Are practice variations among obstetric providers and anesthesiologists responsible for an increase in operative delivery in patients with epidural anesthesia?

Abstract

Background: The consensus of opinion on obstetric outcome in patients receiving epidural anesthesia is still controversial. Women receiving epidural anesthesia may be at increased risk for operative vaginal and/or abdominal delivery according to few investigators.Objective: To investigate and compare biases in the private practices of obstetric care providers— including obstetricians, midwives, and family practitioners—to the biases of practices of epidural techniques by anesthesiologists.Methods: The obstetric care providers and anesthesiologists were coded. The coding was alphabetical (ie, A, B, C, D, etc., for obstetric care providers) and numerical (ie, 1, 2, 3, 4, etc., for anesthesiologists). Each obstetric care provider and each anesthesiologist were combined as follows: A + 1, A + 2, A + 3, etc., B + 1, B + 2, B + 3, etc., C + 1, C + 2, C + 3, etc., D + 1, D + 2, D + 3, etc., E + 1, E + 2, E + 3, etc. Furthermore, each obstetric care provider was compared with various anesthesiologists. Likewise, each anesthesiologist was compared with various obstetric care providers. Only healthy patients following a normal, uncomplicated pregnancy were included. All patients were prehydrated with at least 1,000 mL of lactated Ringer’s solution before epidural placement. All epidurals were placed in the lumbar region using a “loss of resistance” technique. Either 18-gauge Hustead or 17-gauge Tuohy epidural needles were used.Results: When the epidural space was located, a test dose consisting of 3–5 mL of 1.5% lidocaine with epinephrine (1:200,000) was given through the needle. The test dose was followed by an 8–10-mL dose of 0.25% bupivicaine with or without 50–100 μg of fentanyl, which was also given through the needle. The epidural catheter was then placed, and placement was confirmed with a test dose of 1.5% lidocaine with epinephrine (1:200,000). Each patient then received a continuous epidural infusion consisting of 0.125% bupivicaine, 1 μg/mL of fentanyl and 1.25 μg/mL of epinephrine reconstituted in normal saline. Epidural infusions were continued until the patients delivered. Outcome of data is presented by retrospective analysis by patient charts for a period of 1 year.