Higher Socioeconomic Status Improved Epidural Analgesia Awareness among Pregnant Women at a Tertiary-care Academic Hospital in Saudi Arabia

Controversies of Labor Epidural Analgesia

Intrapartum epidural analgesia and neonatal sepsis evaluations: a casual or causal association?

SP22.1 Remifentanil PCIA has no place in labor analgesia

Hyperthermia after epidural analgesia in obstetrics

“THE position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged by the care given her at the birth of her child.”1Although many developments have occurred in obstetric anesthesia since this quote's first publication in 1929, advances in the subspecialty have been complicated by medicolegal, financial, maternal, and fetal considerations. In addition to these concerns, recent economic pressures, variations in payment, patient expectations, and the technical aspects of providing these services have challenged obstetric anesthesia practice.Surveys are frequently used to define and detect changes in practice. Since data were collected more than 20 yr ago for the first obstetric anesthesia workforce survey,2there have been improvements in delivery of obstetric analgesia and anesthesia. Many factors affect the number and type of available anesthesia care providers and the services they provide. The most recent obstetric anesthesia survey reported that although the availability of both regional analgesia and anesthesia for labor and delivery had improved in the previous decade, improvement was still needed in staffing patterns and availability of personnel.3Organizations outside the practice of anesthesiology (e.g. American College of Obstetricians and Gynecologists [ACOG], Association of Women's Health Obstetric and Neonatal Nurses [AWHONN]) have published their own guidelines,4–6∥which impact the management of pain relief. Newer approaches to regional analgesia for labor (e.g. , patient-controlled epidural analgesia, combined spinal–epidural [CSE] analgesia) may aid practitioners in meeting the increased demands of obstetric anesthesia practice, but whether these newer approaches are used substantially is unknown.The 2001 obstetric anesthesia workforce survey was performed in conjunction with the Society for Obstetric Anesthesia and Perinatology to estimate and assess current trends in obstetric anesthesia practice as well as to identify potential areas needing improvement.In 1981 and 1992,2,3workforce surveys were conducted to assess trends in obstetric anesthesia practice. The survey was repeated in 2001, modifying the 1992 instrument to include newer questions to define contemporary practice patterns. The 2001 survey instrument differed from previous surveys by separating the questionnaire into three parts to direct questions to the three key labor and delivery personnel (Chief of Anesthesiology, Chief of Obstetrics, Labor and Delivery Manager) that were most likely to provide the most accurate information. Questionnaires were developed using TELEform® technology (Verity, Inc., Sunnyvale, CA), which simplified the process of data entry and quality control by converting information written on paper documents directly into an electronic database. Each draft survey was distributed to a four- or five-participant focus group to obtain feedback about the survey (e.g. , validity of questions, ease of use) before distribution.The primary focus of the survey was to obtain data on obstetric anesthesia practice from obstetrics and anesthesia providers as well as labor and delivery managers in groups of hospitals defined by the annual number of births and to compare these data across these hospital strata. Using the response rates known from previous surveys, the number of individuals contacted within each stratum was determined with the expectation that approximately 170 respondents would complete and return the survey.A stratified random sample frame of 1,300 hospitals was selected from the American Hospital Association's 2001 Guide to the Health Care Field . Hospitals were stratified based on geographic region (Northeast, Mid-Atlantic, South Atlantic, East North Central, East South Central, West North Central, West South Central, Mountain, and Pacific) and number of births for that year: stratum I (> 1,500 births), stratum II (500–1,499 births), and stratum III (100–500 births).During the presurvey time period, letters were sent to each hospital administrator in the sample (stratum I: n = 336; stratum II: n = 492; stratum III: n = 473) asking them to identify and provide contact information for the three key labor and delivery personnel at their institution: Chief of Anesthesiology, Chief of Obstetrics, and Labor and Delivery Manager. Administrators who did not respond received a second mailing. Following the methods outlined by Dillman,7a survey introductory letter was mailed to the three key personnel at each responding institution, followed by the survey instrument 1 week later. Each of the personnel was contacted periodically up to five times during the survey. Incentives or inducements for completion of the survey were not offered. The identity of all survey respondents remained confidential. Returned questionnaires were scanned using TELEform® software. Response tabulation and statistical analysis (by strata) were completed using SAS® software (SAS Institute, Inc., Cary, NC). Responses were analyzed by strata.A brief follow-up telephone survey of nonresponding hospitals was conducted to identify potential differences between responders and nonresponders. This brief survey focused on several key characteristics, including anesthesia procedures and personnel.Table 1contains data aggregated from the American Hospital Association's Annual Survey Database for the fiscal year 2001. Compared with their 1981 and 1992 data, the number of hospitals providing obstetric care decreased from 4,163 in 1981 and 3,545 in 1992 to 3,160 in 2001. A substantial decrease was observed in the number of stratum III hospitals (100–500 births) providing obstetric care compared with 1992 data (1,603–1,081), and there was a considerable increase in the number of the largest stratum I facilities (824–889).Table 2describes survey respondents, profiles of responding hospitals, and total number of births at responding hospitals for 2001. A total of 378 of the 1,300 initially sampled hospitals responded to the request for contact information on their key labor and delivery personnel (29% overall response). In the Anesthesiology survey, responses were received from 57% of the contacted anesthesiologists and certified registered nurse anesthetists. In the Obstetrics survey, responses were received from 45% of the contacted obstetricians, nurse midwives, and family practitioners. In the Labor and Delivery Manager survey, responses were received from 75% of the registered nurses and other labor and delivery management personnel.Stratum I hospitals (> 1,500 births) were more likely to be regional referral centers for high-risk obstetrics and to have anesthesiology residency and Clinical Anesthesiology year 4 programs. Nevertheless, 20% of hospitals with 500–1,500 deliveries per year consider themselves regional referral centers for high-risk obstetrics (i.e. , high-risk referral center).Compared with previous surveys, there was an overall increase in the percent of maternity cases using regional analgesia for labor across all strata (table 3). There were decreases in the percent of parturients receiving either parenteral analgesia or no analgesia at all compared with 1981 and 1992 survey data. In all hospitals, the use of epidural analgesia increased compared with previous surveys, with the sharpest increase occurring in stratum III hospitals. Spinal analgesia (either with or without local anesthetics) was used in less than 10% of cases. Similarly, CSE was administered in a small number of maternity cases across all strata. Patient-controlled epidural analgesia was used in nearly one-third of stratum I and II hospitals, but only 18% of stratum III hospitals reported its use.The use of spinal anesthesia for cesarean delivery increased across all strata, whereas the use of epidural anesthesia decreased across all strata compared with 1992 survey data (table 3). General anesthesia was used in 5% or less of elective cesarean deliveries. However, general anesthesia was used in 15% of urgent–emergent cases in stratum I hospitals (> 1,500 births), 30% in stratum II hospitals (500–1,499 births), and 25% in stratum III hospitals (100–500 births). CSE anesthesia was used in less than 10% of cesarean deliveries across all strata.Eighty percent of stratum I hospitals reported in-house availability of regional analgesia during labor (table 4). In the smallest hospitals, only 3% reported in-house coverage for regional analgesia for labor. Compared with 1992, stratum II hospitals reported a decrease in in-house coverage from 27% to 20% in 2001. Seventy-seven percent of stratum II hospitals reported on-call coverage for regional analgesia. Compared with 20% provider unavailability in 1992, only 3% of stratum III hospitals reported that regional analgesia for labor was not available. In all hospital categories, the provider availability of regional anesthesia for cesarean delivery was similar to that available during labor.In 2001, across all strata, an anesthesiologist was slightly more often directly involved in the care of patients receiving regional analgesia for labor compared with 1981 and 1992 survey data (table 5). Less than 6% of regional analgesics were administered by obstetricians for labor across all strata, compared with 30% in 1981. In stratum III hospitals, 34% of regional analgesics for labor were administered by independently practicing certified registered nurse anesthetists, and 14% of these anesthetics were administered by certified registered nurse anesthetists under the medical direction of nonanesthesiologist physicians.Respondents were asked for the percentage of various personnel performing newborn resuscitation in their hospitals. In stratum I and II hospitals, pediatricians performed an average of 42% and 48% of neonatal resuscitations during cesarean deliveries, respectively. This was offset by a large increase in the average percentage of resuscitations performed by nursing personnel (e.g. , nurse specialist trained in neonatal resuscitation, labor nurse).Respondents were asked whether their hospitals allowed vaginal birth after cesarean delivery (VBAC) (table 6). Vaginal birth after cesarean delivery was allowed in 98% of stratum I and 92% of stratum II hospitals but was allowed in only 68% of stratum III hospitals. Regardless, only 25–30% of all patients attempted it across all strata. Forty percent of the stratum III hospitals reported that since the introduction of the July 1999 American College of Obstetrics and Gynecology Practice Bulletin on Vaginal Birth after Cesarean Delivery,5VBAC was no longer performed. Both stratum I and II hospitals also indicated a decrease in VBAC attempts since introduction of the practice bulletin. Across all strata, at least 60% of attempted VBACs were successful.Respondents were asked about in-house anesthesia provider coverage during epidural infusions, and VBAC with and without regional analgesia (table 6). During epidural infusions, the majority of institutions in all three strata required anesthesia providers to be in-house. Across all strata, between 63% (stratum III) and 94% (stratum I) of institutions required providers to be in-house when parturients were attempting VBAC with regional analgesia. Eighty-six percent of stratum I hospitals required anesthesia providers to be in-house during attempted VBAC even if regional analgesia was not used. In the smallest hospitals, 33% of respondents stated that in-house anesthesia providers were required during VBAC attempts without regional analgesia.Almost all hospitals allowed ambulation during spinal opioid administration (table 6). Although approximately 50% of hospitals allowed ambulation during epidural or CSE analgesia, a much smaller percentage of patients actually ambulated.Less than 10% of institutions allowed nurses to reinstitute (i.e. , restart) epidural infusions across all strata (table 6). Twenty-eight percent of stratum II hospitals reported that nurses were allowed to adjust infusion rates, but only 7% of stratum I hospitals permitted nursing staff to adjust epidural infusion rates. Nurses were allowed to administer epidural boluses in 13% of stratum II hospitals, but only 3% of stratum I hospitals allowed nurses to administer boluses.The collection rates for professional fees for anesthesia for labor and vaginal delivery as well as cesarean delivery and for other surgical procedures steadily decreased from 1981 to 2001 (table 7).Stratum I hospitals had the largest percentage of health maintenance organization payers, and stratum II and III hospitals had the largest percentage of Medicaid payers. Stratum III hospitals had the highest percentage of Medicaid and private insurer categories but had the smallest percentage of health maintenance organization payers. Percentage payment of actual charges was similar among all groups of payers across all sizes of hospitals.Responses were obtained from 43 hospital administrators (16 stratum I, 13 stratum II, and 14 stratum III) of institutions that did not respond to the initial survey. Collectively, there were no significant differences (P = 0.05) in responses obtained from initial survey respondents compared with nonrespondents.More than 4 million deliveries occur in the United States each year. During the past 20 yr, there has been an increasing trend toward the use of regional analgesia/anesthesia for labor and delivery. Current survey results suggest that there has been improvement in availability as well as staffing of regional analgesia/anesthesia for labor and delivery. These results are particularly notable because the number of anesthesia providers has not kept pace with increasing demand for services.8–10In a report published in 2003, the number of American anesthesia residency graduates decreased by 75% from a high of 1,511 in 1994 to only 400 in 2000.11Although the number increased to 783 in 2003, several factors will continue to intensify and prolong the shortage of anesthesiologists. The number of nurse anesthetists is also expected to decrease because the average age of nurses is increasing and nonhospital jobs are multiplying.12While the availability of trained anesthesiologists has declined,10,13surgical volumes have increased and the scope of practice has extended to outpatient surgical centers, intensive care units, pain clinics, and preoperative testing centers. Increased demand for anesthesia services and availability of skilled anesthesia providers will influence the provision of obstetric anesthesia services.The 2001 survey estimated that in the United States, the total number of hospitals as well as the number of stratum III hospitals (100–500 births) providing obstetric care decreased by 12% and 33%, respectively, compared with the previous decade (table 1). In contrast, both the number of stratum I (> 1,500 deliveries) and II (500–1,499 births) hospitals providing obstetric care increased. The increased number of stratum I and decreased number of stratum III hospitals providing obstetric care is consistent with observations in the 1992 survey and represents redistribution of obstetric services to larger obstetric units or closure of smaller labor and delivery units. Both the American Society of Anesthesiologists and ACOG support regionalization of obstetric care as stated in the “Optimal Goals for Anesthesia Care in Obstetrics.” Although only 8% of deliveries occurred in hospitals with obstetric services between 100 and 500 deliveries per year, these hospitals constituted 36% of the hospitals providing obstetric care. Sixty-six percent of all deliveries now occur in hospitals with more than 1,500 deliveries per year, allowing for enough volume to support comprehensive anesthesia services. Many of these hospitals are also affiliated with medical schools and residency programs. Still, 20% of stratum II and 2% of stratum III hospitals are regional referral centers for high-risk obstetrics (table 2), likely reflecting that some moderate-size facilities are referral sites in sparsely populated areas. According to a joint statement issued by the American Society of Anesthesiologists and ACOG (“Optimal Goals for Anesthesia Care in Obstetrics”), 24-h in-house anesthesia, obstetric, and neonatal specialists are usually necessary in large maternity units and those functioning as high-risk centers.#Such subspecialty care centers should have a board-certified anesthesiologist with special training or experience in maternal–fetal anesthesia in charge of obstetric anesthesia and personnel privileged in administration of obstetric anesthesia should be available in the hospital 24 h a day.14Current survey results suggest that use of regional analgesia for labor increased across all strata, especially in stratum III hospitals (table 3). In addition, fewer parturients received parenteral or no analgesia compared with 1981 and 1992 data.2,3Many factors influence labor analgesia preferences: family and friends, past experience and expectations, cultural background, knowledge of the lay or scientific literature, and the media and medical professionals providing care.15Although few sources address how labor pain management preferences affect provision of pain management, Goldberg et al. 16reported a strong association between a birth plan incorporating epidural analgesics and the likelihood of a parturient receiving one. The study also reported that 40% of women who plan to avoid a labor epidural receive one. More recently, a systematic review of pain during childbirth revealed that behaviors and attitudes of the caregivers are more important for women's satisfaction than the magnitude of pain, pain relief, and intrapartum medical interventions.17Although the long-standing controversy about effects of epidural analgesia on the likelihood of cesarean delivery has been resolved,18some childbirth educators advocate avoidance of regional analgesia in the absence of maternal complications.**In contrast, a joint American Society of Anesthesiologists–ACOG statement makes the point that for many women, regional anesthesia (epidural, spinal, or CSE) will be the most appropriate anesthetic. Although the overall availability of anesthesia providers has decreased,8–10use and availability of regional analgesia for labor in all hospitals has increased, especially in stratum III hospitals. Despite this increase, not all hospitals require anesthesia groups to provide this service, and some hospitals only provide services for cesarean delivery.19Although continuous epidural infusions were improvements in the administration of regional analgesia for labor compared with intermittent bolus techniques,20newer techniques (i.e. , patient-controlled epidural analgesia) have allowed for self-administration of local anesthetics and for reduction or elimination of background infusions. Although patient-controlled epidural analgesia reduces total epidural medication requirements, anesthesiologist-delivered supplemental “top-ups,” and decreases anesthesia personnel workload,21only 18–35% of hospitals used patient-controlled epidural analgesia (table 3). Reasons for a low rate of use are unclear, but one possible explanation may be unfamiliarity or cost of the devices themselves.Since publication of the last obstetric anesthesia workforce survey, CSE is one other technique that is new to obstetric anesthesia practice. Before its development, single-injection spinal analgesia offered the advantage of administration of low doses of spinal anesthetics without the complications associated with epidural catheter insertion. The single injection spinal technique has been used in smaller hospitals because it can be administered by obstetric care providers with little additional training or by anesthesia personnel who do not remain in the hospital.22,23Our survey results suggest that single-injection spinal techniques were used in a small number of hospitals across all the strata. In contrast to the limited duration of single-injection CSE labor analgesia the of both single-injection spinal and epidural Despite these data suggest that CSE was used in less than 10% of all hospitals in 2001. Although CSE to be a it is more complicated than either spinal or epidural the of the the epidural catheter has not been to after the of spinal analgesia, if an is Despite these potential for low CSE have been to at the rate as epidural actual complications do not to be between the use also be by about potential use of regional anesthesia and especially spinal anesthesia for cesarean delivery has increased since publication of the 1992 survey results (table 3). epidural or spinal anesthetics the to be or with The current survey results also suggest that spinal anesthesia was used in approximately 50% of urgent–emergent cesarean deliveries. These results are not because spinal anesthesia many epidural anesthesia, and the for its use in many urgent–emergent cesarean deliveries. Despite about the decreased use of general anesthesia for cesarean delivery and no longer experience in providing general anesthesia for obstetric results suggest that general anesthesia was still used in of urgent–emergent cesarean deliveries in 2001. However, in elective cesarean deliveries, general anesthesia was used in less than 5% of cases in all sizes of previous workforce surveys stated that availability of regional analgesia be changes were observed in the 2001 survey provider availability and personnel providing regional anesthesia for In stratum III hospitals (100–500 births), providers were available on-call for labor and cesarean deliveries in more than of services. In contrast, 20% of these small services had no regional analgesia for labor in Although epidural analgesia is often as several factors may have to its increased use of epidural analgesia can to overall patient with the labor and delivery In addition, an epidural catheter during labor can the associated with general anesthesia and cesarean delivery. However, with current payment and an between and demand for anesthesia staffing of obstetric anesthesia services will continue to be a changes in personnel performing newborn resuscitation at the time of cesarean delivery were observed in stratum I and II hospitals in 2001, approximately 45% of resuscitations were performed by pediatricians compared with in In stratum III hospitals, the percentage of resuscitations performed by family practitioners decreased from in 1992 to 13% in 2001. performed by practice or labor nursing personnel increased in all sizes of hospitals. Anesthesia providers or certified registered nurse are involved in newborn resuscitation This is consistent with previous publication of the most recent obstetric anesthesia workforce survey in VBAC has a more of obstetric practice. Although for VBAC attempts increased from to of and complications associated with of labor in patients with previous cesarean decreased the number of VBAC attempts by to in ACOG issued a practice for VBAC the availability of anesthesia and personnel for cesarean controversy followed this and many anesthesiologists to the VBAC because they for in-house coverage of labor and delivery especially in hospitals. More recently, ACOG issued a VBAC practice the for availability of anesthesia and personnel during attempted the has not been defined in VBAC practice VBAC should be attempted in institutions to respond to with available to provide results decreased of VBAC attempts in all sizes of maternity services (table 6). These results are consistent with the on addition, results suggest that fewer small hospitals attempted and some anesthesia providers remained during attempted Although VBAC attempts can be performed in smaller hospitals if they have the personnel and necessary to respond to obstetric (e.g. , the of VBAC is less well in these on of have also position that the of availability of personnel and facilities a local based on each availability of and geographic much was after publication of a large study the survey results that in hospitals that ambulation during spinal or epidural labor analgesia, the average percentage of patients using ambulation from only 3% in the largest hospitals to in stratum III hospitals (table 6). Stratum III hospitals were more likely to ambulation and for patients to the Despite maternal and fetal of ambulation after regional administration during it is to which patients are to the of ambulation during labor remain the practice of a has been the delivery of obstetric anesthesia care that likely regional analgesia delivery. In 2001, published an position that registered nurses should not adjust epidural infusion rates, or reinstitute epidural infusions, administer epidural catheter or patient-controlled epidural analgesia some nurses have infusions it was important to the to which labor and delivery nurses to position results revealed that nurses in stratum II (500–1,499 births) and III (100–500 births) hospitals were more likely to adjust epidural infusion rates (table 6). However, less than 10% of stratum I hospitals (> 1,500 births) allowed nurses to adjust epidural infusion rates, administer epidural or reinstitute epidural infusions. Although the Society for Obstetric Anesthesia and Perinatology and the American Society of Anesthesiologists have to their statement and have labor nurses to an in pain during has been in their However, most recent on during Labor that appropriate labor and delivery nursing personnel who have been and have current should be to in the management of epidural infusions, including of and of or whether this statement will affect position is respondents were asked is the collection rate of professional fees for and the results are in Although do not whether responders to or collection rates are similar between surgical and obstetric cases. also determined patient categories and percentage of actual charges for cesarean delivery and labor epidural analgesia in all sizes of hospitals. Stratum I hospitals had the largest percentage of health maintenance organization payers, and stratum II and III hospitals had the largest percentage of Medicaid payers. Stratum III hospitals had the highest percentage of Medicaid and private insurer categories but had the smallest percentage of health maintenance organization payers. The number of practitioners that they had been payment increased from 25% in 1992 to in 2001. percent of respondents reported that some had payment, but only responded that payment was by some to previous obstetric anesthesia workforce surveys, there are several to the current A number of are required for the of a sample of the most important for a survey is a complete frame that reduces response by that the sample the of one of the of this study was in contact with key personnel in institutions in the of institutions were but initial were with a high although used the most recent 2001 American Hospital Association's Annual Survey Database to a current and accurate of hospitals, publication of the process of and of hospitals in the United sample sizes are also required for Although sample sizes were based on response rates known from previous of the of surveys is Despite to the number of including by hospital administrators and responses did not rates. The survey instrument was to obtain single from the most in to increase survey This the of the survey for each the potential effects of performed a follow-up telephone survey of nonresponders. these results were not from initial survey providing some that results are Despite medical surveys are often by low response important to a survey is the survey instrument In addition to questions from the previous survey, newer questions were to the 2001 survey to addition of the most recent developments in obstetric anesthesia practice. Before survey the and validity of the instrument by draft to or five in each focus group (i.e. , anesthesia obstetrics labor and delivery management to obtain feedback about survey questions and its ease of These as survey to the a number of substantial changes have occurred in the practice of obstetric anesthesia since publication of the 1992 survey the number of hospitals providing obstetric care but the number of stratum I hospitals increased. Despite the potential in anesthesia provider there was an overall increase in the use of regional analgesia for labor across all strata, and more parturients used some type of analgesia for labor. In addition, regional anesthesia for cesarean delivery increased across all sizes of delivery but general anesthesia is still used in many urgent–emergent cesarean deliveries. Collectively, the 2001 survey results suggest that staffing and payment availability of services and anesthesia personnel have

316: The maternal demographics and intrapartum characteristics associated with epidural analgesia in spontaneous nulliparous labor

Epidurals and cesarean deliveries: a new look at an old problem.

Pain during childbirth is a well known cause of dissatisfaction amongst women in labor. The use of epidural analgesia in labor is becoming widespread due to its benefit in terms of pain relief. After approval of the local Ethics Committee on Research and obtaining informed written consent, 50 American Society of Anesthesiologists (ASA) class I-II consecutive multiparous women in labor requesting pain relief were enrolled in this prospective study. After providing description of the two options of pain relief available to them, they were allocated into two groups according to their request-to receive either parenteral opioid/sedative or epidural labor analgesia. Both groups received analgesia of choice at 4-cm cervical os dilatation. The epidural group received 0.125% plain bupivacaine, while the other group received pentazocine/promethazine intravenously. The time taken to locate the epidural space, catheter-related complications encountered and the amount of intravenous fluid used were documented. The two groups were comparable in terms of socio-demographic data. The mean duration of the first and second stages of labor, respectively, were significantly shorter in the epidural group when compared with those in the non-epidural group ([P < 0.01] and [P < 0.02]). There was no difference in the rate of cesarean delivery between them - epidural analgesia (32% [8/25]) versus parenteral opioid/sedative (44% [11/25]), (OR, 0.60; 95% CI, 0.19-1.90). The maternal blood loss from delivery was minimal, with no statistical difference between the two groups (P = 0.27). The neonatal outcome was the same in both groups. Closed questionnaire showed that the overall experience of labor was much better (it was also better than expected) in the epidural group when compared with that in the non-epidural group (80% versus 4%). Eighteen (72%) women had inadequate pain relief in the non-epidural group as compared to 2 (8%) women in the epidural group. The study shows that epidural labor analgesia is acceptable to women in our setting. More women in the epidural analgesia group were satisfied with the experience of labor than those who did not receive this form of analgesia than among those who received parenteral opioid/sedative.

<h3></h3> Planning, Preparation and Pre-emption are three key concepts in the practice of anaesthesia. In obstetric anaesthesia specifically, these three 'P's are particularly relevant as parturients are commonly present the...

Obese parturients are at high risk of complications during anaesthesia and early use of epidural analgesia in labour has been recommended for obese patients during labour. To assess the outcome of anaesthesia outpatient consultation for obese parturients. We retrospectively compared outcomes of obese patients antenatally and an obese and non-obese control group over a 1-year period. Outcomes included potential airway problems, anaesthetic for caesarean section, use and success of epidural analgesia and cervical dilation at epidural placement. The proportion of obese patients who had predictable intubation difficulty was low (5%). Epidural use analgesia in labour (69 vs 36 vs 66%, P = 0.148) was similar between groups (obese, obese controls and non-obese controls, respectively). Cervical dilation at the time of epidural insertion in the obese group (2.0, 1.0-3.0 cm) was not different from obese controls (3.0, 1.75-5.75 cm). There was no difference in the number of attempts required to site the epidural between groups or the number of patients that required resiting of the epidural catheter. General anaesthesia was not required in any emergency case in this group. The outcomes of obese patients attending the anaesthetic clinic were mixed. Not all patients who were to advised have epidurals did so but those who did requested them in early labour and there was no requirement for general anaesthesia during emergency caesarean section and adverse airway events were avoided in this group.

Objectives: The primary objective is to determine the epidural analgesia rate and its effect on the mode of delivery. The secondary objectives are to assess patient satisfaction, duration of second stage of labour and incidence of maternal, fetal and neonatal outcomes. Methods: A retrospective cohort design utilized in this study, involving all pregnant women received epidural analgesia in labour at Sultan Qaboos University Hospital over 3 years period (March 2020 to March 2023). All data is collected from the delivery register at Delivery ward, SQUH track care system, and epidural record chart. Women’s information remained confidential. All entered data in the SPSS program is stored in a passwordprotected computer. Results: There was a total of 7076 deliveries, out of which 389 received epidural analgesia, with a rate of 5.0% (95% CI: 5.0 – 6.0). Out of 389 deliveries, around half were nulliparous and the other half were multiparous. The rate of spontaneous vaginal delivery constituted 60.7%. On the other hand, instrumental deliveries and LSCS constituted 14.9% and 24.4% respectively. The median and mean (±SD) period of 2nd stage were 24.0 and 38.3±40.1. Only 1% of all included patients had prolonged second stage of labor. The rate of oxytocin use was 54.5%, and around 52.4% of it was among nulliparous. 148 patients (52.5% ) reported full benefit from epidural analgesia use, compared to 6% who reported no benefit. In addition, 12.7% of CTG showed fetal distress and postpartum hemorrhage constituted 6.7% among delivered ladies. The study showed that 10.0% of included ladies suffered one or more of post-partum complications, including fever (n 13, 3.3%), headache (n 10, 2.6%), backache (n 3, 0.8%), hypotension (n 9, 2.3%), urine retention (n 3, 0.8%), pruritus (n 1, 0.3%), and nausea and vomiting (n 1, 0.3%). 6.2% was the rate of NICU admissions among the newborns. Conclusions: The study revealed that 5% was the rate of epidural analgesia usage and spontaneous vaginal delivery was the main mode of delivery. However, the indications for delivery by cesarean section or instruments were not related to epidural analgesia in labour. In addition, there was no significant adverse effect on maternal, fetal and neonatal outcome. Based on that, we need to elaborate more on epidural analgesia awareness and usage in order to be offered. Although some previous reviewed studies reported adverse effects of epidural analgesia on labour outcome. Future researches are recommended including prospective design study, bigger sample size, wider variation and multicenter studies.

Reingeniería de procesos aplicada a la analgesia epidural obstétrica

A Cochrane Systematic Review of randomised controlled trials of epidural analgesia compared with other or no analgesia in labour reported no overall increased risk of caesarean delivery. However, many trials were affected by substantial non-compliance, and there are concerns about the external validity of some trials for contemporary maternity populations. We aimed to explore the association between epidural analgesia in labour and caesarean delivery in clinical practice and compare with findings from randomised controlled trials. Population-based cohort of pregnant women (n = 210 708) without major obstetrical complications who delivered a singleton live infant in hospitals in New South Wales, Australia, 2007-10. Data were obtained from linked, validated population-based data collections. Propensity score matching was used to examine the association between epidural analgesia in labour and caesarean delivery. Epidural analgesia in labour was used by a third (31.5%, n = 66 317) of the women, and 9.8% (n = 20 531) had a caesarean delivery. Epidural analgesia in labour was associated with increased risk of caesarean delivery {risk ratio [RR] 2.5, [95% confidence interval (CI) 2.5, 2.6]}. The association with epidural analgesia in labour was higher for caesarean delivery for failure to progress {RR 3.0, [95% CI 2.9, 3.0]} than for caesarean delivery for fetal distress {RR 1.9, [95% CI 1.8, 2.0]}. Epidural analgesia in labour is associated with caesarean delivery in a large maternity population. Population-based studies contribute important data about obstetrical care, when research settings and participants may not represent the clinical settings or broader population in which obstetrical interventions in labour are applied.

SP68 Dural puncture epidural: a ‘hole’ lot better? Is this the happy medium we were hoping for?

BackgroundThere is a legal obligation to explain the procedure and use of epidural analgesia in labor primarily due to the possibility of potential risks and associated complications. The present study details on the survey carried out to ascertain the current status of obtaining informed consent (IC) for explaining the epidural analgesia in labor.MethodsThe present study is based on a survey through a telephone questionnaire that covered all the hospitals in Korea where the anesthesiologists' belonged to and are registered with Korean Society of Anesthesiologists. The questionnaire included questions pertaining to administration of epidural analgesia to a parturient, information on different steps of obtaining an IC, whether patient status was evaluated, when the consent was obtained, and the reasons behind, if the consent had not being given.ResultsA total of 1,434 respondents took part in the survey, with a response rate of 97% (1,434/1,467). One hundred seventy-four hospitals had conducted epidural analgesia on the parturient. The overall rate of obtaining IC for epidural analgesia during labor was 85%, of which only 13% was conducted by anesthesiologists. The rate of evaluating preoperative patient status was 74%, of which 45% was conducted by anesthesiologists. Almost all of the consent was obtained prior to the procedure.ConclusionsThe rate of obtaining IC for epidural analgesia in labor is relatively high (85%) in Korea. However, it is necessary to discuss the content of the consent and the procedure followed for obtaining IC during the rapid progress of labor.