promuovere ed informare sull’analgesia in travaglio - amarcord... · the differing approach of...

Promuovere ed informare sull’analgesia in travaglio

Congresso Regionale A.O.G.O.I. - A.G.I.T.E. - F.N.C.O. Regione Emilia Romagna

Corso di analgesia perimidollare in travaglio di partoRimini 23 marzo 2011

Dr. Enzo Valtancoli

SERVIZIO SANITARIO REGIONALE

EMILIA — ROMAGNA

Azienda Unità Sanitaria Locale di Forlì

Stabilimento Ospedaliero “G.B. Morgagni — L. Pierantoni

Perché …promuovere e

informare sulla analgesia in travaglio?

Per fornire elementi sufficienti ad orientare le decisioni delle donne , informazioni relative a fenomeni complessi che aiutano ad assumere

decisioni per migliorare il loro stato di salute

ed il loro grado di soddisfazione

The differing approach of professionals

Pregnancy is not a disease but a physiological proc ess

Anaesthetist are medically qualified being trained to treat the sick.Midwives specialise in normally.

There is a differece in approach

• Anaesthetists have to accept there is a different mind set required when a doctor is dealing with women • Anaesthetists have to accept there is a different mind set required when a doctor is dealing with women who are not ill compared to those who are sick

•The anaesthetists often considers that the women cease to be “clients” and become “patients” whenthey are under the care of a doctor

• Women under midwifery care who require epidural analgesia remain”clients”

• Epidurals are perceived by some midwives as a way of denying women the “joy”of natural child birth.

The pregnant and the parturient .W.E.Scott .Best Practice & Research Clinical Anaesthesiology.vol.20,n.4,pp.565-576.2006

Consent for Anaesthesia

Revised Edition 2006

Review Date: January 2011

2

Published byThe Association of Anaesthetists of Great Britain and Ireland,

21 Portland Place, London W1B 1PYTelephone: 020 7631 8801/8804

E-mail: [email protected]: www.aagbi.org

January 2006

Information and the process of consent Obstetric

• The adult parturient is presumed,like all adults,to have capacity.

• This may be compromised by drugs fatigue pain or anxiety, although the compromise will needto be severe to incapacitate her.

• Labour is the wrong time to burden women with excessive in formation .

• It is important that every obstetric unit provides antenatal advice for women concerning pain relief• It is important that every obstetric unit provides antenatal advice for women concerning pain reliefand anaesthesia during labour and delivery.

• This information must be prepared in conjunction (anaest hetists, obstetrics, midwives) and arrangements should be in place to ensure that any patient who wishes to discuss techniques withan anaesthetist may do so.

• Nevertheless the patient must still be provided with appropiate information at the time of the procedure ,the details of which must be documented.

Consent for AnaesthesiaAssociation of Anesthetists of Great Britain and Ireland

Favorire la donna ad eseguire una scelta informata e consapevole per il controllo del dolore

Presentare alla persona assistita:

• i dati epidemiologici e le evidenze scientifiche disponibili sui metodi di sostegno e controllo del dolore

• la casistica ,gli operatori ed i servizi di assistenza presenti nella struttura specifica dove avverrà il parto

• discutere con la persona assistita la sua situazione, il suo profilo di rischio , i vantaggi e gli svantaggi • discutere con la persona assistita la sua situazione, il suo profilo di rischio , i vantaggi e gli svantaggi del ricorso alle differenti metodiche ed estendere la discussione anche ad eventuali “persone risorsa” scelte dalla donna,sottolineando anche gli aspetti non chiariti da evidenze

Alla donna dovrebbero essere fornite informazioni basate su prove di efficacia.ove disponibili,in modo da renderla capace di prendere decisioni sul metodo di assistenza.

.Le scelte della donna devono essere considerate par te integrante nel processo assistenziale .

Assistenza alla gravidanza e al parto fisiologico – linee guida nazionali di riferimento 2003/2004

La centralità della persona assistita

La sanità ( nel senso più esteso del termine ) non deve far nulla in assenza del consenso di

un paziente informato e dunque, pur all’interno di inevitabili limitazioni,

deve essere sempre il paziente a indirizzare e dete rminare l’intervento terapeutico,a strutturare la decisione clinica. a strutturare la decisione clinica.

Per questo si parla di decisione clinica “ condivisa “ fra medico e paziente

TQM-RRVF – Total Quality Management – Rotary Recreational and Vocational Fellowship – dicembre 2002

The Cochrane Collaboration

Working together to provide the best evidence for health care

Cochrane Reviews are systematic reviews of primary research in human health care and health policy.They investigate the effects of interventions for prevention,treatment and rehabilitation.

Cochrane Reviews are designed to facilitate the cho ices that practitioners,consumers,policy-makers and other face in health care.

Without Cochrane Reviews people making decisions ar e unlikely to be able to access to make full use of existing h ealtcare research

Decision aids for people facing health treatment or screening decisions (Review)

Decision aids performed better than usual care interventions in terms of:

• greater knowledge• lower decisional conflict related to feeling uniformed • reduced the proportion of people who were passive in decision making • reduced proportion of people who remained undecided• reduced proportion of people who remained undecided

Exposure to a decision aid with probabilities resul ted in a higher proportion of people with accurate risk perceptions.

O’Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, FisetHolmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner DCollaboration. Published by JohnWiley & Sons, Ltd.

9

Although a great deal of information is made available to women throughout

their pregnancy and there are several published Cochrane reviews on the

effectiveness of specific interventions, there is limited use of decision aids effectiveness of specific interventions, there is limited use of decision aids

to assist women when making decisions regarding pai n relief in labour .

National Institute for Clinical Excellence (NICE)

suggest that there is an urgent need to fill a gap in knowledge by undertaking research on

effective ways of helping health professionals to support pregnant women in making

informed decisions during labour , also that healthcare professionals should consider how their

own values and beliefs inform their attitude to coping with pain in labour and ensure their care

supports the women’s choice .

National Institute for Clinical Excellence (NICE): guideline 6;antenatal care.Routine Care for the Healthy Pregnant WomanLondon: Nice 2003

National Institute for Health and Clinical Excellence :intrapartum Care;Care of Healthy Women and their babies during Childbirth edited by:Welsh A.London: RCOG Press; 2007

La deontologia medica impone obblighi precisi di tutela del cliente/paziente…

Che cosa … dobbiamo dire alle donne? Che cosa … dobbiamo dire alle donne?

Aim of the guideline

Clinical guideline have been definited as “ systematicically developed statements which assist clinicians and patientsin making decisions about appropiate treatment for specific conditions”.

The guideline has been developed with the aim of providing guidance on care of healthy women and their babies during childbirth.

Medical conditions indicating increased risk sugges ting planned birth at an obstetric unit

Disease area Medical condition

Cardiovascular Confirmed cardiac diseaseHyprtensive disorders

Respiratory Asthma requiring an increase in treatment or hospital treatmentCystic fibrosis

Endocrine Hyperthyroidism,diabetes

Renal Abnormal renal function,renal disease requiring supervision by a renal specialist

Neurological Epilepsy,myasthenia gravis,previous cerebrovascular accident

Gastrointestinal Liver disease associated with current abnormal liver function testsGastrointestinal Liver disease associated with current abnormal liver function tests

Psychiatric Psychiatric disorder requiring current inpatient care

Immune Systemic lupus erythematosus,scleroderma

HaematologicalHaemoglobinopathies-sikle-cell disease,beta-thalassaemia major,history of thromboembolicdisorders immune thrombocytopenia purpura or other platelet disorder or platelet countbelow 100.000,Von willembrand’s disease,bleeding disorder in the woman or unbornbaby,atypical antibodies which carry a risk of haemolytic disease of the newborn

InfectiveRisk factors associated with group b streptococcus whereby antibiotics in labour would berecommended,hepatitis B/C with abnormal liver function test,Carrier of/infected withHIV,Toxoplasmosi-women receiving treatment,Current active infection of chickenpox/rubella/genital herpes in the woman or baby,Tubercolosis under treatment

Factors Additional information

Previous complications

unexplained stillbirth/neonatal death or previous death related to intrapartum difficultyprevious baby with neonatal encephalopathypre-eclampsia requiring preterm birthplacental abruption with adverse outcomeeclampsiauterine ruptureprimary postpartum haemorrhage requiring additional treatment or blood transfusionretained placenta requiring manual removal in theatrecaesarean section,shoulder dystocia

multiple birthplacenta praeviapre-eclampsia or pregnancy-induced hypertension

Others factors indicating increased risk suggesting planned birth at an obstetric unit

Current pregnancy

pre-eclampsia or pregnancy-induced hypertensionpreterm labour or preterm prelabour rupture of membranesplacental abruptionanaemia-haemoglobin less than 8.5 g/dl at onset of labourconfirmed intrauterine death,induction of labouralcohol dependency requiring assessment or treatment,onset of gestational diabetesmalpresentation.breech or transverse lieBMI at booking of greater than 35 kg/m2recurrent antepartum haemorrhage

Fetal indications small for gestazional age in this pregnancyabnormal fetal heart rateultrasound diagnosis of oligo-polyhydramnios

Previous gynaecologicalhistory

myomectomyhisterotomy

Strategies for risk reduction

• revise the orientation and training• revise communication• standardize equipement and drug administration • conduct team training,practice for emergencies• use evidence based practices,create protocols

• standardization improves outcomes and when based on evidence should be implemented• every member of the team should be empowered to intervene and halt harmful processes• cesarean delivery is a process alternative not an outcome or quality endpoint•effective peer review is essential

Intrapartum care – Clinical Guideline september 2007

Practice guidelines for obstetric anesthesia: An U pdateReport by the

American Society of Anesthesiologists Task Force on Obstetric Anesthesia

Early insertion of a Spinal or Epidural Catheter fo r Complicated Parturients: recommendations

Early insertion of a spinal or epidural catheter for ostetric (twin gestation or preeclampsia) or anesthetic indications (anticipated difficult airway or obesity)

should be considered to reduce the need for GAshould be considered to reduce the need for GAif an emergent procedure becomes necessary.

…Consultants and ASA members agree that early insertion of a spinalor epidural catheter for complicated parturients

reduces maternal complications.

Submitted for publication october 31, 2006. Anesthesiology : volume 106 (4) aprile 2007 pp 843-863

•The diagnosis of the onset of labour and timing of admission or request for midwife visit at homeand observations undertaken

• Assessment and management of progress in labour, including “active management”and identification/management of delay in the first stage of labour

• Assessment of fetal wellbeing including appropiate use of electronic fetal monitoring• Care of women in labour including observations,nutrition, fluid balance and bladder care• Advice on non-invasive birth tecniques aimed at promoting the birthing process in the first stage of labour

Appropiate use and effect of pharmacological and no n-pharmacological pain reliefAppropiate use and the effects of regional analgesi a and care of women who have had regional analgesi a

•Appropiate care during the birth process including the effect of positions and water birth and management

Care in the first and second stage of labour

Intrapartum care – Clinical Guideline september 2007

•Appropiate care during the birth process including the effect of positions and water birth and management of the second stage with regardto pushing techniques

• Appropiate tecniques to reduce perineal trauma,including advice for women with previous third-or four degree tears or genital mutilation

• Assessment and management of delay in the second stage of labour including appropiate criteria for operative vaginal birth using either forceps or ventouse

• Identification and management of women with meconium-stained liquor• Identification and management of women with prelabour rupture of membranes at term,with particular reference to observations and duration of “watchful waiting” before induction,factors during prelabour rupture of membranes at term that influence maternal and neonatal outcomes following birth,use of antibiotics before birth and criteria for antibiotics in healthy newborns.

Potential adverse effects of maternal labour pain o n the fetus

Maternal pain – work - stress

Left oxygen shift metabolic acidosis Uterine vasoconstriction lipolysis hyperglycemia

Apnoeic episodes Placental flow decreases Free fatty acids increase

Hyperventilation respiratory alkalosis Release of cortisol and catecolamines

Oxygen transfer

decreases

Placental exchange

decreasesFetal free fatty acids

increaseFetal hyperglycaemia +

hypoxia

Fetal metabolic acidosis

……………………………………………………………………………………………Placental membrane.....................

Maternal changes produced by regional analgesia tha t may affect the baby

Potentially unfavourable effects Potentially favourable effects

occasional hypotension reduced maternal stress

fever reduced maternal hyperventilation

Increased need for oxytocin uterine vasodilation

prolonged second stage of labour fewer episodes of desaturation

increased need for instrumental delivery placental drug transfer is unimportant

Effect of regional analgesia on the baby

Direct effect

Indirect effects

Regional analgesia produces various maternal change s,some of which may be potentially detrimental to the baby and others that may be beneficial.

Probably the most important affect is reduced maternal stress and pain.

Sympathetic blockage may have good or ill effects.

Direct effect

Adverse direct fetal drug effects are likely only if maternal systemic effects of the drugs given neuraxially reach a detectable threshold.

Longer acting local anaesthetics (bupivacaine,ropivacaine,levobupivacaine) correctly-sited are more slowly absorbed and systemic effects are usually observed only after accidental intravenous administration.

Although opioids are well recognised to produce direct fetal and neonatal depression when used systemically their potential to do so when used for regional analgesia is much less.

Fetal and neonatal effects of pethidine

Fetal effects reduced muscolar activity

aortic blood flow

Oxigen saturation

short-term heart-rate variability

Neonatal effects depressed APGAR scores

respiration

neurobehavioural scores

muscle tone and suckling

a detrimental effect on breast feeding

Analgesia in labour and fetal acid-base balance:a meta-analysis comparing epidural with systemic o pioid analgesia

Painful labour led not only to maternal respiratory alkalosis but also to progressive metabolic acidosis which was transmitted to the fetus during the first stage of labour, while the second stage was associated with further deterioration in fetal acid-base balance.

F.Reynolds,S.K.Sharma,P.T.Seed – BJOG: an International Journal of Obstetric and Gynaecology –december 2002,vol.109,pp 1344-1353

Arterial ph reflects both a respiratory and metabolic component;thus during labour both maternal et fetal values are influeced by the extent to which a mother in pa in is stimulated to hyperventilate.

Systematic analgesia is often not sufficiently effective to prevent this hyperventilation.

Base excess is therefore a more specific index of metabolic aci dosis and hence fetal hypoxia . Once born a baby can no longer rely on maternal ventilation to maintain acid-base balance and neonatal respiration may be depressed following maternal systemic opioid analgesia.The presence of adequate buffer base is therefore i mportant to the newborn.The normal umbelical artery ph is said to be > 7.2 and base excess -10 to 0 mEq/L.

Conclusion

Analgesia in labour and fetal acid-base balance:a meta-analysis comparing epidural with systemic o pioid analgesia

F.Reynolds,S.K.Sharma,P.T.Seed – BJOG: an International Journal of Obstetric and Gynaecology –december 2002,vol.109,pp 1344-1353

Umbelicaly artery ph is influenced by maternal hyperventilation.Base excess is therefore a better index of metabolic acidosis after labour.

Epidural analgesia is associated with improved neon atal acid-base status,suggesting that placental exange is well preserved in associat ion with maternal sympathetic

blockade and good analgesia.

Although epidural analgesia may cause maternal hypotension and fever,longer second stage of labour and more instrumental vaginal deliveries,these potentially adverse factors appear to be outweighted by benefits to neonatal

Passaggio transplacentare dei farmaci

Acidi deboli

tiopentalediazepamfentanil (lip.816)

Basi deboli

lidocainabupivacainaropivacaina

sufentanil (lip.1727)

> liposolubilità > velocità di diffusione > onset della analgesia

Il passaggio è influenzato da variazioni del flusso ematico utero-placentare e/o dalla permeabilità placentare.La permeabilitàviene ridotta dalle alterazioni vasali che si verificano in stati patologici (tossiemia gravidica,diabete mellito,malattie vascolari ipertensive).

Una grave ipossia materna,una grave ipovolemia o ipotensione possono indebolire l’efficienza della barriera lipoidea placentare.

Placental drug transfer

Drugs used for anaesthesia and analgesia cross the placenta by passive diffusion;

Drugs used to provide systemic and regional analgesia cross the placenta readly in the unbound and

non-ionised state,while hydrophilic sustances such as neuromuscolar blocking drugs diffuse across

only slowly and are unlikely to attain effective concentration in the fetus.

The trasnplacental distribution of lipophilic substances ,whose unbound and non-ionised moiety equilibrates

readily across the placental membrane,is influenced by the transplacental gradient for pH and binding protein.

As fetal plasma pH.is lower than maternal,free base tends to concentrate on the fetal side due to ion trapping,

the reverse being true for weak acids .

.

Effects on the baby of maternal analgesia and anaesthesia – F.Reynolds – ESA Munich 9-12 june 2007

This increases the exposure of the acidotic fetus t o basic drugs such as opioid analgesic and local anaesthetics

Labour analgesia and the baby: good news is no news

The effects on mother and baby of labour pain

Painful labour produces several adverse changes in maternal physiology and biochemistry.Some changes have important implications for the baby. Maternal respiration increases by 75-150% during the first stage of unmodified labour; this is associated with a number of maternal changes that may have adverse fetal effects:

• hypocarbia and respiratory alkalosis

• increased oxigen consumption

• under - ventilation between contractions

• compensatory metabolic acidosis which appears to be transferred readily to the fetus

• vasocostriction which effects the uterine arteries

• a shift in the maternal oxygen dissociation curve counteracting the double Bohr effect.

• maternal hyperventilation lowers the umbilical artery PCO2 but as labour progresses this changeis overtaken by metabolic acidosis of increasing severity, such that the longer the second stage of labour the lower the cord PH at birth.

Labour analgesia and the baby: good news is no news – F.Reynolds - St.Thomas’Hospital,London –Int.Journal of Obst. Anesthesia (2011) 20,38-50

Maternal pain and stress have adverse fetal effects

Maternal anxiety is associated with increased plasma catecholamines and cortisol and prolonged labour.

Painful labour activates the stress response with release of ACTH and B lipotropin hence cortisol and B endorphin though the latter fails to exert much analgesic effect.

Increased sympathoadrenal activity may lead to incoordinate uterine action and reduced uteroplacental perfusion.

The metabolic outcome is hyperglycaemia with a poor insulin response,lipolysis with increased free fatty acids,ketones and lactate.

Such acids cross the placenta and together with catecholamines, increase fetal oxygen requirement,so maternal metabolic acidosis from this further cause is compounded in the baby.

While the maternal stress response is somewhat counterproductive it can besuppressed by neuraxial analgesia

By contrast the fetal stress response to labour, which results in a conspicuouscatecholamine surge,is beneficial for adaptation to extrauterine life and is not suppressedby maternal neuraxial analgesia

A double unwhammy for epidural !


Cardiotocography

Loss of short-term variability , decelerations and the occasional major bradycardia may be noted although a meta-analysis of randomised trials comparing epidural with systemic analgesia found no significant difference in fetal heart rate abnor malities between the groups.

Mayor bradycardias however appear not to be an issue with epidural analgesia with or without opioids though they have been reported to occur in 15-28% of cases after intrathecal sufentanil.

The focus of such studies has been whether or not these bradycardias are associated with an increased caesarean section rate (apparently not) but ignoring the obvious and much more important question…

are they associated with any adverse neonatal outcome?

important question…

There seems to be no evidence that they are


Breast feeding

Breast feeding is undoubtedly crucial to neonatal w elfare and therefore should be an important outcome measure.

It is affected by many variables such as :

intention to breastfeed social class

local tradition and support mode of delivery


initial mother-infant contact length of labour

education

Hence type of analgesia can play only a minor role

Breast feeding studies: epidural vs. other or no an algesia

Type of study Epidural type (n) Controls (n) Outcome measures

findings

Y.Beilin(Professor Anesthesiology-Obstetric-Gynecology and Reproductive Sciences-New York University)

C.Bodian

J.Welser

2005

• prospective• randomized• double blind

• intermediate – dosefentanyl group (1-150Y)(59 women)

• high – dose fentanylgroup > 150 Y(58 women)

No fentanyl group(60 women)

• on postpartum day 1• 6 weeks postpartum

on postpartum day 1difficulty breastfeeding

• high – dose (21%) • intermediate – dose (10%)• no fentanyl (10%)

At 6 weeks

• high – dose (17%) • intermediate – dose (3.5%)• no fentanyl (1.2%)

No significant difference

.

Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding

S.Torvaldsen(Centre overweightand obesity-Sydney)

C .Roberts(centre Perinatal-healthservice-Sydney)

J .Simpson(School Public Health)

J.Thompson(Women’s and Children H - Sydney)

2006

Intrapartumepidural analgesia and breastfeeding: a prospective cohort study

•1280 women• retrospective all

• singleton mixedparity• no selection ofthose intending tobreastfeed

• epidural labour

• PCEA bup+fent3.3y /ml

• all had i.m.peptidine

• caesarean section(epidural and spinalanaesthesia)

No groupQuestionnaires on

discharge and 8-16-24 weeks.

predictors of partialbreastfeeding 1 weekIntrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties

breastfeding at 24 weeksAnalgesia, maternal age and education were associated with breastfeeding cessation

women who had epidurals being more likely to stop breastfeeding than women who used non-pharmacological methods of pain relief

no analgesia 72%;no epidural 64%;

epidural 52%;

Breast feeding studies: epidural vs. other or no an algesia

Type of study Epidural type (n) Controls (n)

Outcome measures

findings

S.Jordan (Reader Health

Science.Swansea)

S Emery(Consultant

Gynaecologist)

M.Storey(Paediatrics Swansea)

J.D.Evans(Epidemiology)

2009

Associations of drugs given in labour with breastfeeding

Retrospective review Cardiff births over 10years 1989-1999(tot.48366 women )

No selection of those intending to breastfeed

Not stated Not stated

Regression analysis factors in breastfeeding at 48 h in 44641 women mixed parity

lower breastfeeding rates at 48h:

• confirmed previously reported associations with i.m. opioid

• oxytocin alone or in combination

with ergometrine (↓ 6-8%)

• prostaglandins administered for induction of labour.

length of labour not included in regression analysis

M.J.Wilson Anaesthetist(Sheffield)

C.MacArthur(Epidemiology)

D.Bick(Professor ofMidwifery)

A.Shennan(Professor of Obstetrics)

2010

Epidural analgesia and breastfeeding

• randomized controlled trial of epidural techniques with and without fentanyl and a non epidural comparison group

• controls matched for parity, del type and ethnicity

1054 women

• CSElow dose bup+fent bolus

• LDI: low dose bup+fent

• high-dose: bup boluses

• 151 pepthidine

• no analgesia(351

women)

• interview 24-48h on postpartum

initiated breast feeding.

• postal questionnaire

12 months:

duration of breast feeding

Number initiating breastfeeding:

• all epidural groups and groups no analgesia

• pepthidine group lower initiation rates

• dose of fentanyl:not support an effect on breastfeeding

It is impossibile to infer any adverse effect of neuraxial analgesia per se from existing studies

The one implication is that when prolonged epidural analgesia for labour

Breast feeding

Labour analgesia and the baby: good news is no news – F.Reynolds - St.Thomas’Hospital,London –

Int.Journal of Obst. Anesthesia (2011) 20,38-50

The one implication is that when prolonged epidural analgesia for labour using a local anaesthetic-opioid combination is extended for emergency

caesarean section it is probably preferable for the baby’s sake to avoid further opioid epidurally or systemically.

Quale è … l’opinione delle donne sulle informazioni ricevute

e cosa ci richiedono al fine di migliorare l’accessibilità e l’efficacia dei servizi forniti ?l’accessibilità e l’efficacia dei servizi forniti ?

More in hope than expectation: a systematic review of women’s expectationsand experience of pain relief in labour

All qualitative papers were assessed in terms of validity,methods used and analysis of the results,using the Critical Appraisal Skills Programme appraisal tool for qualitative research.

Once all studies had been appraised,four key themes were identified:

J.E.Lally,M.J Murtagh,S.Macphail and R.Thomson –

Institute of Health and Society –the Medical School,Newcastle University – BMC Medicine 2008,6:7

1 the level and type of pain

2 pain relief

3 involvement in decision-making

4 control

Expectations and experience of

The studies identified a wide range of experiences; one study found no difference in expectation and experience of pain levels; in most studies women found the pain worse than anticipated; in only one study did women report the pain to be better than expected.

There is a gap between expectation and experience of labour pa in because women understimated the intensity of the pain


level and type of pain

pain relief

Women wanted to access effective pain relief. A wide of preferences was identified ranging from women wanting no drugs at all during labour to those requesting sufficient drugs to make it a manageable or pain-free experience.

An expectation-reality gap was identified where wom en expecting a drug-free labour did not have one

J.E.Lally,M.J Murtagh,S.Macphail and R.Thomson –Institute of Health and Society –the Medical School,Newcastle University – BMC Medicine 2008,6:7

Expectations and experience of involvement in

Women are as concerned about being involved generally

Firstly . multiparous women who place emphasis on being fully informed rather than primiparous women who are concentrating on controlling emotions rather than being involved in decision-making.

Secondly . studies reported that preparation helped women cope physically and psychologically with their labour; also their knowledge of pain relief helped them make informed choices.

Expectations and experience of control

decision-making


The studies which looked at expectations of control did differentiate between types of contol:

• women expected to be in control of staff• expected to be in control of their own behaviour• expected to be in control during contractions

Given the importance of this sense of control preparation of women for labour is crucial

J.E.Lally,M.J Murtagh,S.Macphail and R.Thomson –Institute of Health and Society –the Medical School,Newcastle University – BMC Medicine 2008,6:7

control

Survey of the factors associated with a woman’s cho iceto have an epidural for labor analgesia

Althought epidural analgesia provides effective pain relief in labor, there are women

who choose not to use the technique during childbirth.The objectives of this study were to determine:

• Identify important factors associated with women receiving or not receiving labor epidural analgesia

• Determine the primary sources of information concerning epidural analgesia used by women

J.Harkins,B.Carvalho,A.Evers,S.Mehta and E.T.Riley – University of South Florida College of Medicine –Tampa USA Department of Anesthesia Stanford University School of Medicine – Stanford Anesthesiology Research and Practice – vol.2010,article ID 356789,8 pages


Before coming to the hospital After coming to the hospi tal

What was the number onereason why you might

have wanted an epiduralfor labor?

Received epidural ( n.242 )What was your mainreason for actually

obtaining an epiduralfor your labor?

Received epidural ( n.242)

pain control 192 (79%) pain control 211 (87%)

previous experience 17 (7%) previous experience 5 (2%)

encouraged by friend / family

15 (6%) encouraged by friend or family

7 (3%)

other 10 (4%) other 7 (3%)

relief of fatigue / stress 7 (3%) relief of fatigue or stress 7 (3%)

encouraged by professional 2 (1%) encouraged by nurse 3 (1%)

encouraged by obstetrician 2 (1%)

Before coming to the hospital After coming to the hos pital

What was the number oneconcern you regarding

epidurals,which may haveled you towards avoiding

an epidural for labor

no epidural epidural ( n.58)What was your main reason

for not obtaining anepidural for labor pain?

No epidural received(n.58)

desire for natural childbirth 16 (27%) desire for natural chilbirth 19 (33%)

concern of possible risks to themselves

14 (23%) concern of possible risks to themselves

15 (26%)

pain from needle or 11 (19%) pain from needle or 5 (9%)pain from needle or procedure

11 (19%) pain from needle or procedure

5 (9%)

afraid of delaying labor or increasing risk of cesarean

10 (17%) afraid of delaying labor or increasing risk of cesarean

3 (5%)

concern over possible risk to baby

6 (10%) concern over possible risks to baby

2 (3%)

other 2 (4%) too far along in labor 5 (9%)

other 9 (16%)

Survey of the factors associated with a woman’s cho iceto have an epidural for labor analgesia

Partner preference and having had a previous epidural were the two factors that emerged from the multiple logistic analysis as significant predictors of a woman receiving an e pidural .

One interesting observation is how many women changed their minds , from having a low desire for an epidural on arrival to the hospital to wanting one during the course of labor.epidural on arrival to the hospital to wanting one during the course of labor.

This suggests that many women do not have clear expectations of the severity of l abor pain and perhaps unable to make an informed choice until after they have actually experienced labor pain.


Phase 1 developement of an index to measure the quality of neuraxial labour analgesia: exploring the perspectives of childbearing women

Transition question

1. Think back to when you first decided to have an epidural.What worried you most about having one?

Key question:

Women’s experiences and perspectives of neuraxial labour analgesia were explored in focus groups and in depth interviews < 72 hr.following childbirth

once your epidural was in place and working:

2. What did you like most about it?

3. What things bothered you about it ?

4. If you could improve the epidural you received,what would you want? That is,what is it about your epidural you would want changed?

5. How would you describe an ideal or quality epidural for labour and delivery?

P.Angle, C.Kurtz Landy,C.Charles,J.Yee,J.Watson - Can J Anesth / J Can Anesth (2010)57:468-478

Phase 1 developement of an index to measure the qua lity of neuraxial labour analgesia:exploring the perspectives of chil dbearing women

Women’s perspectives must be incorporated into the assessment of quality neuraxial analgesia in order for research to measure this outcome in a meaningful manner.

.Four major themes emerged:

1 the enormity of labour pain


2 the fear and anxiety related to epidural pain relief

3 what women value about epidural pain relief

4 the relative value of achieving epidural pain relief vs avoidance ofepidural drug side effects

Theme 1. The enormity of labour pain

This theme described partecipant’s experiences as they struggled to deal with pain over the

course of labour. There are third subtheme:

1. “ an unbearable level of pain” which described the nature of the pain partecipants

encountered.Many women voiced that they were already close to or beyond their ability to cope

by the time they decided to have epidural analgesia.

2. ” an inability to focus” which described the impact of pain on women’s mental capacity to

focus and process information.

3. ”the struggle to maintain Self-control” described the difficulties women encountered in

maintaining mental and emotional control in the face of severe pain.


Theme 2: Fear and anxiety related to epidural pain relief

There are four subthemes :

1. being able to freely choose epidural relief

2. apprehension over access and availability of epidural pain relief 2. apprehension over access and availability of epidural pain relief

3. apprehension over the effects of the epidural on labour progress

4. fears related to epidural insertion


Theme 3: What women value about epidural pain relief

This theme was composed of five subthemes that captured the variety of ways partecipants described the impact of epidural analgesia on their labour and delivery experiences .

• pain relief restores feelings of internal control and the ability to focus

• modern neuraxial analgesia permits participation and control

• the value of pain relief that preserves bodility sensations of labour progress

• the value of pain relief that preserves mobility and strenght

• pain relief improves women’s labour and delivery experiences


Theme 4: The relative value of epidural pain relief vsavoidance of epidural drug side effects

The four major theme included two subthemes and captured women’s perspectives on the importance of ensuring pain relief over common epidural side effects.

• pain control is most important

• the relative importance of preserving strength and mobility over avoidance of other epidural drug side effects


Knowledge and decision-making for labour analgesia of Australian primiparous women

Women described their labour pain relief plans as flexible in relation to their labour circumstances; however most women wanted to take an active role in decision-making

Camille H.Raynes-Greenow,Christine L.Roberts,Kirsten McCaffery,Judith ClarkeCentre of Perinatal Health Services Research-University of Sydney – Midwifery /2007) 23,139-145

Objective: to asses and investigate knowledge of labour pain management optionsand decision-making among primiparous women


1 How much pain should be experienced in chilbirth?

2 Are you fearful of labour pain?

3 What are the pain relief options available to you?

4 What are the pros and cons of these opinions?

5 Are there any risks to mother or baby?

6 Where did you hear of these methods?

7 Which information source was most helpful?

8 Do you feel like there is some information that you are missing, or is confusing?

9 What is your preference for the way written information is presented ?( personal stories,list of pros and cons,referenced,written by a doctor)

10 Have you made any specific plans for pain relief ? Who has helped you make these decisions ? How realistic do you think your plans are ? How definite/flexible are your plans ?

11 Have you considered having a support person ?


Intrapartum analgesic knowledge

When asked if they knew of the pain-relief options for labour,all women felt that they were very knowledgeable about intrapartum pain management and readily enumerated both pharmacological and non-pharmacological pain-management methods.

Outcomes for epidural analgesia were rarely if ever mentioned.The risks that were mentioned were usually based on the experience of others.Being unsure of side-effects and holding misconcept ions were common for all analgesic options.

Source and reliability of information

Most women talked about books that were widely used and well liked although leaflets and magazines were also frequently used.The most common source of information was anecdotal information from family and friends.Women felt that their friends and family were honest,candid and reliable.

Camille H.Raynes-Greenow,Christine L.Roberts,Kirsten McCaffery,Judith ClarkeCentre of Perinatal Health Services Research-University of Sydney – Midwifery /2007) 23,139-145

This gap between perceived knowledge and actual knowledge is a concern as it suggest that

“women may not be truly participating in informed d ecision-making”

1There is a gap between expectation and experience of labour pain because women understimated the intensity of the pain .Many women voiced: “ an unbearable level of pain” ” an inability to focus” ”the struggle to maintain Self-control

2Studies reported that preparation helped women cope physically and psychologically withtheir labour; also their knowledge of pain relief helped them make informed choices.

3When asked if they knew of the pain-relief options for labour, all women felt that they were veryknowledgeable about intrapartum pain management …. Being unsure of side-effects and holding misconceptions were common for all analgesic options .

Reassuming

Partner preference and having had a previous epidural were the two factors that emergedfrom the multiple logistic analysis as significant predictors of a woman receiving an epidural.

holding misconceptions were common for all analgesic options .

4 The most common source of information was anecdotal information from family and friends

L’organizzazione di un piano di assistenza per il supporto ed il controllo del dolore della donna in travaglio di parto deve tener conto dei bisogni e della situazione clinica della persona assistita e

delle risorse / vincoli presenti nella singola struttura / situazione nella quale avviene il parto.

I ginecologi,le ostetriche e gli anestesisti devono avere una visione strategica degli obiettivi e condividerli, c’è la necessità di sviluppare

una cultura della gestione…

Concludendo

una cultura della gestione…

Alla donna dovrebbero essere fornite informazioni basate su prove di efficacia in mododa renderla capace di prendere decisioni sul metodo di assistenza

Le scelte della donna devono essere considerate par te integrante nel processo assistenziale

24/02/11

promuovere ed informare sull’analgesia in travaglio - amarcord... · the differing approach of...

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