Epidural Service Research Articles

Analgesia for labour pain – analysis of the trends and associations in the Grampian region of Scotland between 1986 and 2001

BackgroundAlthough intrapartum analgesia has been in use since Victorian times, there have been few attempts to study its usage from routinely collected data. This population based epidemiological study aimed to analyse retrospective data on the distribution of different types of labour analgesia used by women in the Grampian region of Scotland between 1986 and 2001 in order to examine time trends and associations.MethodsData records on all deliveries occurring in the years 1986 to 2001 were extracted from the Aberdeen Maternity and Neonatal Databank.The rates of the use of epidural, opioid and Entonox or no analgesia for pain relief in labour in each year were calculated.Maternal, pregnancy, labour and delivery characteristics were compared among the users of three different analgesics by univariate and multivariate analyses.ResultsA total of 81,418 deliveries were analysed. Of these, 12,659 (15.5%) women had epidural, 33,819 (41.5%) had used opioids and 26,974(33.1%) received either Entonox or no analgesia at all. The women who received epidural analgesia were younger, shorter and heavier and had larger babies (OR = 1.05, 95% CI 1.01, 1.08). Three quarters of them were primigravidae and had longer periods of gestation. They were also more likely to have suffered pregnancy related complications (OR = 2.11, 95% CI 1.8, 2.4). Labour was more likely to have been induced (OR = 2.8, 95% CI 2.6, 2.9) and to have lasted longer in this group of women. Women in this group were 5 times more likely to have an instrumental delivery (95% CI 4.9, 5.1) and 7 times more likely to have a Caesarean section (95% CI 5.7, 9.3).ConclusionNon epidural analgesia was found to be the most popular choice for pain relief in labour in the Grampian region between 1986 and 2001, although an increase in the uptake of epidural services is starting to occur. The type of labour analgesia used is associated with the epidemiological characteristics of the women's pregnancy, labour and delivery.

Using clinical governance to standardise an epidural service

Continual epidural infusions are an accepted intervention for the management of postoperative pain (McQuay and Moore 1998). Benchmarking nationally through an unpublished audit of Pain Society members identified variation in the concentrations prescribed and delivery systems used. These differences were reflected in local practice. As a result of the local disparity in the management and provision of epidural infusions, the acute pain service at Southampton University Hospitals NHS Trust worked in conjunction with the pharmacy department to standardise the service provided to patients and staff. This process was complicated by the difficulty in obtaining anaesthetist consensus for a standard solution that was commercially available and funding for the dedicated delivery system.

Patient-controlled epidural analgesia for labor and delivery: a novelty or a practical method?

Patient-controlled analgesia, familiar worldwide as “PCA” and derived from a conceptual framework designed to improve standards of pain relief, developed rapidly from an experimental paradigm to the gold standard of modern acute pain management. While PCA has been universally adopted for postoperative parenteral drug administration, as an approach to epidural drug delivery during childbirth, its acceptance has been slow and characterized by isolated flourishes of energy and pockets of clinical activity. Once largely confined to academic or tertiary maternity units, patient-controlled epidural analgesia (PCEA) now seems to be more widely used, although new survey data are awaited before this impression can be affirmed or refuted. World wide, the clinical use of PCEA during labor and delivery varies widely. In parts of North America and Western Europe, PCEA has firmly established a place in the provision of epidural analgesia for parturition, partly accounted for by regional practice patterns, by requirements with respect to epidural management by medical and nursing staff, and by remuneration issues. In other countries and institutions, a variety of factors, not least of which is cost-containment, finds PCEA rarely considered as an alternative to continuous infusion epidural analgesia (CIEA) or intermittent bolus epidural analgesia (IBEA). Consumer-focused epidural services placing emphasis on choice or satisfaction frequently offer PCEA as an option or have adopted PCEA as the routine approach. Nevertheless, while there is strengthening evidence for several advantages of PCEA compared with the alternatives methods of drug delivery, assessing and documenting maternal satisfaction is difficult and any general benefit of PCEA in this respect is largely theoretical. This chapter reviews the literature pertaining to the efficacy and safety of PCEA during labor and delivery, especially in comparison with CIEA and IBEA.

Provision of postoperative epidural services in NHS hospitals.

To describe facilities for postoperative epidurals in UK National Health Service Hospitals, a questionnaire was sent to each hospital performing surgery below the head and neck. Of 271 hospitals, 256 replied (95%). While almost all offer postoperative epidurals, only 78 (30%) offer them to all surgical disciplines. Most hospitals rely on acute pain nurses for troubleshooting during the day, and on trainee anaesthetists after hours. Administration is most commonly by continuous infusion. There was no restriction on the use of epidural opioids in 67% of hospitals. Most (96%) hospitals have a protocol for epidural care, although the specified level of monitoring varies widely. There is no consensus of practice on removal of epidural catheters relative to anticoagulation. Levels of training in epidural care also vary widely. Two hundred and thirty-six hospitals (92%) have an acute pain team. Despite the expansion in acute pain services, facilities for postoperative epidurals are deficient in many NHS hospitals.

Survey of 1057 patients receiving postoperative patient-controlled epidural analgesia.

Data were collected from 1057 consecutive patients who received patient-controlled epidural analgesia for postoperative pain relief, using 0.1% bupivacaine with 5 microg x ml(-1) fentanyl in all cases. Prescriptions were not otherwise standardised. On the first postoperative day, 741/801 patients (92.5%) had adequate analgesia and 692/719 (96.2%) were free of nausea. During a total of 3858 treatment days, two patients (0.19%) had an episode of severe respiratory depression and one patient (0.09%) became unrousable. Hypotension occurred in 45 patients (4.3%). There were no cases of epidural haematoma or abscess. We conclude that a patient-controlled epidural analgesia service as described is both efficacious and safe for use on surgical wards.

Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures.

Six hundred and forty patients received epidural analgesia for postoperative pain relief following major surgery in the 6-year period 1993-1998. Although satisfactory pain relief was achieved in over two-thirds of patients for a median duration of 44 h after surgery, one-fifth of patients (133 individuals) still experienced poor pain relief. Almost one out of three patients (194 individuals) had a problem with their epidural. Eighty-three patients (13%) suffered a technical failure and 84 (13%) patients had their epidurals removed at night time when pain-free because of pressure on beds. Seven patients had their epidural replaced and subsequently experienced excellent pain relief for a median of 77 h. Lack of resources prevented a further 480 patients from receiving the potential benefits of epidural analgesia. These results would suggest that the practical problems of delivering an epidural service far outweigh any differences in drug regimens or modes of delivery of epidural solutions.

Physiological changes of pregnancy

Summary The major physiological alterations of pregnancy present a significant risk to the parturient and fetus as well as a considerable challenge to the anesthesiologist when general anesthesia is administered. Consequently, general anesthesia should be avoided for elective surgical procedures involving parturients and until at least 6 to 8 weeks postpartum. The decision to undertake general anesthesia in the urgent situation must involve a process of weighing the potential risks of a failed intubation, hypoxemia, and aspiration versus the indications for urgent surgical intervention. In my practice, I ask the obstetrician two questions when presented with an urgent/emergent cesarean delivery. The first question (What is the indication for casarean delivery?) determines whether regional anesthesia is an option (ie, fetal distress) or not (ie, maternal hemodynamic instability). If regional anesthesia remains an option, then the second question (Are you going to scrub?) follows. If the response is affirmative, then sufficient time exists to undertake the regional anesthetic with either a 25G or 22G atraumatic spinal needle. However, if the obstetrician's plan is to splash and slash without scrubbing their hands, and the airway looks reasonable, then I will undertake a rapid sequence induction of general anesthesia. Consequently, anesthesiologists involved in the care of the parturient population must become proficient with regional anesthesia. The provision of a modern epidural labor analgesia service 21 will obviate the need for the induction of general anesthesia in the majority of cases because the epidural catheter will facilitate the rapid induction of surgical anesthesia. Resuscitation of the parturient also requires an understanding of the physiological alterations of pregnancy, specifically the adverse effects of aortocaval compression. It is of paramount importance to the successful resuscitation of the parturient to ensure adequate uterine displacement to avoid aortocaval compression. Finally, anesthetic management options must take into account the presence of two patients, with maternal concerns being given priority over fetal concerns.

A survey of the current practice of obstetric anaesthesia and analgesia in Malaysia [correction of Malaysis

A survey covering 30% of the deliveries in Malaysia was done to determine the practice of obstetric anaesthesia and analgesia for 1996. From the survey, it was found that the regional anaesthesia rate for caesarean section was 46% in the government hospitals compared to 29.2% in the private hospitals, with spinal anaesthesia being the most common regional anaesthetic technique used in both types of hospitals. The epidural rate for labour analgesia was only 1.5% overall for the country. Epidural analgesia services were available in all private hospitals whereas 17.6% of government hospitals surveyed did not offer this service at all. Although the use of epidural analgesia for labour was low in Malaysia, the overall rate of regional anaesthesia for caesarean section (41.9%) is very much in keeping with the standards of safe practice recommended by the United Kingdom.

Controversies of Labor Epidural Analgesia

Controversies of Labor Epidural Analgesia

A survey of epidural analgesia for labour in the United Kingdom.

A postal survey of obstetric units throughout the UK was conducted to obtain information about the provision of epidural analgesia for labour. Ninety per cent of units offered a 24-h epidural service and the average epidural rate was 24%. The most commonly administered epidural test dose was 3 ml of bupivacaine 0.5% and bupivacaine 0. 25% was most often used as the initial epidural top-up. Continuous infusions of low-dose bupivacaine and opioid mixtures were the most popular method of maintenance epidural analgesia. Twenty-four per cent of units offered combined spinal-epidural analgesia in addition to standard epidural analgesia. Midwives played a prominent role in the administration of epidural bolus top-ups and also in the assessment and maintenance of continuous epidural infusions.

Practice of epidural analgesia for labour pain: a German survey

Epidural analgesia is one of the preferred methods of analgesia for labour. The aim of the present survey was to evaluate current practice in obstetric analgesia in departments of anaesthesia and to make a comparison with former surveys from Germany and other countries. Questionnaires on the practice of pain relief, especially epidural analgesia, during labour and delivery were sent to 1178 anaesthesic departments in Germany in the second half of 1996. Five hundred and thirty-two completed replies were received, which represent 46.9% of all German obstetric units. The majority of the departments of anaesthesia practising epidural analgesia have an epidural rate of less than 10% and 10.2% of the departments do not offer this method to their parturients. In 86.8% of all units performing epidural analgesia, the epidural catheter is placed by an anaesthetist. Only 6.5% of the units provide a 24-h epidural service which is exclusively assigned to labour and delivery. In 77.8% of the units, this service is not exclusively assigned to obstetrics, but also to other duties. Of the obstetric units offering epidural analgesia, 14.7% have no epidural service at night. Plain local anaesthetics for epidural analgesia are used by 55.9% of the departments, a combination of local anaesthetics with epidural opioids by 28.7%. Epidural analgesia is predominantly (82.2%) maintained by intermittent bolus administration. Although the rate of epidural analgesia increased during recent decades, this method is not offered to all parturients. Further improvements in the use of epidural analgesia for labour seem to be necessary.

Practice of epidural analgesia for labour pain: a German survey.

Epidural analgesia is one of the preferred methods of analgesia for labour. The aim of the present survey was to evaluate current practice in obstetric analgesia in departments of anaesthesia and to make a comparison with former surveys from Germany and other countries. Questionnaires on the practice of pain relief, especially epidural analgesia, during labour and delivery were sent to 1178 anaesthetic departments in Germany in the second half of 1996. Five hundred and thirty-two completed replies were received, which represent 46.9% of all German obstetric units. The majority of the departments of anaesthesia practising epidural analgesia have an epidural rate of less than 10% and 10.2% of the departments do not offer this method to their parturients. In 86.8% of all units performing epidural analgesia, the epidural catheter is placed by an anaesthetist. Only 6.5% of the units provide a 24-h epidural service which is exclusively assigned to labour and delivery. In 77.8% of the units, this service is not exclusively assigned to obstetrics, but also to other duties. Of the obstetric units offering epidural analgesia, 14.7% have no epidural service at night. Plain local anaesthetics for epidural analgesia are used by 55.9% of the departments, a combination of local anaesthetics with epidural opioids by 28.7%. Epidural analgesia is predominantly (82.2%) maintained by intermittent bolus administration. Although the rate of epidural analgesia increased during recent decades, this method is not offered to all parturients. Further improvements in the use of epidural analgesia for labour seem to be necessary.

Observations on labor epidural analgesia and operative delivery rates

Objective: Our purpose was to compare operative vaginal and abdominal delivery rates in a large population before and after on-demand labor epidural analgesia became available. Study Design: We retrospectively compared patients who gave birth during a 20-month period immediately before the introduction of an on-demand labor epidural analgesia service with those who gave birth during a 20-month period after the epidural usage rate had reached a plateau at approximately 60%. Operative vaginal and cesarean delivery rates were stratified according to parity and history of prior cesarean delivery. Results: A total of 4859 women gave birth during the study period when on-demand epidural analgesia was available, and 4778 women gave birth in the study period before the availability of on-demand epidural analgesia. Comparisons between the women with and those without on-demand availability of epidural analgesia demonstrated no statistically significant differences in the rate of spontaneous vaginal delivery (69.5% vs 68.3%), the overall cesarean delivery rate (19.0% vs 19.4%), the primary cesarean delivery rate (13.2% vs 13.4%), or the operative vaginal delivery rate (11.1% vs 11.9%) between the 2 periods. There were no statistically significant differences in mean gestational age at the time of delivery between the 2 groups, whereas there were statistically significant increases in the proportion of nulliparous women and in mean birth weight during the on-demand epidural period. Analysis after substratification of the study groups according to parity also revealed no statistically significant differences in the primary cesarean delivery rate or the proportion of women undergoing vaginal delivery. The sample size was adequate to exclude a 2% increase in the primary cesarean delivery rate between the 2 periods with 80% power. Subgroup analysis of the population of women who gave birth while epidural analgesia was available on request demonstrated that nulliparous parturient women who requested epidural analgesia were almost twice as likely to require operative vaginal or cesarean delivery as women who did not request epidural analgesia, a finding suggesting that women who request labor epidural analgesia have an inherent propensity toward operative delivery. Conclusion: The introduction of an on-demand labor epidural analgesia service does not increase the rate of cesarean delivery or operative vaginal delivery. (Am J Obstet Gynecol 1999;180:353-9.)

Pain Relief in Labour

Associated Director; Division of Obstetric Anesthesiology; Department of Anesthesiology Critical Care Medicine; Johns Hopkins University; Baltimore, MarylandJames C. Eisenach, M.D., EditorPain Relief in Labour. Edited by Felicity Reynolds. London, BMJ Publishing Group, 1997. Pages: 256. Price: 27.00 [pound sign].Pain Relief in Labour is one of a growing number of textbooks in the area of management of labor pain. This textbook by Russell, Scrutton, and Porter has some influences characteristic of practice in the United Kingdom. The textbook is intended for the nonanesthesia care provider, such as midwives, obstetricians, and general practitioners. The emphasis is, not unexpectedly, on nonregional labor analgesic techniques, including “natural childbirth,” transcutaneous electrical nerve stimulation, acupuncture, hypnosis, herbal remedies (including aromatherapy), homeopathy, and inhalational analgesia for labor.This textbook begins with a description of US and UK surveys of labor analgesia practices. A Table depictsthat in the United States in 1990. 0% of cases were performed with inhalational analgesia for labor analgesia, and 33% of cases were performed with epidural analgesia for labor. In contrast, in the United Kingdom in 1992, 60% of cases were performed with inhalational analgesia for labor analgesia, and 20% of cases were performed with epidural analgesia for labor. The authors state that inhalational analgesia with nitrous oxide is an option despite their statement that “nausea and vomiting is very common with nitrous oxide.” The data presented may incorrectly convey to the reader a sense that inhalational analgesia is without complications or without loss of maternal protective airway reflexes and loss of maternal consciousness. The authors state that “failure to provide epidural analgesia was the single most frequent cause of anxiety and disappointment among laboring women. There are insufficient anaesthetists in the UK and many countries to provide an efficient epidural service universally.”Who should inform the mother about pain relief and methods of analgesia? The authors suggest “midwives not anaesthetists” provide information to the patient but recommend development of a liaison between midwives, obstetricians, general practitioners, and anesthetists. This comment raises concerns regarding which individual can effectively and accurately disseminate information regarding regional analgesic techniques for labor. Should the nonanesthesia care provider carry this responsibility?The psychological methods of pain relief, including “natural” childbirth, psychoprophylaxis, hypnosis, and biofeedback are discussed with emphasis on the benefits of antenatal training for these psychological methods and suggestion that these methods should be “strongly encouraged” by the midwives, obstetricians, and general practitioners. The physical methods of pain relief, including transcutaneous electrical nerve stimulation, massage, water bath, aromatherapy, homeopathy, and herbalism, suggest effective analgesia for the first stage of labor only. Reports on efficacy are anecdotal and without clear scientific evidence. The authors state, “Though many nonpharmacological approaches to pain relief have been put forward, few have been widely used and fewer still subjected to randomized trials.”The authors briefly review the anatomy and physiology of regional analgesia for labor with nice diagrams and illustrations of spinal-epidural anatomy. There is also a brief review of the indications and contraindications of regional analgesia for labor and reference to the effects and complications of regional analgesia for labor (i.e., potential association of epidural analgesia for labor with obstetric outcome).The final part of the textbook illustrates “practical procedures” for regional analgesia for labor with sample infusion regimens. A guide is also provided for the nonanesthesia care provider on how to administer an epidural top-up dose.Is this book worth buying? This textbook is more suited for the nonanesthesia care provider, such as the midwife, obstetrician, or general practitioner. For anesthesiology trainees and practitioners, this book is of peripheral interest only.Sumedha Panchal, M.D.Associate Director; Division of Obstetric Anesthesiology; Department of Anesthesiology Critical Care Medicine; Johns Hopkins University; Baltimore, Maryland(Accepted for publication September 23, 1998.)

A survey of parturients using epidural analgesia during labour. Considerations relevant to antenatal educators.

The use of epidural analgesia (EA) during labour is increasing in Australasia. This highlights the need for improved educational and resource materials, current factual information about EA, and identification of consumer attitudes towards EA. In this survey, 350 parturients who had recently used EA for labour pain relief in a single maternity unit were asked to complete a questionnaire about their expectations and experience. The response rate was 90%. Prepartum information was most commonly derived from hearsay and least commonly from medical health professionals, 56% of respondents wanted pain to be made tolerable and 34% wanted complete pain relief. Almost half considered unrestricted mobility and delivery without obstetric assistance important. A minority were concerned about possible effects of EA on the baby or labour outcome. Anticipated pain during epidural placement was significantly greater than that experienced. Satisfaction with EA was high, although 36% described unpleasant or annoying effects associated with EA. Parent educators and epidural service providers should be aided by knowledge of where parturients obtain information and of consumer views about EA.

9 The effects of epidural analgesia on the course and outcome of labour

The potential effects of epidural analgesia on the progress and outcome of labour have been the subject of lasting controversy. Retrospective reviews indicate that epidurals are associated with longer labours and/or an increase in the incidence of instrumental or operative delivery. Similar results were obtained in non-randomized prospective studies. None of them established a causal relationship, because without randomization the selection bias cannot be ruled out. Other factors, such as premature rupture of membranes and maternal socioeconomic status, may affect the outcome of labour. It was also reported that introduction of the on-demand epidural service did not increase the primary caesarean section rate. The few prospective randomized studies are contradictory and not very reliable owing to small patient populations and high cross-over rates. There is, however, unanimity among the authors regarding the superiority of pain relief provided by epidural blocks over systemically administered opioids.

Epidural Labor Analgesia and the Incidence of Cesarean Delivery for Dystocia

We performed this retrospective study to examine the changes in cesarean delivery rates associated with the establishment of a labor epidural service.In April 1993, St. Louis Regional Medical Center established an on-demand labor epidural service. We obtained demographic data for all patients and reviewed the operative records of all patients undergoing cesarean section who delivered 12 mo before and 16 mo after the start of the labor epidural service. We compared labor epidural rates and total and nulliparous dystocia cesarean delivery rates before and after the epidural service started and among patients who did and did not receive labor epidural analgesia when it was available. Included were 3195 patients who delivered before and 3733 patients who delivered after epidural analgesia became available. Labor epidural rates were 1.2% vs 29.4% for the Before group versus the After group (P < 0.001). Total (9.1% vs 9.7%) and nulliparous dystocia (5.7% vs 6.4%) cesarean delivery rates did not significantly change with the availability of epidural analgesia. However, the total (11.6% vs 8.8%; P = 0.009) and dystocia (8.0% vs 1.0%; P = 0.001) cesarean delivery rates were higher among patients who received epidural analgesia when it was available. We conclude that epidural labor analgesia is associated with, but does not cause, cesarean delivery for dystocia. Implications: Increased epidural analgesia use did not change the overall dystocia cesarean delivery rate, although dystocia was more common among women who chose an epidural analgesia. Consequently, limiting epidural availability will not affect cesarean delivery rates. The evidence does not support advising patients that epidural labor analgesia increases the risk of cesarean delivery. (Anesth Analg 1998;87:119-23)

Availability of anesthesia personnel in rural Washington and Montana.

Availability of anesthesia personnel in rural Washington and Montana.

Does epidural analgesia during labor affect the incidence of cesarean delivery?

There is substantial evidence that there is an increased incidence of cesarean delivery among patients who receive epidural analgesia during labor. The controversy as to whether there is a causal relationship between epidural analgesia and cesarean delivery. Two prospective, randomized studies suggest that epidural analgesia may increase the incidence of operative delivery in laboring women. However, retrospective population-based studies suggest that the introduction of an epidural analgesia service, or the increased use of epidural analgesia, does not increase the cesarean delivery rate. It is possible that epidural analgesia during labor may increase the risk of cesarean delivery in selected patients. Such an effect--if it exists at all--appears to be small in contemporary practice. Furthermore, the availability and use of epidural analgesia may encourage other patients to undergo an adequate trial of labor or attempt vaginal birth after cesarean delivery. It is important to consider the impact of epidural analgesia on the total population of obstetric patients. Maternal-fetal factors and obstetric management, not epidural analgesia, are the most important determinants of the cesarean delivery rate. Finally, physicians should remember that pain relief is itself a worthy goal.

Training, Skills and Approach to High‐risk Obstetrics in Rural GP Obstetricians

One hundred and sixty seven (82%) of the 204 practising South Australian rural GP obstetricians responded to a questionnaire on training, skills and approach to high-risk obstetrics. The mean length of training was 8.5 months; 78% of GP obstetricians held a diploma. There was a mean of 13 years experience and 22 deliveries per year. However, 26.3% of practitioners had stopped obstetrics in the previous 12 months and cited indemnity insurance and lifestyle factors as the main reason for stopping. The GPs practised a wide range of skills; forceps (96%), Caesarean section (42%) and had good access to epidural services (83.6%), blood transfusions (91%) and specialist advice. High-risk obstetrics such as twin pregnancy, fetal growth retardation, insulin-dependent diabetes and preterm labour, are avoided by most rural GP obstetricians. The mean visual analogue comfort score for providing obstetric care was 7.46 (2.16) and correlated with length of training (p = 0.008) and number of deliveries per year (p = 0.02). Health authorities must continue to support and encourage country GP obstetricians to provide this essential service to rural women.