Anesthesia, Evidence and Experience

How to organize obstetric analgesia services for labor patients? Our practical experiences (Part II)

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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Practical aspects in organizing epidural analgesia service for labor

Anesthesiological examination at the prepartum outpatients' clinic.

In our experience, the opportunity to meet the expectant mothers at the anesthesiology outpatient clinic three to four weeks before estimated time of delivery is reassuring to both the expectant mother and the anesthesiologist.

The availability of epidural analgesia for labor can also be publicized through an informative leaflet distributed in the hospital's admittance office and the obstetric prenatal outpatient clinic (Figure 1).

Figure 1. The leaflet that is distributed by the prenatal outpatient clinic and the hospital admitting office. The epidural technique and laboratory tests needed are explained.

In addition, during a course on hospital delivery, there is a two-hour meeting with the anesthesiologist. The presentation includes pictures and films to describe epidural analgesia, its benefits, possible complications, and statistics in our hospital. Our outpatient visit is covered by the state health insurance system, which means that there is no cost to the patient. For the hospital, the estimated cost is related to the 10-12 weekly hours of activity, and mostly comes from staff salaries.

In our case, a portable computer is used to present anesthesiology information, and the patient's exam is entered on the computer, which is connected to a local network and to our centralized system.

Later, when the patient arrives for the delivery, it is easy for the anesthesiologist to review the information from the anesthesia database using one of the delivery room computers.

When we started, the labor analgesia outpatient clinic was open once a week and we had five visits. As the popularity of the service has increased, we currently examine 50 mothers-to-be a week, over the course of three afternoons. In 70% of the outpatient anesthesia visits, epidural analgesia later became the choice during the delivery. The rest includes late arriving patients, and those who deliver in other places.

Of the mothers coming to the outpatient visit, 10% already know that they will have their childbirth in another hospital. However, they consider meeting the anesthesiologist useful and informative. Dissemination of information seems important in educating patients about the role of the anesthesiologist in pain management.

Obstacles in creating an epidural analgesia service for labor.

The limited number of anesthesiologists is an obstacle, as they may be occupied with many other activities. They may work in the operating room, emergency room, consulting at the pain clinic, or meeting patients at the surgical wards.

In our hospital, there may be just one anesthesiologist on night duty taking care of labor analgesia, as well as participating in other duties.. A second on-call anesthesiologist can be contacted from outside the hospital when indicated.

Pre-planned teamwork

A trained clinical team can prepare the patient so that the epidural space can then be located and the catheter inserted in less than 10 minutes. Still another 10 minutes may be needed to obtain sufficient analgesia. If the continuous infusion technique is used, an additional 10 minutes may be necessary for a stable level of analgesia.

Hence, it may take up to 30 minutes to start epidural analgesia for labor. In our hospital, the control of epidural analgesia will then be entrusted to the obstetrician, who will call the anesthesiologist at the moment of delivery. A properly trained obstetric team is capable to follow the effect of the continuous epidural infusion and will contact the anesthesiologist if the analgesia proves insufficient. Figure 2 illustrates the decision-making flow in our anesthesiology department. The above protocol is consistent the guidelines accepted by the American Society of Anesthesiology for USA.

Figure 2. Epidural analgesia for labor (EAL), decisional hierarchy at the the Buccheri la Ferla Hospital

Strategic points in organizing a labor analgesia service

• Training and updating of anesthesiologists' skills to perform epidural analgesia is the key issue.
• Training should start first in the surgery room with the patient positioned laterally.
• Organized meetings facilitate teamwork with the obstetric staff.
• Merit of the anesthesiological outpatient clinic for pre-partum expectant mothers is important.

Our protocol for labor epidurals

The contraindications of epidural analgesia include:

• No patient consent
• Significant hemorrhage
• Impaired coagulation
• Systemic infections
• Neurological diseases

Proper timing to start epidural analgesia must be decided by the gynecologist. Hence, timing will consequently vary according to the experience of the individual doctor.

Epidural analgesia protocol followed in our hospital is shown in Table 1 (See appendix). The control of the analgesia as well as monitoring of physiological parameters (ECG, non-invasive blood pressure, and pulse oximetry) monitored from the start of the anesthesiological procedure, are entrusted to the obstetric staff in the labor room. They can notify the anesthesiologist if the analgesia proves insufficient, and when the patient is transferred to our separate delivery room.

At the end of the delivery the epidural infusion is suspended. Thereafter, the epidural catheter (protected by an antibacterial filter) is carefully closed. In our hospital, the epidural catheter is removed after 24 hours by the anesthesiologist on duty. Our experience suggests that leaving the epidural catheter in place for 24 hours after delivery is useful in case of eventual surgical needs

All the details of the epidural analgesia are documented on a computer along with the previously recorded anesthesiological examination findings. That provides a complete history of the anesthesiological activity.

Labor analgesia in practice

The 11,285 epidural analgesia cases from May 1988 to December 2002 represent 50% of the annual deliveries.

Considering typical obstetrical complications, the data related to the use of forceps is interesting. In recent years, the frequency of the use of forceps has been 0.1-0.4%. That number is low compared to our statistics from the first two years of epidural analgesia. Initially, our use of forceps in epidural analgesia patients was quite a high, 9.6%.

Another important reason for the low incidence of forceps in recent years is the improved understanding between anesthesiologists and the delivery room staff (obstetricians, gynecologists). Our statistics reveal that epidural analgesia doesn't significantly influence the process of labor.

With regard to cesarean sections, it must be pointed out that pharmacological induction is used increasingly in delivery, in conjunction with epidural analgesia. Induction of labor may cause a bias in increasing the incidence of surgical deliveries, and that must be separated from the effect of epidurals. Another point to note is the lack of homogeneity of this obstetric population (Table 2).

The most common anesthesiological complication is post-dural-puncture headache. That complication is closely correlated with the experience of the operators [3,4]. In our statistics, the incidence of post dural puncture headache is only 0.1%. Other possible complications may include hypotension and excessively deep epidural block. It seems to us that they are not that significant, however, if one administers epidural analgesia by continuous infusion and bears in mind pre-filling with fluids (we prefer using gelatin plasma expander). In our 11,285 cases of epidural anesthesia for labor, there have been no major neurological complications.

Safety of Anesthesiological Techniques in the Course of Obstetric Emergencies

The extensive use of epidural analgesia in labor in our hospital (50% of deliveries) makes it also possible to perform C-sections utilizing the epidural catheter, which is already in place.

Figure 3 shows that in more than 90% of cases epidural anesthesia was the only anesthesiological technique used.

Figure 3. Efficacy of epidural anesthesia.

Use of regional anesthesia, (particularly spinals blockades) in elective Cesarean sections, predisposes the use of the same technique in emergencies, as well. (Figure 4).

Figure 4. Anesthesia technique for cesarean section.

A retrospective study of 2,823 patients undergoing C-sections from 1998 to 2000 has assessed the combines effect of these two factors: extensive use of epidural anesthesia in labor and the use of spinal anesthesia in planned C-sections. (Figure 5).

Figure 5. Our retrospective study findings.

Conclusions

Our experience shows that it is possible to organize an epidural analgesia service as part of normal anesthesiological activity, without additional anesthesia resources.

It is possible to achieve agreement and co-operation with the obstetric staff. Then, it is worthwhile emphasizing the benefits of labor epidurals, like increased safety compared to general anesthesia in obstetric patients.

A carefully planned educational campaign is a good way to achieve wide acceptance of labor analgesia among the public.

Epidural analgesia for labor has certainly contributed to the increase in obstetric activity in our hospital. Patient satisfaction is high, regardless of socioeconomic level, with 90% of patients requesting EAL in subsequent deliveries.

Litterature

Reference listing can be found at the end of authors' first article, in CWWJ's issue 16 (March 2004).

Appendix

*) Disclaimer: Articles and other educational material Clinical Window Web Journal (CWWJ) makes available always represent authors' individual opinions and experiences, and reflect their local circumstances which may be different from the unique situation of our readers. CWWJ does not recommend any specific treatments, medications or care protocols.

Last updated: 9 July 2004 Created
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