Multifaceted Anesthesia

The anesthesia department's role outside the O.R. is important in organizing obstetric analgesia services for labor patients

A column reflecting experiences from the first 11.000 epidurals in Palermo, Italy.

Dr. V. Lanza, MD, Dept. Head

Vincenzo Lanza & Giuseppina Di Fiore Department of Anesthesiology Buccheri La Ferla Hospital Fatebenefratelli Palermo, Italy http://www.unipa.it/~lanza/bucing.htm Click for the Dr .Lanza's Curriculum Vitae

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How it all got started?

Our anesthesia department first started offering obstetric analgesia services routinely in 1988. By the end of the year 2002, we had collected experience from 11,285 epidural analgesias performed for the treatment of labor pain. When the service was first initiated, our obvious aim was to provide safe and effective analgesia for the patients. First, we had to solve several organizational problems. This 14-plus year exercise has been a real learning experience, and we want to share it with your.

In the first part of this article, there is a literature review. In it, we discuss the facts from scientific publications, and then place them in the perspective of the Italian health care infrastructure. There is also an introduction about the role of epidural analgesia during the different stages of labor.

The second part of the article will appear in a later issue of the journal. We will then report our observations from our practical in-house experience over the first 14 years of service.

Obstacles at the start of the epidural analgesia service

General anesthesia was just a tradition, and initially there was too little regional analgesia experience.

In the 1980's, the techniques of regional anesthesia were not widely known in Italy, especially in the south. In contrast, general anesthesia was commonly considered a safe and comfortable practice, which could be used in all patient groups. That belief, although widespread, was mistaken. Already over ten years ago, many surveys had reported that general anesthesia carried the risk of serious neurological complications, and was not safer than regional anesthesia. A review by Kroll [1] of 1,541 complaints of lesions after anesthesia, revealed that more than half of 227 neurological injuries occurred during general anesthesia. In another study by the French INSERM, it was found that out of 4,430 spinal anesthesias there were only 19 injuries (six of which were fatal), or 0.43%. In the latter study, approximately 70% of the patients were of advanced age and therefore were at an increased risk for complications.

In any case, when selecting the method of anesthesia to be used during labor, one must primarily consider the safety and comfort of both the newborn and the mother, also taking into account that the method is appropriate for the planned surgical technique. In 1986, the British report "Confidential Enquiries into Maternal Deaths" [2] revealed that anesthesia was the third leading cause of maternal death.

During the following decade, the use of general anesthesia decreased from 77% to 40%, and this was in spite of an increase in the number of C-sections. It must also be noted that from 1991 to 1993, anesthesia moved from the level of third to eight as the leading cause of maternal mortality [3]. That drop coincided with the decrease in the number of labor related general anesthesias, as well as an improvement in monitoring techniques [4].

What about using an epidural on patients not previously seen by the anesthetist?

Anesthetizing a patient who hasn't had an anesthetist's preoperative examination performed or the necessary laboratory tests taken, continues to be an obstacle for many anesthesiologists. In such a situation, the following points may be worth considering:

• Anesthesia must often be practiced under emergency conditions on not previously examined patients and with minimal laboratory evaluations.
• Reports have appeared suggesting that preoperative laboratory evaluations may be so unreliable that without a clinical evaluation of the patient, laboratory results may be virtually useless. For instance, it has been claimed that coagulation lab tests may be less sensitive and specific than a proper case history.
• Typically, the patient at the labor unit is usually young, and during her nine months of pregnancy, she has been met and examined several times. Hence, the authors feel that such patients are at less of an anesthesiological risk than a patient undergoing an emergency appendectomy.
  

What is the underlying reason in slow expansion of obstetric anesthesia?

It seems to us that even today, many anesthesiologists in Italy amazingly consider analgesia during delivery an unnecessary practice. On one hand, none questions the appropriateness of hospitalizing the patient, making delivery a medical event. On the other hand, it is understood that a patient undergoing a medical event may have physical and mental pain. There may even be too many who consider it normal that an episiotomy is performed without appropriate analgesia, while none would perform uncomplicated inguinal herniotomy that way. One may claim that from a surgical standpoint, the episiotomy is equivalent to the inguinal herniotomy.

However, standards of service may vary. In a private clinic, the anesthesiologist may be called at the moment of the episiotomy to administer general anesthesia. One might then question the issue of timing and choice of anesthesia method. The point is that after having experienced the pain and stress throughout the delivery, the new mother would now be unconscious and unable to witness the birth of her baby - and the birth of the child is for many the most gratifying part of the whole undertaking.

Figure: Epidural analgesia for labor (EAL) annual statistics at the Buccheri La Ferla Hospital (Palermo, Italy) 1988-2002.

Organizational obstacles in anesthesia service management

Many anesthesia departments complain about organizational constraints, like a chronic lack of staff, and hence the impossibility of managing labor analgesia service. Hospitals typically allocate enough resources for emergency anesthesia services, but would consider it necessary to have an additional anesthesia team for the obstetric analgesia services. The rationale may then be that the department would considered it mandatory to follow a pregnant patient close enough for the duration of the delivery, but could not get the resources for that. In a way a safety issue is then the constraint. There is some discussion on whether it is safer to administer epidurals by continuous infusions instead of boluses, and we will revisit that topic later.

Does use of epidurals have any negative effects on the course of labor?

A topic often debated in obstetrics, is the effect of epidural analgesia on the progress and outcome of labor. For the structured review of the effect of epidural analgesia, we consider it important to analyze each phase of labor separately.

First stage of labor - the latent phase

Until a few decades ago, it was a belief that regional analgesia administered during the latent phase significantly prolonged labor, while the same technique applied when labor is more advanced had little or no effect [5,6]. Thereafter, new studies have appeared questioning the validity of that dogma [7,8]. It was demonstrated that epidural analgesia might cause, at most, a temporary 10 to 20 minute reduction of uterine contractility, provided that all measures are used to avoid hypotension. Nonetheless, it seems that the habit of avoiding regional analgesia in the latent phase is firmly established. In fact, many of the later studies have only focused on the active phase of the labor.

First stage of labor - the dilation phase

Several non-randomized studies have appeared, suggesting that epidural analgesias has only a negligible effect on this phase of labor [9,10,11]. In a few reports, [12,13,14], a transitory reduction in uterine activity after epidural block has been demonstrated, but there are doubts that other factors than epidural block may cause that phenomenon. One hypothesis proposes [15] that the rapid intravenous infusion of liquids might inhibit release of antidiuretic hormone. Consequently, the production of oxytocin would then be temporarily suppressed.

However, the benefits of pre-hydratation before administering an epidural block are indubitable. Although the above theory could partially explain the temporary variations in uterine contractility observed in association with epidural analgesia, sufficient administration of fluids is important. One must also prevent aorto-caval compression by the lateral decubitus position, because the decrease in uterine perfusion may occur even in the absence of demonstrable hypotension [16].

As far as epidural analgesia technique is concerned, it is evident that drug administration by either intermittent boluses or by continuous infusion (17,18] did not have a significant impact on the duration of the first stage of labor.

In 1999, a prospective study appeared [19] reporting the effects of epidural analgesia on the duration of labor, and the incidence of surgical deliveries (C-sections). Two groups of labor patients were formed (N=125 and 130) comparing effect of early establishment of an epidural block (before or after four centimeters of cervical dilation). The results of this study reveal that an early establishment of the epidural block did neither increase the duration of labor nor the incidence of surgical deliveries. The duration of labor in the group that received an early administration of epidural analgesia was in fact reduced.

In conclusion, it seems that during the first stage of labor epidural analgesia has no clinically significant effect on the duration of labor, provided that the uterus is dislocated to the left and hypotension is avoided.

Second stage of labor

There are several reasons why epidural analgesia can influence the duration of labor in the second stage, as well as the form of delivery. Some authors claim that epidural analgesia may cause a decrease in the production of oxytocin through a reduction in the Ferguson reflex. In addition, epidural block may reduce the effectiveness of maternal expulsive efforts.

Local anesthetics in high concentrations are more likely to cause motor block and the loss of reflex. Increase in the volume of injected solution does not have such a negative effect. In the past, studies tended to attribute an increase in the incidence of surgical deliveries to epidural analgesia. Typically, anomalies of progression of the fetus in the birth canal or malpositioning due to the pelvic muscle relaxation [10,20] were then pinpointed.

In reality, it is difficult to compare the data collected from inhomogeneous populations. Nulliparas are usually over-presented among those who receive epidural analgesia. They comprise a patient group with a prolonged duration of labor, not too infrequently resulting in surgical delivery. Such mixing factors make it difficult to objectively evaluate the specific effects of epidural analgesia on uterine activity during delivery.

A few recent studies are worth mentioning at this point. In one hospital, after the establishment of epidural service during labor the incidence of surgical deliveries did not increase [21]. There was another study demonstrating a lack of correlation between surgical delivery and epidural technique, compared to other forms of analgesia (e.g. intravenous or parenteral) [22]. In the journal Anesthesiology, a paper appeared where the incidence of surgical delivery was more correlated with the obstetrician's therapeutic tendencies than with epidural analgesia [23].

Hence, when estimating incidence of C-Sections, maternal or fetal reasons and obstetric department's therapeutic tendencies should be taken as main factors, and not epidural analgesia. We conclude that in view of recent data, any fear of increase in surgical deliveries due to epidural analgesia seems unjustified.

Are all the mothers well informed to ask for epidural analgesia?

It seems that in our public healthcare system the demand for epidural analgesia is surprisingly low. The causes that should be explored are cultural factors, and the lack of familiarity with the possibility of having epidural analgesia in labor.

In the past few years, progress in obstetrics has improved safety and quality of delivery. Option of childbirth in the hospital is now available for women of all social classes. We feel however that for many obstetricians the need for anesthesia during delivery has yet to be accepted - and some obstetricians may still view epidural as an unnecessary, added risk. In a very traditional thinking, the discomfort of labor is often seen as a gift that the puerpera offers to the newborn.

It is equally important to realize that expectant mothers may be unaware of the availability of an effective analgesic technique. That may be so if primary health care staff does not provide necessary information. It is also important that the reputation of the anesthesia department's analgesia service is recognized in the region. The second part of our article will demonstrate importance of adequate and positively presented patient information. That is important to avoid any resistance and to gain optimal acceptance among obstetric anesthesia patients.

Performing epidural puncture for labor analgesia
[Photo by Dr. I. Kalli]

Bibliography

1. Kroll DA, Caplan RA, Posner K, Ward RJ, Cheney FW. Nerve injury associated with anaesthesia - Anesthesiology 73: 202-207,1990
2. Department of Health and Social Security Report on Health and Social Subjects 29. Report on the Confidential Enquiry into Maternal Deaths in the England and Wales 1979-1981. London: HMSO, 1986.
3. Anaesthetic Services for Obstetrics - a Plan for the Future. Association of Anaesthetists of Great Britain and Ireland and Obstetric Anaesthetists Association. London 1987.
4. Chamberlain G, Wraight A, Steer P. Pain and its relief in Childbirth. The Results of a National Survey Conducted by the National Birthday Trust. Chamberlain G, Wraight A, Steer P (Eds.). Churchill Livingstone; Edinburgh 1993.
5. Friedman E.A. et al.: Caudal anesthesia: the factors that influence its effect on labor. Obstet. Gynaecol. 13: 442-450, 1959
6. Friedman E.A. et al.: Dysfunctional labor. Prolonged latent phase in the nullipara. Obstet. Gynaecol. 17: 135-148, 1961
7. Vasika A. et al.: Effect of conduction and inhalation anesthesia on uterine contractions: experimental study of the influence of anestesia on intra-amniotic pressure. Am. J. Obstet. Gynaecol. 82: 600-611, 1961
8. Vasika A. et al.: Spinal and epidural anesthesia, fetal and uterine response to acute hypo- and hypertension. . Am. J. Obstet. Gynaecol. 90: 800-810, 1964
9. Phillips J.C. et al.: Epidural analgesia and its effects on the normal progress of labor. Am. J. Obstet. Gynaecol.129: 316-323, 1977
10. Cowls G.T. et al.: Experiences with lumbar epidural block. Obstet. Gynaecol. 26: 734-739, 1965
11. Moir D.D. et al.: Management of in coordinate uterine action under continuous epidural analgesia. Br. Med. J. 2: 396-400, 1967
12. Craft J.B. et al.: Effect of lidocaine with epinephrine versus lidocaine (plain) or induced labor. Anesth. Analg. 51: 243-246, 1972
13. Jouppila P. et al.: Fetal heart patterns and uterine activity after segmental epidural analgesia. Br. Obstet. Gynaecol. 84: 481-486, 1977
14. Matadial L. et al.: The effect of epidural anesthesia on uterine activity and blood pressure. Am. J. Obstet. Gynaecol.125: 846-854, 1976
15. Cheek T.G. et al.: Rapid intravenous saline infusion decreases uterine activity in labor: Epidural analgesia does not. Anesthesiology 71: A884, 1989
16. Schellenberg J.S.: Uterine activity during lumbar epidural analgesia with bupivacaine. Am. J. Obstet. Gynaecol.127: 26-31, 1977
17. Li D.F. et al.: Continuous extradural infusion of 0,0625% or 0,125% bupivacaine for pain relief in primigravid labor. Br. J. Anaesth. 57: 264-270, 1985
18. Bogod D.G. et al.: Extradural infusion of 0,125% bupivacaine at 10ml hr-1 to women during labor. Br. J. Anaesth. 59: 325-330, 1987
19. Rogers R.: Epidural Analgesia and Active Management of Labor: Effects on Length of Labor and Mode of Delivery. Journal of Obstetrics and Gynecology 93: 995-998, 1999
20. Johnson W.L. et a.: Effect of pudendal, spinal and peridural block anesthesia on the second stage of labor. Am. J. Gynaecol.113: 166-173, 1973
21. Fogel ST, Shyken JM, Leighton BL, Mormol JS, Smeltzer JS. Epidural labor analgesia and the incidence of cesarean delivery for dystocia. Anesth Analg 1998 Jul;87(1): 119-23
22. Sharma SK, Sidawi JE, Ramin SM, Lucas MJ, Leveno KJ, Cunningham FG Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor. Anesthesiology 1997 Sep;87(3): 487-94
23. Segal S, Blatman R, Doble M, Datta S The influence of the obstetrician in the relationship between epidural analgesia and cesarean section for dystocia. Anesthesiology 1999 Jul;91(1): 90-6
    

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