to Buccheri La Ferla |
|
V. LANZA
Anesthesia Department
Buccheri La Ferla Hospital Fatebenefratelli -Palermo-Italy
Peridural anesthesia is an effective technique for providing analgesia during labour and delivery. The fact that it is not at all widely used in Italy can be ascribed to the lack of technical knowledge among health-care providers and the lack of information available to pregnant women. This paper covers the inherent problems in peridural anesthesia in delivery (PAD) and the possibility of organizing an PAD service that will enable the hospital to offer safe and effective analgesia to all pregnant women who wish to avail themselves of it.
1.1 Lack of familiarity with peridural anesthesia
Regional anesthesia techniques are not widely used in Italy, and are used even less in southern parts of the country. General anesthesia is considered by most anesthesiologists and surgeons to be a safe, reliable technique that can be used on all patients. Many practitioners emphasize the supposedly high rate of neurological complications following epidural anesthesia or analgesia. This is incorrect; large-scale studies have shown that general anesthesia also involves neurological complications and that it is not any safer than regional anesthesia. According to Koll (1) out of 1541 reports of injury following anesthesia, more than half of the 227 cases of neurological damage were related to general anesthesia. In another survey conducted by INSERM (France), 19 accidents (6 of which were fatal) were reported, accounting for 0.43% of 4430 administrations of spinal anesthesia. In this last survey approximately 70% of the patients were elderly and therefore, presented a higher risk of complications. A survey in our hospital reveals 2 non-fatal accidents related to 6690 administrations of spinal anesthesia. Therefore, the rate of complications for spinal anesthesia in our hospital is 0.02%. These data show that the number of serious complications related to spinal techniques is not higher than that of general anesthesia.
1.2. Risks of peridural anesthesia in a patient who has not been previously examined..
Administering anesthesia to a patient without a preanesthetic evaluation (including history, physical examination, and blood work) is an insurmountable obstacle for many anesthesiologists.
We can raise two objections:
1.3 Assuming responsibility for "superfluous" anesthetic
Many Italian anesthesiologists consider analgesia in childbirth unnecessary, despite the fact that labour and delivery are considered to be medical procedures. It is, however, considered "normal" that this medical procedure take place with a significant amount of pain. It is "normal" for an episiotomy to be performed without anesthesia while no one would ever say that an uncomplicated inguinal herniotomy (equivalent to an episiotomy from a surgical standpoint) should be performed without anesthesia. Furthermore, in private practice, the anesthesiologist is often called in for the episiotomy and administers general anesthesia, thus rendering the patient unconscious during expulsion of the fetus. The final result of this approach is that after having withstood the pain and stress of labour, the patient is deprived of the opportunity of seeing her child born, which is the most gratifying part of the entire process.
1.4 Organizational difficulties for the management of PAD
Many anesthesia departments suffer from chronic personnel shortages and are therefore unable to set up a PAD service. In hospitals with sufficient staff, an additional shift is considered necessary for the PAD service. In both these cases it is considered impossible to follow a parturient for the entire duration of her labour. These reasons may be considered valid if single bolus PAD is planned because this method requires the anesthesiologist to be present throughout; they are inconsistent when a continuous infusion technique that we will discuss below is used.
1.5 Negative impact of PAD on labour
Peridural anesthesia prolongs labour and increases the need for forceps. Both these complications vary considerably according to the individual surveys. It is believed that PAD leads to a 15% to 25% increase in the use of low forceps. There is a marked difference between the single bolus and continuous infusion techniques. The latter offers a more constant level of analgesia and less pronounced muscular relaxation; it causes a negligible delay in labour that has no effect on the fetus. As to the use of forceps: the level of understanding and team-work between the obstetric and anesthesia staff are also important factors. The main reason for using forceps is the lack of propulsive force in the premum abdominale during the expulsion stage. Continuous PAD is usually sufficient to avoid the need for an additional bolus to assure correct analgesia of the perineum and at the same it prevents excessive muscle relaxation. Another reason for using forceps is the lengthening of the expulsion stage under PAD. If the obstetrician does not have sufficient experience with PAD s/he may be induced to take the fully dilated patient to the delivery room and urge her to bear down vigorously. In this case, prolongation of the expulsion stage caused by PAD will be interpreted as a pathological delay and thus lead to the use of forceps. After some practice with PAD the obstetrician will be able to judge correctly when to take the patient to the delivery room and thus avoid unnecessary use of forceps (2). In our ten-year experience, use of forceps with PAD has dropped from an initial 11% to a rate that is nearly comparable to that found in delivery without PAD.
Patient demand for PAD is surprisingly low within the Italian national health service. The reasons are twofold: general educational/cultural background and lack of knowledge about PAD.
2.1 Cultural factors
Many cultures consider childbirth to symbolize a sacrificial and propitiatory moment for the new baby's good life. In our predominantly Catholic, country, the Biblical phrase "In sorrow thou shalt bring forth children" is the standard accompaniment to pregnancy and childbirth. The pain of delivery is seen as the puerpera's "gift" to the baby. Moreover, in southern Italy, a pagan-type message has been added: the mother makes this sacrifice of pain to assure her child a normal birth. In some parts of the hinterland, the lack of pain during delivery would be considered a bad omen; labour would not play its sacrificial role and the baby would, therefore, be exposed to complications. The "medicalization" of childbirth, including hospitalization for delivery, has, however, overcome many obstacles and is now accepted by most of the population. The concept that labour and delivery involves the need for anesthesia as do all surgical procedures, on the other hand, is not making any inroads. This problem is particularly evident among those obstetricians who view PAD as an unnecessary added risk.
2.2 Lack of knowledge about PAD
pregnant women, often unaware of the possibility of effective pain relief, put up much resistance, especially if the hospital does not give them the necessary information about the techniques and does not offer adequate experience in this area. Appropriate information and positive results are sufficient to resolve the problems related to mistrust of PAD as we will see below.
3.1Prepartum obstetric analgesia outpatient clinic
 |
Fig.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 our experience, the evaluation of the puerpera three weeks before delivery has been an effective method of spreading information about the technique among patients and anesthesiologists. The creation of an outpatient service for pre-PAD examinations was combined with a leaflet (Fig.1) that is distributed by the prenatal outpatient clinic and the hospital admitting office. In addition to traditional preanesthetic evaluation, the anesthesiologist talks to the patient and discusses any questions that she may have about PAD.
 |
At our hospital, the PAD examinations is recorded on a PC and then transferred to the department's network. When the parturient arrives in the labour room ,the anesthesiologist can call up the examination data on the computer in the delivery room and administer the PAD with greater peace of mind. If there is no computer system, a standard file of anesthetic evaluations can be set up and the anesthesiologist can refer to it when necessary. |
Our outpatient clinic began with an average of 5 examinations per week. As it expanded, the demand also rose so that in 1993 the clinic was expanded to 4 days per week and averaged 40 examinations. Outpatient clinics are held in the afternoons in the context of intramural activities; an arrangement with the National Health Service allows the service to be provided free of charge. Resource utilization can be quantified in 10-12 hours a week. Not all the examinations performed are followed by delivery in our hospital. (Figure 2 shows that) 70% of the examinations are followed by PAD. The other 30% includes patients who do not arrive at the hospital in time for PAD (12% in 1993) and patients who deliver elsewhere. About 10% of this latter group is already aware of the fact that they will have their babies elsewhere without PAD, but consider the anesthetic evaluation important for the delivery. (Figure 2 also shows that) an average of 33% of the PADs administered in one year are performed on patients who had not been examined previously. On the whole the data show that the spread of PAD has created an awareness of the anesthesiologist's role among pregnant women, and reveal how gratifying PAD can be within the framework of an anesthesia department.
 |
FIGURE 2 Pregnant out-patient visits and epidural anesthesia for delivery (PAD) processed by the informatic system. |
3.2 Creating the PAD Service
The usually limited number of anesthesiologists that are available at any
given time, and the extensive involvement in other hospital services (i.e.,
operating room, emergency room, pain treatment, surgical wards, etc.) hinders
the performance of PAD. In our hospital ,PAD is performed by the
anesthesiologist on duty with the support of the anesthesiologist on call, if
surgical cases that cannot be postponed require another anesthesiologist. A
well-trained team of anesthesiologists is capable of locating the peridual space
and positioning the catheter in about 5-10 minutes. Analgesia is achieved in ten
minutes and another ten minutes are needed to obtain a stable level of analgesia
using the continuous infusion technique. Thus, approximately 30 minutes are
usually required to start a PAD. The PAD is monitored by the midwife or
obstetrical nurse, who calls the anesthesiologist when delivery is imminent.
 |
Table 1 Decisional hierarchy to give a PAD in the Buccheri la Ferla Hospital |
The method used to established a PAD service can be summarized as follows:
1) Training all medical staff in continuous peridural anesthesia technique.
2) Building an obstetrical team through organizational meetings.
3) Starting the PAD service with the most expert and experienced anesthesiologists in the department. (with the support of the anesthesiologist on call).
4) Creating an outpatient clinic for prepartum anesthetic evaluation. Currently, there are 10 anesthesiologists in our hospital working in the surgical and obstetrical departments, with 24 hour shifts for PAD. In 1999, 2774 elective and 512 emergency procedures were performed in addition to PAD.
3.3 Continuous peridural analgesia in labour and delivery
The absolute contraindications we apply are listed in Table 2. It is the obstetrician, in consultation with the anesthesiologist, who must decide the most appropriate time to initiate the PAD. Therefore, the time PAD is started varies according to the physician's experience.
|
|
|
ABSOLUTE CONTRAINDICATIONS TO PAD
|
 |
As shown in (Figure 3), the ideal moment occurs when a dilatation of 3 cm combines with the conditions shown in Table 3.
 |
TABLE 3
THE IDEAL MOMENT TO PERFORM A PAD |
The decisional hierarchy we follow at our hospital for PAD is shown in Table
4.
| Before peridural anesthesia |
|
| Technique |
|
| Management of peridural anesthesia during labour and delivery |
|
Our continuous infusion technique calls for a 200 ml EVA bag filled with ropivacaine 2mg/ml. The bag filled with Ropivacaine 0,2% is connected to an infusion device without air inlet and a system of three controlled flow devices (Intraflo-Abbott) are connected in series. Finally, the bag containing the anesthetic is inserted in a pressurizing device and compressed to 300 mmHg (Fig.4).
| FIGURE 4 | |
 |
Under these conditions the system will deliver 9 ml/hour. Using three-way stopcocks one or more of the Intraflo devices can be removed from the system, and infusion speed can be reduced to 6 or 3 ml/hour. The system is connected to the peridural catheter with a stiff extension tube, for blood pressure measuring and an antibacterial filter. One bag is sufficient for 2 to 3 PADs. A fresh terminal extension tube and antibacterial filter are used for each patient. It is possible to obtain bolus by using the bypass in the Intraflo devices |
Some authors recommend cutting the rubber peg in the by-pass to avoid accidental administration. In our experience in both PAD and post-operative analgesia, there have been no reports of incidents that would reflect on the safety of the system which has been found fully reliable for long-term management of continuous epidural analgesia. Even though, in the long run, slow infusion deliveries a relatively large amount of local anesthetic, it does not cause any significant shifts in the extent or depth of the blockade. The labour-room obstetrical team controls the analgesia and monitors cardio circulatory parameters, and alerts the anesthesiologist of any insufficiency in the analgesia and when the patient is transferred to the delivery room. Analgesia of the perineum is checked prior to expulsion of the fetus, it should be sufficient if the anesthetic infusion has been ongoing for at least two hours. If the perineal analgesia is insufficient, 10 ml of lidocaine, 2%, make it possible to obtain full coverage of the perineum in 10 minutes. At the end of delivery, the anesthetic infusion is stopped and the peridural catheter, protected by the antibacterial filter is carefully closed. Analgesia is continued for the first 24 hours post-partum using diclofenac i.m. The peridural catheter is removed 24 hours later by the anesthesiologist on duty. Keeping the peridural catheter in place for 24 hours after delivery is advantageous because it makes it easy to obtain analgesia for any surgical procedures of the uterus or perineum. The PAD data are transcribed onto the computer, and along with the data on the previous anesthesiological examination will comprise a complete dossier on the anesthesia. After six-months training for the paramedical delivery room staff, it is possible to perform more several PADs contemporaneously using this technique.
4.1 Complications
From May 1988 when we opened the obstetrics department in our hospital up to December 1999 we performed 8875 PADs. Currently, deliveries under PAD account for 50% of all births in our hospital in one year.
Obstetrical complications are shown in Figure 5, while the analgesic efficacy of the technique is analyzed in Figure 6, with patient responses graded on a three-point scale:
Pain 0: satisfactory analgesia
Pain 1: additional bolus(es) of anesthetic required
Pain 2: other techniques required in addition to peridural
 |
FIGURE 5 - Obstetrics complications of
epidural analgesia deliveries. Decimal digits are not tabulated. |
 |
FIGURE 6 ANALGESIC EFFICACY OF PAD |
The anesthetic complications we encountered were mainly headache following infraction of the dura mater. This is strictly related to the anesthesiologists' level of experience (3)(4). In our survey the incidence of headache is 0.06% and can therefore be considered negligible; backache is also negligible. Other complications such as hypotension, excessive depth of the blockade with complete relaxation of the prelum abdominale are irrelevant with PAD administered in continuous infusion with gelatin preloading. The datum regarding the use of forceps is very significant. The percentage which was quite low in the beginning when compared with data published by other authors dropped even further even though we maintained the same anesthesiological standards we developed initially. During the three year period the use of forceps stabilized at 2.2% as compared with 0.3% in spontaneous deliveries. When we include the first two years of activity (Figure 5) forceps were used in 9.6% of deliveries with PAD. Even this final percentage is very low when compared with the data in the literature (Table 5). This shows that starting a PAD service does not involve an unacceptable utilization rate of forceps, even at the outset. Therefore, PAD does not have any significant effect on the progress of labour. It is also important to note that more and more frequently, labour with pathological aspects is being treated with PAD and even then the use of forceps has not risen to unacceptable levels.
The low rate of use of forceps can also be attributed to the improved understanding between anesthesiologists and delivery room staff (obstetricians, gynecologists) which is certainly one of the most important aspects in obtaining effective analgesia in deliveries.
4.2 Advantages
PAD has certainly contributed to the growth of the obstetrical department in our hospital; 40% of our patients come to us for painless childbirth. The obstetrical effects of PAD on labour are positive. The advantages are mainly evident in discinetic labour with cervical spasms. In these cases PAD is capable of accelerating the first stage to a significant extent. During expulsion, analgesia accelerates the placental stage and allows the obstetrician to perform a better hemostasis. Furthermore, there is less bleeding post-partum. Patient approval is high irrespectively of cultural or educational background and prompts 90% of our pregnant women to request PAD at their next delivery.
CONCLUSIONS
Our experience demonstrates:
how it is possible to organize a PAD service without within the framework of a normal anesthesiology department without a separate, specialized team; that is it possible to achieve a satisfactory understanding with the obstetrical team, by highlighting the advantages that PAD brings to obstetrics; the widescale of patient acceptance of PAD when information is correctly provided.
BIBLIOGRAPHY
1. Kroll D.A.,Caplan R.A.,Posner.K.. et al: Nerve inyury associated with
anaesthesia - Anesthesiology 73:202-207,1990
2. Lanza V. et al.: Analgesia peridurale per infusione continua nel travaglio di
parto. Minerva Anest. vol.56 n.12, pag.1451-1454
3. Matouskova A.,Dottori O.,Forssman L.:An improved method of epidural analgesia
with reduced instrumental delivery rate. Acta Obstet Gynecol.
Scand.83(suppl):31,1979
4. Morison D.H. Smedstad K.G.: Continuous infusion epidurals for obstetric
analgesia. Can.Anaesth.Soc.J., 1985 vol.32.
return to Buccheri La Ferla Anesthesia Department
visitors n.
