A survey of epidural analgesia practice in Western Australian obstetric units

Obstetric anaesthesia: an approach to improving the standards of services

There has been considerable discussion about obstetric anaesthesia standards and about the role of peer review in quality improvement. We carried out two postal surveys in 1990 and 1991 in major obstetric departments in Northern England, in order to assess practice and facilities against professionally derived standards, with the aim of stimulating and reviewing change. The reference standards were a local adaptation of those produced by the Obstetric Anaesthetists Association, and covered operating facilities, anaesthetic equipment, management and manpower, training, and protocols. In 1990, considerable variation in practice and facilities was identified with deficiencies in all hospitals. After feedback of the results of the first survey, a further survey conducted in 1991 identified improvement in 23/26 standards. Reference to standards was widely included in business plans and contracts for services. Following further feedback of the second survey and some revision of standards, a third survey was carried out using site visits. This revealed further improvement in 8/26 standards, but apparent deterioration in 11/26. The overall change from the first to the third survey was of apparent improvement in 15/26 standards and deterioration in 6/26. Surveys of practice against professionally derived standards and the targeted feed back of results can lead to improvements in practice and facilities.

Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia

BACKGROUND

Although epidural analgesia provides the most effective labour analgesia, it is associated with some adverse obstetric consequences, including an increased risk of instrumental delivery. Many centres discontinue epidural analgesia late in labour to improve a woman's ability to push and reduce the rate of instrumental delivery.

OBJECTIVES

To assess the impact of discontinuing epidural analgesia late in labour on: i) rates of instrumental deliveries and other delivery outcomes; and ii) analgesia and satisfaction with labour care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (1 September 2003).

SELECTION CRITERIA

Randomised controlled trials of epidurals discontinued late in labour compared with continuation of the same epidural protocol until birth, in women who receive an epidural for analgesia in the first stage of labour.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study eligibility and quality and extracted the data. We analysed categorical data using relative risk (RR), and continuous data using weighted mean difference.

MAIN RESULTS

We identified six studies, of which five were included (462 participants). Three of these were high quality studies whilst the other two were judged to be of lower quality because placebo was not used and the method of randomisation not described. All studies used different epidural analgesia protocols (type of drug, dosage or method of administration). Overall, the reduction in instrumental delivery rate was not statistically significant (23% versus 28%, RR 0.84, 95% confidence interval (CI) 0.61 to 1.15) nor was there any statistically significant difference in rates of other delivery outcomes. The only statistically significant result was an increase in inadequate pain relief when the epidural was stopped (22% versus 6%, RR 3.68, 95% CI 1.99 to 6.80).

REVIEWERS' CONCLUSIONS

There is insufficient evidence to support the hypothesis that discontinuing epidural analgesia late in labour reduces the rate of instrumental delivery. There is evidence that it increases the rate of inadequate pain relief in the second stage of labour. The practice of discontinuing epidurals is widespread and the size of the reduction in instrumental delivery rate could be clinically important; therefore, we recommend a larger study than those included in this review be undertaken to determine whether this effect is real or has occurred by chance, and to provide stronger evidence about the safety aspects.

Management of labour among women with epidural analgesia

To assess current practices in the labour management of low risk primiparous women with epidural analgesia we surveyed delivery suites in New South Wales (NSW) that annually provide at least 100 epidurals to 'standard primipara'. Epidural rates among 'standard primipara' at these hospitals ranged from 14 to 85% (median 46%). Continuous epidural infusion was the most commonly used technique (63%). For 'standard primipara' with an epidural 62% of units usually augmented labour with oxytocin, 89% discontinued the epidural in second stage and 67% had policies of delayed pushing. There is wide variation in epidural availability and in labour management, perhaps reflecting the limited evidence for effective interventions to reduce any unintended effects of epidural analgesia.

Surveys on the use of regional anaesthesia in obstetrics

Regional anaesthetic techniques in obstetrics have gained more and more importance during the last few years. Several surveys published recently show a remarkable increase in caesarean sections performed under regional anaesthesia, in many countries. Furthermore, epidural analgesia has proved to be one of the most effective methods of pain relief during vaginal delivery. Especially in patients at risk of an abdominal delivery, an epidural catheter already in place during labour can be used for consecutive caesarean section without delay and is used as a strong argument in favour of epidural anaesthesia. This article gives an overview of recent surveys of regional anaesthesia in obstetrics.

Labour ward midwifery staff epidural knowledge and practice

A survey was conducted amongst labour ward midwives at our hospital to evaluate education, knowledge and attitudes toward the management of epidural analgesia in labour. Sixty of 80 distributed forms were returned, giving a 75% response rate. Forty-two per cent of respondents had more than ten years' practice experience. Only 51% achieved a predetermined pass score for knowledge about epidural analgesia. Though most had received formal education about epidural analgesia, 35% felt postgraduate education was insufficient. A majority of midwives supported epidural analgesia on demand (78%), during established labour (74%), or for women at increased risk of caesarean section (82%). Midwives with lower knowledge levels were more likely to recommend epidural analgesia early in labour to multiparous women (P = 0.001) and to women with either a small or a large baby (P = 0.06). The majority of midwives (93%, 70% and 65%) would "almost always" top-up women with cardiac or medical diseases, multiple pregnancy or hypertensive disease, respectively. A clear requirement for ongoing education, with input from the anaesthetic department, was identified, irrespective of personal experience. Practice patterns are discussed and recommendations made with respect to improvement of epidural analgesia management and continuing education.

Attitudes and practices of New Zealand anaesthetists with regard to epidural and subarachnoid anaesthesia

A survey was conducted among 259 New Zealand specialist anaesthetists to assess attitudes and practices with regard to epidural or subarachnoid anaesthesia (ESA). Ninety-four per cent replied and virtually all of the respondents indicated that they performed ESA at some time. ESA was used by most anaesthetists for most patients undergoing major hip or knee surgery, abdomino-perineal resection, cystectomy, caesarean section or transurethral resection of the prostate, ESA was used is about half of patients undergoing abdominal aortic aneurysm repair, femoro-popliteal bypass or thoracotomy and there was marked variation between anaesthetists in the frequency of using ESA for these procedures. There was broad consensus about the importance of a number of factors that might influence the decision to employ ESA; in particular that systemic sepsis and prolonged bleeding time were important contraindications and that patient preference and chronic lung disease were important indications. However respondents were equally divided as to whether they felt that recent myocardial infarction or congestive heart failure constituted indications or contraindications to ESA.

A five-year prospective analysis of the efficacy, safety and morbidity of epidural anaesthesia performed by a general practitioner anaesthetist in an isolated rural hospital

During a five-year period, 324 epidurals were performed by a general practitioner anaesthetist in an isolated rural hospital. Of these 160 were for obstetric purposes, 72% in primagravida patients, the majority in early and established labour (median cervical dilatation of 3.0 cm). The median epidural insertion time was seven minutes: 80% were free of all complications, there were no dural taps and there was a failure rate of 2%. The median visual analogue pain score (VAPS) was 8.3 prior to insertion and at peak of epidural blockade it was reduced to 0.5. Ten per cent of patients had unblocked segments, half of these were corrected and 90% of patients had even blocks. Despite higher pain scores in the 6-10 cm cervical dilatation group, epidural analgesia was just as effective when compared to the 0.5 cm group. Seventy-seven percent of women interviewed the day after delivery were fully satisfied with the epidural: 19% said it was considerable help, 2% some help and 2% said no help at all. During epidural caesarean section (n = 72), 75% of patients were comfortable, 17% had some discomfort and 7% required general or spinal anaesthesia. The incidence of hypotension (systolic blood pressure less than 90 mmHg), was 24.6% with a median ephedrine dose of 10 mg; however, with a greater than 20% drop in systolic blood pressure, the dose of ephedrine required to maintain blood pressure increased in a log-dose fashion. For women who received epidurals in labour, the caesarean section rate was 25%, instrumental vaginal delivery 34% and spontaneous vaginal delivery 41%. There were no adverse neonatal outcomes.

Obstetric epidural services in rural South Australia

A survey of sixty South Australian country hospitals found that 35 units had more than 25 deliveries per year (total deliveries 4,247, which is 21.5% of total live births in South Australia during 1989). Twenty-five of these units had an epidural service (71%) and the overall epidural rate was 16.7%, 9.5% provided by general practitioner anaesthetists and 7.2% by specialists. General practitioner anaesthetists were involved more in the medium-sized units (50-200 deliveries per year), whereas specialists provided more services in the larger regional units and the small units as visitors. The epidural rate varied between 6-20% depending on the size of the unit. Most country regions in South Australia have reasonable access to an epidural service. The more geographically isolated areas are being serviced by general practitioner anaesthetists.