Does labour epidural slow the progress of labour and lead to complications? Obstetricians’ perception working in private and public sector teaching hospitals in a developing country
Address for correspondence: Dr. Muhammad Sohaib, Department of Anaesthesia, Aga Khan University Hospital, Stadium Road P.O. Box 3500, Karachi 74800, Pakistan.
E-mail: m.sohaib@yahoo.com
Muhammad Sohaib, Samina Ismail
Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan
Abstract
Background and Aims: Obstetricians play a major role in the decision making for provision of analgesia for the woman in labour. As epidural analgesia (EA) is the most preferred technique, it is important to know obstetricians’ perception regarding its effect on progress of labour and associated complications. Methods: The 6 months cross-sectional study included 114 obstetricians from teaching hospitals. After informed consent, obstetricians were asked to fill a predesigned questionnaire containing 13 close ended questions regarding their perception on the effect of EA on progress of labour, EA complications and whether they would recommend EA to their patients or not. Other variables included age, gender, training in EA, practice type and hospital settings (private or public sector). Results: Majority of the obstetricians had the perception of EA prolonging the first stage (89.5%) and second stage (98.2%) of labour, increasing the rate of caesarean section (87.7%), instrumental delivery (58.8%) and increasing the incidence of backache (85.5%). None of the obstetricians received any formal training in EA. Majority (84.2%) were not sure if they would recommend EA to their patients. When these responses were compared between public and private sector, a statistically higher percentage (P < 0.001) of public sector obstetricians had negative perception of EA. Conclusion: Perception of obstetrician regarding EA is contrary to the current evidence. There is a need to introduce formal curriculum on EA in obstetric training program and conduct regular refresher courses.
Key words: Caesarean section, complication, epidural, labour
Introduction
The use of epidural analgesia (EA) in labour is widespread in modern labour ward practice, and its benefits in terms of pain relief are well-recognized.[1] It not only provides significantly effective analgesia as compared to parenteral opioid, but has also been
first stage of labour and 21% believed that it shortens the duration.[4] Another study, conducted in India, showed that 30% of obstetricians had the perception of labour epidural (LE) prolonging the duration of labour without specifying which stage of labour.[5] One survey conducted in Turkish hospitals to assess the
shown to decrease the duration of active first and
second stages of labour.[2,3]
Obstetricians play an important role in decisions pertaining to patient’s management including those related to labour analgesia; therefore it is important to know how the obstetrician perceived the effects of EA on the progress of labour, outcomes and side effects. A previous study from Australia on this subject showed that 29% of obstetricians believed that EA prolongs the
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Sohaib and Ismail: Obstetricians’ perception towards labor epidural
knowledge and attitude of obstetricians regarding EA showed inadequate knowledge of obstetricians in the subject.[5]
Different studies have quoted higher rate of labour EA in developed countries.[6-10] There is a paucity of data on obstetricians’ perception regarding LE from developing countries. In order to improve labour EA services, there is a need for a better understanding of obstetricians’ perception towards LE. As only when the perceptions are understood, appropriate measures can be taken to improve collaboration between anesthesiologist, obstetricians and patients.
Therefore, the primary objective of this study was to find out the perception of obstetricians working in teaching hospitals regarding the effect of LE on the duration of labour, side effects, incidence of caesarean section and instrumental vaginal delivery. Obstetricians were also asked as what method in their opinion is the most effective for labour pain relief and if they would like to recommend LE to their patients or not.
METHODS
After approval from Hospital Ethics Committee and written informed consent, this cross-sectional survey was conducted from December 2012 to May 2013 on 114 obstetricians working in teaching hospitals of one of the states of our country. We included consultant obstetricians or senior postgraduate trainees in their final year of gynaecology and obstetrics training program. Participants not willing to participate were excluded from the study. Four teaching hospitals were included in the study; two from public and two from private sector. Permissions were obtained from the heads of the department of obstetrics and gynecology unit of each of the participating hospital. Participants who fulfilled the inclusion criteria were approached and explained the purpose of the study. They were assured about the confidentiality of their personnel details and the name of their institution. Participants willing to take part in the study were enrolled after written informed consent. The data collection tool was a predesigned questionnaire having 13 close- ended questions. The enrolled participants were handed over the predesigned questionnaire and were collected after 15’20 min by the primary investigator. The questionnaire was divided into three sections. The first section was designed to collect information pertaining to gender, years of experience, practice type
(credential consultants or final year trainee), source of knowledge regarding LE, whether they have received formal education or not and hospital settings (private or public sector).
The second section included the perception of LE on the progress of labour; whether in the opinion of participating obstetrician, LE increases the duration of different stages of labour, increase the incidence of cesarean section or operative vaginal delivery. The options included ‘yes,’ ‘no’ and ‘do not know.’
The third section included the perception of obstetricians regarding the side effects of LE; they were asked if they think that LE is associated with long- term low back ache and whether LE has any effect on neonatal Apgar score.
The fourth and the final section of the questionnaire included the perception of obstetricians as to which method of labour pain relief is safest in their opinion for primigravida and multigravida. The options included parenteral opioids, entonox and epidural analgesia. The final question was whether they would recommend LE or not. The options included ‘yes,’ ‘no’ or ‘don’t know.’
One hundred and fourteen participants were included in this study which was based on a previous study of Pirbudak et al.[6,11] in which 60% obstetrician’s knowledge regarding LE was reported, so the perception of obstetrician’s regarding LE were estimated within 9% level of precision with 95% confidence interval (CI) using World Health Organization sample size calculator. All statistical analysis was performed using Statistical Packages for Social Science version 19 (SPSS Inc., Chicago, IL, USA). Frequency and percentage were computed for categorical variables and analyzed by Chi-square and fisher exact test while mean and standard deviation were estimated for numeric observation. P ‘0.05 was considered as significant.
RESULTS
The demographics of the study population, included gender, practice type, hospital settings and years of experience are shown in Table 1. None of the participating obstetricians received formal training of EA as a part of their postgraduate curriculum but around 50% of the respondents had received information on EA from lectures (62.5%) and from seminars/conferences (37.5%).
780 Indian Journal of Anaesthesia | Vol. 59 | Issue 12 | Dec 2015
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