- or long-term outcomes for mother or baby, and this is cost neutral for the NHS.

FUTURE WORK

Questions remain about whether or not other positions could increase the incidence of SVB further in this group of women. The results also raise questions about the role of maternal position in second-stage labour in women without an epidural.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN35706297.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in Health Technology Assessment, Vol 21, No. 65. See the NIHR Journals Library website for further project information.

Practice of Labor Analgesia among Anesthesiologists Across India: Cross-sectional Study

BACKGROUND

The practice of labor analgesia is an essential part of standard obstetric care. There are many guidelines and programs, which have been setup in labor pain management, in the developed country. In India, the practice of labor analgesia is not very popular. The role of labor analgesia providers lies in educating the parturients about the need of labor analgesia and also to develop comprehensive programs and guidelines in providing it.

AIM

The aim of our study was to assess knowledge and practice of labour analgesia among anaesthesiologists across India.

METHODS

Survey was carried out using SurveyMonkey, an online internet website. Questionnaires were sent by mail to 11,986 anesthesiologists. The questions were based on methods of labor analgesia practice, regional analgesia techniques, commonly used drugs, complications and myths surrounding labor analgesia.

STATISTICAL ANALYSIS

Responses were compiled and data was analysed. Results were expressed as percentages.

RESULTS

There were 1351 responses to the survey. Labor analgesia was practiced mainly by anesthesiologists across India (71.34%, n = 945). Regional analgesia techniques were the most common techniques followed in providing labor analgesia (69.61%, n = 940) and among regional analgesia techniques, epidural analgesia (43.52%, n = 588) was the most common method. Bupivacaine was considered the drug of choice (64.10% n = 866) and Fentanyl was the standard adjuvant used (83.34% n = 1126). Majority of the respondents did not believe in myths surrounding labor analgesia.

CONCLUSION

Epidural analgesia is the most common technique practiced, bupivacaine the commonly used local anaesthetic, fentanyl common adjuvant used in practice of labour analgesia by anaesthesiologists across India.

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.

Long-term effects of epidural analgesia in labor: a randomized controlled trial comparing high dose with two mobile techniques

BACKGROUND

Epidural analgesia provides the most effective pain relief in labor, but it is not known if it causes adverse long-term effects. The objective of this study was to assess the long-term effects of two mobile epidural techniques relative to high-dose epidural analgesia in a randomized controlled trial.

METHODS

A total of 1,054 nulliparous women were randomized to traditional high-dose epidural, combined spinal epidural, or low-dose infusion. Women in all groups were followed-up at 12 months postpartum by postal questionnaire to assess long-term symptoms. The primary long-term outcome was backache occurring within 3 months of the birth persisting for longer than 6 weeks. Secondary outcomes were frequent headaches and fecal and urinary stress incontinence.

RESULTS

No significant differences were found in long-term backache after combined spinal epidural or low-dose infusion relative to high-dose epidural. Significantly less headache occurred in combined spinal epidural analgesia than high-dose epidural (OR: 0.57, 95% CI: 0.36-0.92), but no difference was found for low-dose infusion. Significantly less fecal incontinence (OR: 0.51, 95% CI: 0.30-0.87) and stress incontinence (OR: 0.65, 95% CI: 0.42-1.00) occurred with low-dose infusion.

CONCLUSION

Trial evidence showed no long-term disadvantages and possible benefits of low-dose mobile relative to high-dose epidural analgesia.

Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection

In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.

Use of local anaesthetics and adjuncts for spinal and epidural anaesthesia and analgesia at German and Austrian University Hospitals: an online survey to assess current standard practice

Background

The present anonymous multicenter online survey was conducted to evaluate the application of regional anaesthesia techniques as well as the used local anaesthetics and adjuncts at German and Austrian university hospitals.

Methods

39 university hospitals were requested to fill in an online questionnaire, to determine the kind of regional anaesthesia and preferred drugs in urology, obstetrics and gynaecology.

Results

33 hospitals responded. No regional anaesthesia is conducted in 47% of the minor gynaecological and 44% of the urological operations; plain bupivacaine 0.5% is used in 38% and 47% respectively. In transurethral resections of the prostate and bladder no regional anaesthesia is used in 3% of the responding hospitals, whereas plain bupivacaine 0.5% is used in more than 90%. Regional anaesthesia is only used in selected major gynaecological and urological operations. On the contrary to the smaller operations, the survey revealed a large variety of used drugs and mixtures. Almost 80% prefer plain bupivacaine or ropivacaine 0.5% in spinal anaesthesia in caesarean section. Similarly to the use of drugs in major urological and gynaecological operations a wide range of drugs and adjuncts is used in epidural anaesthesia in caesarean section and spontaneous delivery.

Conclusions

Our results indicate a certain agreement in short operations in spinal anaesthesia. By contrast, a large variety concerning the anaesthesiological approach in larger operations as well as in epidural analgesia in obstetrics could be revealed, the causes of which are assumed to be primarily rooted in particular departmental structures.

Epidural analgesia practices for labour: results of a 2005 national survey in Ireland

BACKGROUND AND OBJECTIVE

The last 25 years have seen changes in the management of epidural analgesia for labour, including the advent of low-dose epidural analgesia, the development of new local anaesthetic agents, various regimes for maintaining epidural analgesia and the practice of combined spinal-epidural analgesia. We conducted a survey of Irish obstetric anaesthetists to obtain information regarding the conduct and management of obstetric epidural analgesia in Ireland in 2005. The specific objective of this survey was to discover whether new developments in obstetric anaesthesia have been incorporated into clinical practice.

METHODS

A postal survey was sent to all anaesthetists with a clinical commitment for obstetric anaesthesia in the sites approved for training by the College of Anaesthetists, Ireland.

RESULTS

Fifty-three per cent of anaesthetists surveyed responded. The majority of anaesthetists (98%) use low-dose epidural analgesia for the maintenance of analgesia. Only 11% use it for test-dosing and 32% for the induction of analgesia. The combined spinal-epidural analgesia method is used by 49%, but two-thirds of those who use it perform fewer than five per month. Patient-controlled epidural analgesia was in use at only one site.

CONCLUSION

It appears that Irish obstetric anaesthetists have adopted the low-dose epidural analgesia trend for the maintenance of labour analgesia. This practice is not as widespread, however, for test dosing, the induction of analgesia dose or in the administration of intermittent epidural boluses to maintain analgesia when higher concentrations are used. Since its introduction in 2000, levobupivacaine has become the most popular local anaesthetic agent.

Anaesthesia and analgesia: contribution to surgery, present and future

Anaesthetists provide comprehensive perioperative medical care to patients undergoing surgical and diagnostic procedures, including postoperative intensive care when needed. They are involved in the management of perioperative acute pain as well as chronic pain. This manuscript considers some of the recent advances in modern anaesthesia and their contribution to surgery, from the basic mechanisms of action, to the delivery systems for general and regional anaesthesia, to the use of new drugs and new methods of monitoring. It assesses the resulting progress in acute and chronic pain services and looks at patient safety and risk management. It speculates on directions that may shape its future contributions to the management of the patient undergoing surgery.

Detection of Intravascular Epidural Catheter Placement: A Review

Intravascular placement of an epidural catheter is recognised as a potentially fatal complication of epidural anaesthesia and analgesia. Up to 10% of epidural catheters may be inserted into an epidural vessel, the majority of which will be recognised; however, a proportion (1% of all epidural catheters inserted) may not be identified as lying intravascularly. Opinions differ on the optimal method for identifying intravascular catheters and no perfect method exists. Some debate the need for a test of correct location, as a lack of specificity may mean that a proportion of correctly located catheters are withdrawn and resited. This review outlines the incidence and risk factors associated with intravascular placement and aims to evaluate the detection methods that have been described, in an attempt to answer the question: “What is the optimal way of detecting intravascular placement of an epidural catheter?”

Flexible therapeutic landscapes of labour and the place of pain relief

Flexibility in the design and enactment of spaces of healthcare is important in how providers respond to variations in patient expectations and experience. Health geographers have contributed to a wide body of literature concerning the therapeutic qualities of landscapes and the material, social and symbolic orderings of place and their uniqueness for individuals. In this paper, we draw upon these findings and a 'culture of place' approach to consider the complexities of maternity care and issues of pain relief. Given that pain is widely held to be a subjective experience and one that, in an era of patient decision making, increasingly demands discretionary approaches to its relief, we consider how medical professionals help to construct flexibility in healthcare and how this affects therapeutic landscapes. Drawing on analysis of four focus groups involving parent educators, midwives, health visitors, anaesthetists and obstetricians in the NE of England, we explore the material and discursive construction of flexible therapeutic landscapes and pain relief. Our findings suggest that flexibility is constrained and fashioned in association with health care professional's sense of place as already constituted. We propose that providing maternity care professionals with an explicit awareness of how places are relationally constructed, may help in expanding the therapeutic qualities of particular settings, and support a (more) flexible approach.

Demande d'analgésie périmédullaire par les patientes et les équipes obstétricales dans quatre régions françaises. Partie II : réalisation des analgésies périmédullaires

OBJECTIVE

Epidural analgesia (EA) is widely used in France to treat the labour pain. The aim of this study was to evaluate and analyse the rate of EA and the ratio between EA required by parturients and total EA realised (performance ratio).

STUDY DESIGN

An epidemiological survey was sent in all maternity units of 4 French areas. Patients and methods. - 48 of the 84 maternity units were participating to the study. In each centre, 25 patients fulfilled the questionnaire and the medical team fulfilled a questionnaire about the organisation of the ward. Rate of EA and performance ratio were calculated. Student t test, chi2 test and logistic regression model were used as requested; p<0.05 was considered as significant.

RESULTS

The mean rate of epidural analgesia (EA) rate, in the French areas studied, was 61.6%. It was significantly higher in university (79+/-13.7%) and private hospital (73.1+/-20.4%) than in general hospitals (54.6+/-19.6%, p<0.01), and also in those where anaesthesiologists are dedicated to the maternity unit (71.3+/-17.8 vs 54.6+/-22.1%, p<0.01) and in hospitals where anaesthesiologists were on duty in the hospital versus on call at home (69.8+/-21.4 vs 56.1+/-19%, p<0.02). Median duration of EA was 180 minutes, and 21.3% of them lasted more than five hours. Most of EA was performed between 8 AM and 6 PM. Patients' request was the major reason of EA insertion (OR=11.81), then the midwife request (OR=9.01). Other significant factors were the type of the hospital, the anaesthesiologist on duty and parity of women. The ratio between the number of EA requested by parturients and the total number of EA performed was significantly better in university hospitals (100.3+/-13%) and private hospitals (92.2+/-15.7%) than in general hospitals (79.4+/-17.3%, p<0.02). For the patients who had requested EA and did not have EA, the main reason was that labour was too fast (122/167) and then that there was a fail in anaesthesiological organization (59/167). The contraindications were rare (14/167).

CONCLUSION

To correctly answer to the request of EA, it seems necessary that one or more anaesthesiologists were dedicated to the maternity units, and that they were on duty into the hospital. So it seems important to have large maternities with adequate number of anaesthesiologists.

Obstetric epidural test doses: a survey of UK practice

BACKGROUND

With the advent of low-dose epidural analgesia in labour, the content of the test dose has once again become the subject of debate.

METHOD

A postal survey of 500 members of the Obstetric Anaesthetists' Association was conducted in 1999-2000, assessing the use of test doses during epidurals in labour and for caesarean section.

RESULTS

There was a 67% response rate. Test doses are used in labour, at elective caesarean section and before epidural top-up for emergency caesarean section, by 90%, 93% and 37%, respectively. There was large variation in both drugs and doses. During labour, doses of bupivacaine range from 3 to 20 mg and of lidocaine 15 to 90 mg. There has been a three-fold increase in the use of low-dose local anaesthetic test doses since a previous national survey in 1997. The size of local anaesthetic test doses used at caesarean section is also variable. Epinephrine is used in 5% of labour, 14% of elective and 34% of emergency caesarean sections. Signs and symptoms that are commonly sought after test doses include somatic motor block, blood pressure change, sensory effect and symptoms from systemic local anaesthetic. The effect of the test dose is usually assessed after 5 min.

CONCLUSION

There is no consensus about the nature of the ideal test dose in obstetric anaesthesia. There is a trend to use less concentrated test doses during labour. Doses that risk a high block if given spinally are still used. Epinephrine, aspiration testing and cardiovascular monitoring are uncommon.

Umfrage zur aktuellen Situation der Regionalan�sthesie im deutschsprachigen Raum

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The last part of the trilogy contains the presentation and evaluation of the data about the methods in obstetric anaesthesia. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia, 384 hospitals (51.2%) responded of which 278 had an obstetric unit. Caesarean section rate was 22.5+/-8.2% and for elective caesarean section spinal anaesthesia was mostly used. General anaesthesia was never used in 58.3% of Swiss, 10.2% of German, and 21.1% of Austrian hospitals. For non-elective caesarean section 42.1% of the hospitals often used a spinal anaesthesia, and 44.8% sometimes, in Switzerland these were 92.9% and 7.1%, respectively. Pain relief for labour was usually achieved with epidural anaesthesia or drugs. The trend from general to regional anaesthesia for caesarean section is continued, as is the trend from local infiltrative techniques to epidural anaesthesia for vaginal delivery. Switzerland was in the forefront for these developments.

Obstetric epidurals and chronic adhesive arachnoiditis

It has been suggested that obstetric epidurals lead to chronic adhesive arachnoiditis (CAA). CAA is a nebulous disease entity with much confusion over its symptomatology. This review outlines the pathological, clinical, and radiological features of the disease. The proposed diagnostic criteria for CAA are: back pain that increases on exertion, with or without leg pain; neurological abnormality on examination; and characteristic MRI findings. Using these criteria, there is evidence to show that epidural or subarachnoid placement of some contrast media, preservatives and possibly vasoconstrictors, may lead to CAA. No evidence was found that the preservative-free, low concentration bupivacaine with opioid mixtures or plain bupivacaine currently used in labour lead to CAA.

The combined spinal–epidural technique

In recent years, the use of regional anaesthesia techniques for surgery, obstetrics and post operative pain management have increased in popularity. The combined spinal-epidural (CSE) technique has attained widespread popularity for patients undergoing major surgery below the umbilicus who may require prolonged and effective postoperative analgesia. The CSE technique is now well established in several institutions. This chapter includes the clinical experience, advantages and potential problems, and discusses future perspectives of the CSE technique.

Comparison of continuous infusion versus midwife administered top-ups of epidural bupivacaine for labour analgesia: effect on second stage of labour and mode of delivery

Using a population-based study we retrospectively compared the effect of continuous versus intermittent top-up epidural analgesia on the outcome of labour at the University Hospital of Wales. We analysed the labour outcome of 410 primigravid deliveries over an 18-month period during a change in delivery suite protocol. Data were retrieved from the Cardiff Births Survey and the sample was analysed in two groups: group 1 (n = 201) received a continuous infusion of 0.1% bupivacaine plus fentanyl 2 microg/mL and group 2 (n = 209) received intermittent top-ups of the same solution. Outcome measures were the number of operative deliveries and the proportion of those deliveries that were due to prolongation of the second stage of labour. There were no significant differences in terms of group characteristics, women undergoing assisted vaginal delivery (group 1: 83 vs. group 2: 70, OR 0.8 CI 0.5-1.2), caesarean section (group 1: 59 vs. group 2: 61, OR 1.0 CI 0.6-1.5), and women with prolonged second stage (group 1: 50 vs. group 2: 47, OR 1.1 CI 0.6-1.8). The presumed reduction in motor blockade associated with intermittent top-up epidural regimes did not affect the outcome of labour.

Obstetric anaesthetists' workload

The current recommendation of one consultant session per 500 deliveries with full sessional cover for units over 3000 deliveries is arbitrary and is not based on workload. The Audit Commission has questioned the wide variability of anaesthetic staffing on labour wards. The aim of this study was to investigate whether there is a relationship between current workload and obstetric anaesthetic staffing in five maternity units. In 1998, a 2-week diary of workload in the participating obstetric units was assessed in terms of staffing and clinical and nonclinical activities. The busiest time was 08:00 to 12:30. The working patterns between consultants and trainees varied considerably. Time spent on nonclinical activity by consultants averaged 51%. Any calculation of consultant sessions will need to take into account nonclinical activities. Other factors requiring consideration are the number of high-risk cases, as well as the number and experience of trainees.

Trends in labour and birth interventions among low-risk women in New South Wales

OBJECTIVE

To examine recent trends in obstetric intervention rates among women at low-risk of poor pregnancy outcome.

DESIGN

Cross-sectional analytic study

SETTING AND POPULATION

A population of 336,189 women categorised as low-risk of a poor pregnancy outcome who gave birth to a live singleton in NSW from 1 January 1990 to 31 December 1997.

MAIN OUTCOME MEASURES

Obstetric intervention rates including oxytocin induction and augmentation of labour, epidural analgesia, instrumental births, caesarean section and episiotomy

METHODS

Trends over time were assessed by fitting trend-lines to numbers of births or by trends in proportions. Unconditional logistic regression was used to assess the impact of epidural analgesia on instrumental birth over time.

RESULTS

Rates of operative births did not rise despite increases in maternal age and use of epidural analgesia. Instrumental births declined over time from 26% to 22% among primiparas and 5% to 4% among multiparas. There was also a shift to vacuum extraction rather than forceps. Although instrumental birth was strongly associated with epidural analgesia, the strength of the association declined over the study period, for primiparas from an adjusted odds ratio of 7.2 to 5.2 and for multiparas from 13.2 to 10.3.

CONCLUSIONS

Increased use of epidural analgesia for labour has been a feature of the management of birth at term during the 1990s. The decline in the strength of association between epidural analgesia and instrumental birth may reflect improved epidural techniques and management of epidural labour, and recognition of the adverse maternal outcomes associated with forceps and vacuum births.

Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia

Neuraxial blockade is widely used for pain relief in labour. This form of analgesia may be associated with an increase in instrumental delivery rates due to dystocia. 'Traditional' epidurals cause motor blockade and hence immobility. Using a low dose anaesthetic-opioid combination with either epidural or combined spinal-epidural, selective sensory blockade can be achieved, allowing mobility as well as pain relief. In this study, we randomised women with combined spinal-epidural analgesia either to mobilise (upright group n = 25) or to remain recumbent (n = 41) in the second stage of labour. We found women in the upright group had significantly shorter total second stage, (132 vs 109 min,P = 0.019) particularly during the pushing phase (73 vs 51 min, P = 0.011). Although there were fewer instrumental deliveries in the upright group, this was not statistically significant. Women who were randomised to the upright group, did actually mobilise. We conclude that mobilisation in the second stage of labour is possible, and may reduce the length of the second stage.

Epidural and spinal analgesia and labour

Epidural and spinal analgesia for pain relief in labour are now commonplace. Adverse effects such as hypotension and toxicity to anaesthetic agents are well described and easily managed. The effects on obstetric outcome, however, have been unclear to both obstetricians and anaesthetists, but are important due to the large number of pregnancies involved. Efforts to define implications for mother and child have been frustrated by a relative lack of evidence derived from good quality, large randomized trials. Ethical and methodological difficulties together with an abundance of confounding factors have conspired to cause considerable difficulties for researchers in this area. Nevertheless, recent evidence has significantly advanced knowledge in the field and has implications for future practice.

Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial

BACKGROUND

Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique.

METHODS

Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally.

FINDINGS

The normal vaginal delivery rate was 35.1% in the traditional epidural group, 42.7% in the low-dose combined spinal group (odds ratio 1.38 [95% CI 1.01-1.89]; p=0.04); and 42.9% in the low-dose infusion group (1.39 [1.01-1.90]; p=0.04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group.

INTERPRETATION

The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified.

National obstetric anaesthetic practice in the UK 1997/1998

In the United Kingdom, the Royal College of Obstetricians and Gynaecologists requires maternity units recognised for training to complete annual statistical returns. Analysis of these data revealed that anaesthetists were directly involved in more than 251 000 procedures in the peripartum period in 1997/1998. There had been an increase in the number of women delivered by Caesarean section (18. 5% of all deliveries) compared with previous reports. The proportion of Caesarean sections performed under regional anaesthesia had increased for both elective and emergency Caesarean section deliveries (85.5% and 70.2%, respectively). For pain relief in labour, there had been neither an increase nor a decrease in the uptake of regional analgesia (23.6%). There were limited training opportunities for anaesthetists in general anaesthesia for Caesarean section and for obstetricians in vaginal breech delivery. The known admissions to intensive care units equated to over 100 women per month in the United Kingdom requiring intensive care as a result of childbirth.

Ropivacaine 0.2% versus bupivacaine 0.1% with fentanyl: a double blind comparison for analgesia during labour

We have performed a randomized, double-blind comparison of two epidural drug regimens for analgesia in labour. In the bupivacaine group (BUPIV), 101 healthy parturients received 0.1% bupivacaine with fentanyl 2 microg ml(-1). In the ropivacaine group (ROPIV), 102 women received 0.2% ropivacaine. Both groups received an initial loading dose of 15 ml, a continuous infusion of 8 ml h(-1), and top-ups of 10 ml. Breakthrough pain not responding to a routine top-up was treated with an 'escape' top-up of 10 ml 0.25% bupivacaine. The two groups were compared for complete analgesia at 30 min, routine and 'escape' top-up requirements, midwife assessment of analgesic efficacy, delivery mode, patient visual analogue scores (VAS) for first and second stage analgesia, overall satisfaction, and patient assessment of motor blockade. Patients receiving ropivacaine received fewer routine top-ups (median 1.0 vs. 2.0, P=0.001) and fewer escape top-ups (9.8% vs. 21.8%, P=0.02). The ropivacaine group was more likely to be pain free in the first stage (51% vs. 33.7%, P=0.01). There were no significant differences in patients' assessment of motor block or mode of delivery between the groups. Pain relief and satisfaction scores from midwives and patients were consistently better in the ropivacaine group, but did not reach statistical significance.

A survey of regional analgesia and anaesthesia for obstetrics in selected countries in the Far East

A survey was conducted in several countries in the Far East in an attempt to determine the practice of obstetric analgesia and anaesthesia there. Survey forms were sent to a total of 11 countries but in the end responses from only four countries were able to provide useful information. Responses from Singapore, Hong Kong, Taiwan and Malaysia covered between 44.9% (Singapore) and 24.6% (Malaysia) of their countries' total deliveries in 1997 and were thought to be adequate to give an impression of the obstetric analgesia and anaesthesia services in their respective countries, although this would not necessarily be completely accurate. From our survey, we found that the availability of regional analgesia for labour paralleled the economic status of the country and that a significant number of caesarean sections are conducted under regional anaesthesia, mainly spinals.

Patient-controlled epidural analgesia or continuous infusion: advantages and disadvantages of different modes of delivering epidural analgesia for labour

Patient-controlled epidural analgesia, intermittent top-up and continuous infusion are equally effective in providing epidural pain relief during labour. Patient-controlled epidural analgesia is associated with a significant reduction in hourly dose requirements when compared with continuous infusion, and by transferring the responsibility for epidural top-up, it offers the parturient the psychological benefit of being in control. For these reasons, patient-controlled epidural analgesia may become the method of choice for epidural pain relief during labour. However, the safety of the method needs to be documented more extensively, and the advantage of a reduction in hourly dose requirements needs to be visualized in terms of an improvement in labour or neonatal outcome. Moreover, the optimal dose, drug combination and settings still remain to be determined.

The combined spinal-epidural technique

Epidural and spinal blocks are well-accepted regional techniques, but they have several disadvantages. The CSE technique can reduce or eliminate the risks of these disadvantages. CSE block combines the rapidity, density, and reliability of the subarachnoid block with the flexibility of continuous epidural block to extend duration of analgesia. The CSE technique is used routinely at many institutions, particularly for major orthopedic surgery and in obstetrics. It has been used in tens of thousands of patients without any reports of major problems. Although at first sight the CSE technique appears to be more complicated than epidural or spinal block alone, intrathecal drug administration and siting of the epidural catheter are both enhanced by the combined, single-space, needle-through-needle method. Concerns about the epidural catheter entering the theca via the small puncture hole are now considered to be unfounded, but as with all epidural catheter techniques, vigilant monitoring of the patient during and after any injection is paramount. CSE is an effective way to reduce the total drug dosage required for anesthesia or analgesia. The intrathecal injection achieves rapid onset with minimal doses of local anesthetics and opioids, and the block can be prolonged with low-dose epidural maintenance administration. In addition, the sequential CSE method can be used to extend the dermatomal block with minimal additional drugs or even saline. Reduction in total drug dosage has made truly selective blockade possible. Many studies have confirmed that low-dose CSE with local anesthetic and opioid, or low-dose epidural block alone, will provide effective analgesia with minimal motor and proprioceptive block. Such neurologic selective blockade has made it possible for most patients to walk and bear down normally in labor or postoperatively. There remains concern about the risk of infection being increased when the CSE technique is used in place of epidural block alone. Despite a recent flurry of reports of meningitis with CSE procedures, there is no evidence the CSE block is more hazardous than epidural or subarachnoid block alone. Arguably, the single-space, needle-through-needle CSE technique will continue to improve with new needle designs and other advances to improve further the success rate and reduce complications, such as neurotrauma, PDPH, and infection. Over the past decade it has become clear that the CSE technique is a significant advance in regional blockade.