Obstetric regional analgesia in the Jesenice General hospital in year 2006
Background: The aim of this retrospective analysis of the obstetric regional analgesia (ORA) in Jesenice General Hospital in year 2006 was to evaluate our work and present results. We analysed workload, quality of the analgesia and patients’ satisfaction. We also estimated the OR for vacuum extraction (VE) in nulliparous labouring women having ORA. We compared quality of analgesia and total local analgesic consumption in nulliparous women having VE or spontaneous delivery.
Methods: We performed retrospective analysis of labours with ORA in year 2006. All women received epiduraly mixture of 0.1 % bupivacaine with 2 µg of fentanyl per ml in intermittent boluses.The labour pain was assessed using visual analogue scale (VAS). We used median and interquartile range to describe distribution of these values and mean with standard deviation to describe distribution of other data (local anaesthetic consumption). We considered patient with pain VAS 3 or less adequately treated, VAS 4 and 5 sufficiently and VAS 6 and more insufficiently treated. We used odds ratio as measurement of risk for VE, t-test for differences in local anaesthetic consumption and Mann-Whitney test to evaluate differences in pain between tested groups.
Results: 225 labouring women opted for ORA or 38 % of all labouring women in year 2006. We performed 224 ORA, 59 % during regular work, 41 % during turn of duty. 18 % of ORA were performed between 10 p.m. and 7.00 a.m. In 98 % of cases epidural analgesia was used. Anaesthesiologic work took 16 minutes in average (SD 6.06). Analgesia was started at VAS median 5 (IQR 4–6.5) and at average cervical dilatation 4.1 cm (SD 1.4). Average consumption of bupivacaine was 55 mg (SD 23.7) and fentanyl 91.7 µg (SD 46.5). Most common complications were inadequate analgesia, and misplacement of epidural catheter (10/222), dural tap (6/222), and unilateral analgesia (2/222). 70 labours were ended with VE (13 %; n = 532). There were 27 (8.7 %; n = 309) VE in labours without ORA, and 42 VE in labours with epidural analgesia. OR for VE in labouring women with epidural analgesia was 2.62 (CI 2.43–2.80). Nulliparous women with ORA having VE had equally good analgesia but needed more local anaesthetic (p < 0.05). There was no difference in pain between nulliparous women with induced or spontaneous start of labour. Median pain during labour was estimated 4 (IQR 2–5). 15 % of patients had inadequately treated pain and 13 % of patients were only partially satisfied, unsatisfied or disappointed. 84 % of women estimated pain as equal or less than expected, 87 % were satisfied or very satisfied. 96 % of women would have ORA again.
Conclusions: ORA is invasive method of labour pain relief that can be safely and effectively performed in small hospital. Trust and cooperation among all members of staff in delivery room is essential. Each obstetric ward should find balance between adequate analgesia and unwanted side effects of ORA. The method is not to be compromised by maternal dissatisfaction or excessive analgesia with obstetric side effects.
McDonald A. Obstetric pain. In: McMahon S, Koltzenburg M, eds. Wall and Melzack’s Textbook of pain. 5th ed. Oxford: Elsevier Churchill Livingstone; 2005. p. 793–816.
Melzack R. The myth of painless childbirth. Pain 1984; 19: 321– 37.
Gogarten W, van Aken H. A century of regional analgesia in obstetrics. Anaesth Analg 2000; 91: 773–5.
Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review. Am J Obstet Gynecol 2002; 186: S69–77.
Lieberman E, O’Donoghue C. Unintended effects of epidural analgesia during labor: a systematic review. Am J Obstet Gynecol 2002; 186: S31–68.
Eberle RL, Norris MC. Labour analgesia. A risk-benefit analysis. Drug Saf 1996; 14: 239–51.
Halpern SH, Leighton BL. Misconceptions about neuraxial analgesia. Anesth Clin N Am 2003; 21: 59–70.
Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review). In: The Cochrane Library, Issue 4, 2002.
Eltzschig HK, Lieberman ES, Camann WR. Regional anesthesia and analgesia for labor and delivery. N Engl J Med 2003; 348: 319–32.
Beilin Y, Leibowitz AB, Bernstein HH, Abramovitz SE. Controversies of labor epidural analgesia. Anesth Analg 1999; 89: 969– 78.
Loo CC, Dahlgren G, Irestedt L. Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth 2000; 9: 99– 124.¸
Wong CA. Neurologic deficits and labor analgesia. Reg Anesth Pain Med 2004; 29: 341–51.
Reš-Muravec U, Mlakar-Pleško A, Stopar T, Grmek S, Likar R, Jordan T, et al. Naše izkušnje z epiduralno porodno analgezijo. Zdrav Vestn 2003; 72 Supl II; 105–10
Uranjek J, Juvan-Kramer K. Vpliv različnih koncentracij bupivakaina in levobupivakaina s fentanilom na potek poroda v epiduralni analgeziji: retrospektivni pregled. Zdrav Vestn 2006; 75: 787–93.
Brownridge P. The nature and consequences of childbirth pain. Europ J Obstet Gynecol Reproductive Biol 1995; 59: S9–S15.
Lowe NK. The nature of labor pain. Am J Obstet Gynecol 2002; 186: S16–S24.
Collis RE, Plaat FS, Morgan BM. Comparison of midwife top-ups, continuous infusion and patient-controlled epidural analgesia for maintaining mobility after a low-dose combined spinalepidural. BJA1999; 82: 233–6.
Smedvig JP, Soreide E, Gjessing L. Ropivacaine 1 mg/ml, plus fentanyl 2 µg/ml for epidural analgesia during labour. Is mode of administration important? Acta Anaesthesiol Scand 2001; 45: 595–9.
Boutros A, Blary S, Bronchard R, Bonnet F. Comparison of intermittent epidural bolus, continuous epidural infusion and patient controlled-epidural analgesia during labor. Int J Obstet Anesth 1999; 8: 236–4.
Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001; 358: 19–23.
Ranta PO. Obstetric epidural analgesia. Curr Opin Anaesthesiol 2002; 15: 525–31.
Hart EM, Ahmed N, Buggy DJ. Impact of the introduction of lowdose epidural (bupivacaine 0.1 % fentanyl 2 µg/ml) compared with bupivacaine 0.25 % for labour analgesia. Int J Obstet Anesth 2003; 12: 4–8.
Chua SM, Sia AT. Automated intermittent epidural boluses improve analgesia induced by intrathecal fentanyl during labour. Can J Anaesth 2004; 51: 581–5.
Hess PE, Patt SD, Lucas TP, Miller CG, Corbett T, Oriol N, et al. Predictors of breakthrough pain during labor epidural analgesia. Anesth Analg 2001; 93: 414–8.
Finster M. Effects of epidural analgesia on the progress of labor and the mode of delivery. Europ J Obstet Gynecol Reproductive Biol 1995; 59 Suppl: S31–3.
Zimmer EZ, Jakobi P, Itskovitz-Eldor J, Weizman B, Solt I, Glik A, et al. Adverse effects of epidural analgesia in labor. Europ J Obstet Gynecol Reproductive Biol 2000; 89: 153–7.
ACOG committee opinion. Int J Obstet Anesth 2002; 77: 297–8.
Caton D, Frölich MA, Euliano TY. Anesthesia for childbirth: controversy and change. Am J Obstet Gynecol 2002; 186: S25–30.
Liu EH, Sia AT. Rates of cesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review. BMJ 2004; 328: 1410–7.
Kinsela SM. Epidural analgesia for labour and instrumental vaginal delivery: an anaesthetic problem with obstetric solution? Br J Obstet Gynaecol 2001; 108: 1–2.
Feinstein U, Sheiner E, Levy A, Hallak M, Mazor M. Risk factors for arrest of descent during the second stage of labor. Int J Obstet Anesth 2002; 77: 7–14.