Epidural Analgesia during Labor: Attitudes among Expectant Mothers and Their Care Providers

Abstract

Introduction:

Varying levels of knowledge and attitudes among parturients and physicians toward epidural analgesia result in its low utilization. We aimed to assess the knowledge, attitude, and practice of parturients, obstetricians, and anesthesiologists regarding epidural labor analgesia.

Methodology:

We surveyed obstetricians, anesthesiologists, and parturients availing care and later delivered at our hospital from July 1, 2017, to December 31, 2017. Knowledge, attitude, and practice regarding epidural analgesia were collected using a semi-structured predesigned questionnaire. Data were described as frequencies and analyzed for association between parity and various beliefs and attitudes using Chi-square or Fisher's exact test.

Results:

About 33% of the parturients knew that delivery is possible without labor pains, but only 18% were satisfied with the procedure. Timely epidural anesthesia could not be availed by 83% of the parturients due to unavailability of service. Among the obstetricians, 64% preferred epidural analgesia and thought that epidural analgesia prolongs the duration of labor, and 55% thought that it would increase the incidence of lower uterine segment cesarean section (LUSCS). In our survey, 48% of all anesthesiologists thought that epidural analgesia would lead to an increase in the incidence of instrumental delivery, 52% required intravenous analgesics with epidural, and 63% thought that it would not increase the incidence of LUSCS. Fear of labor and delivery pain, knowledge status, unwillingness and demand for epidural analgesia, satisfaction level, and reasons for not undergoing the procedure were significantly associated with the gravid status.

Conclusion:

Wide gap between desire for labor analgesia and its availability exists. A collaborative approach between anesthesiologists and obstetricians is required to disseminate correct information regarding epidural analgesia.

INTRODUCTION

Labor pain is a complex interaction between various physical and psychological factors. The parturient deals with not only her pain but also numerous myths created by the society, forcing her to endure a long and painful labor experience that may lead to exhaustion and physical and mental distress. The American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists have endorsed the use of analgesia during labor and delivery. Maternal request has been indicated as a sufficient justification for pain relief during labor.[1] Epidural analgesia provides superior pain relief during different stages of labor and may allow paturients to rest and relax facilitating their cooperation during labor and delivery. However, varying levels of knowledge and resulting attitudes toward epidural analgesia among parturients and their doctors are associated with its low utilization.[2] Therefore, in this study, we aimed to assess the knowledge, attitude, and practice of parturients, obstetricians, and anesthesiologists regarding epidural labor analgesia. This will help us in understanding the reason for its low utilization and make necessary recommendations to enable a smooth introduction of an effective epidural labor analgesia program at our hospital.

METHODOLOGY

Study design and setting

After obtaining the Institutional Ethical Committee approval, we surveyed obstetricians, anesthesiologists, and parturients in our hospital from July 1, 2017, to December 31, 2017. Parturients were requested to complete the survey following informed consent. The mothers read the survey, and study investigators were available to assist participants completing the survey and clarify any question that arose. Verbal and written informed consent was taken from all the parturients in their vernacular language. The hospital where the study was conducted is located in an urban area of Ludhiana district, Punjab, India. This tertiary level care privately funded hospital is a teaching hospital with undergraduate medical and postgraduate students and caters to the health-care needs of Ludhiana district and adjoining districts. According to 2011 census, Ludhiana district has a population of 1.6 million with the literacy rate of 82%.[3]

Sampling

We used consecutive sampling for including parturients in the study. We included all parturients who were availing antenatal care and later delivered their baby at our hospital in patient labor ward from July 1, 2017, to December 31, 2017. We excluded parturients who had complicated pregnancy and were refused to give consent. For this interview, we included faculty members, senior residents, and postgraduate students from the departments of obstetrics and gynecology and anesthesia. They were contacted personally and those agreeing to participate were given a structured questionnaire to be fill. Postgraduate students included in the study had at least 2 years of training and experience in the subject.

Data collection and data analysis

The first part of the survey had questions regarding the sociodemographic profile of the respondents such as age, religion, education level, parity, occupation, residence, and previous cesarean section. The second part consisted of 15 questions and assessed knowledge, source of information, and perception on labor analgesia. On an average, each survey took about 10 min. The filled out questionnaires were then checked for completeness. These questions were developed from focused discussion by authors. Answer types included choosing from a menu of choices. The data were entered into SPSS software for analysis. Data were presented as frequency and percentages. Separate tables were constructed for parturients, obstetricians, and anesthesiologists. In addition, responses of multigravid and primigravid patients were compared for various beliefs and attitudes using Chi-square or Fisher's exact test. P < 0.05 was taken as statistically significant.

RESULTS

During the study period, a total of 102 parturients were recruited in this study who attended the antenatal clinic. The average age of the parturients was 28.9 ± 2.53 years and 50% resided in urban areas. Thirty percent of the parturients were graduates, 23% were postgraduates, and only 3% were illiterates. In our study sample, 91% of the parturients had some fear about labor and 94% were concerned about delivery pain [Table 1]. Thirty-three percent of the parturients knew that delivery is possible without suffering from labor pains and 47% of the parturients had information about labor analgesia. Fifty-nine percent were ready to request for an epidural analgesia in labor after getting full information, and the reasons for unwillingness are mentioned in Table 1. In the previous delivery, only 6% of the parturients obtained epidural anesthesia, and only 18% were satisfied with the procedure. Respondents stated that timely epidural anesthesia could not be obtained in the current pregnancy because, in 83% cases, service was unavailable, in 15% cases, doctors refused citing epidural to be unsuitable, and in 3% cases, the anesthesiologist was busy. The experience of labor and delivery with epidural analgesia was good in 15% cases. Approximately 3% of the patients found the procedure to be painful.

Table 1.

Knowledge and beliefs of parturients (n=102)

In our sample, 82% of the obstetricians preferred epidural analgesia for labor, and 77% thought the correct time of insertion to be 4-cm dilatation [Table 2]. Amongst the surveyed obstretrician,55%believed that epidural analgesia increases the incidence of lower uterine segment cesarean section (LUSCS) and 91% believed that epidural analgesia increases the incidence of instrumental delivery. Furthermore, 46% thought that epidural analgesia would be beneficial for nulliparous patients. On surveying the anesthesiologists, 59% thought that the correct time of epidural catheter placement was on maternal request [Table 3]. The use of patient-controlled analgesia (PCA) pump and adjuvants was preferred by 82% and 85% of the surveyed anesthesiologists. Forty-eight percent of the surveyed anesthesiologists believed that epidural analgesia would lead to an increase in the incidence of instrumental delivery by 15–25%. Epidural was beneficial in nulliparous women; However 52% of the anesthesiologist preferred continuous epidural PCA along with intravenous analgesics. Two-thirds thought that epidural would not increase the incidence of LUSCS. The most feared complication thought by 44% of the surveyed anesthesiologists was inadvertent dural puncture and local anesthetic toxicity. Different combinations and concentrations of ropivacaine, bupivacaine, and levobupivacaine along with fentanyl were used by 41% of the anesthesiologists Table 3 and 74% did not prefer test dose with 2% xylocaine with epinephrine.

Table 2.

Attitude of obstetricians included in the study (n=44)

Table 3.

Attitude of anesthesiologists included in the study (n=54)

Furthermore, we found that fear of labor and delivery pain, knowledge status, unwillingness and demand for epidural analgesia, satisfaction level, and reasons for not undergoing the procedure were significantly associated with the gravida status [Table 4].

Table 4.

Comparison of knowledge and beliefs with gravidity of the parturient

DISCUSSION

This study found that only 33% of the surveyed parturients knew that delivery is possible without suffering from labor pains and epidural is an effective method of pain relief. Only 6% of those patients who asked for epidural labor analgesia actually underwent the procedure because service was not available when asked for (83%), which shows the gap between knowledge and practice. Moreover, many misconceptions and fears associated with epidural use were prevalent. Most obstetricians (64%) and anesthesiologists also prefer epidural analgesia for labor. However, the gap needs to be filled by more obstetricians and anesthesiologists discussing the facility with patients and making it available round the clock.

A previously published study shows that information leaflets and the antenatal education classes are the main sources of knowledge on epidural analgesia for the parturients.[4] However, the main sources of information for this study participants were relatives and informal talks in the hospital. Our sociocultural norms, due to which majority of females feel comfortable to discuss personal matters within themselves, might be responsible for it. Many other studies in low- and middle-income countries reported low level of knowledge compared to the developed countries,[5] which may be another reason for low level of awareness among the patients. Moreover, Taneja et al. reported that majority of the obstetricians in India were not taught labor analgesia during their residency program and their practical exposure to the procedure was limited.[6] The authors further concluded that despite a certain degree of awareness, there is still a need to further educate, train, and increase communication between obstetricians, anesthesiologists, and parturients regarding the implementation of effective labor pain relief in India. In another study, labor pain was commonly expected among parturients and tolerated it as a natural process.[7] However, 98% reported that they would ask for effective pain relief if given a choice.

The provision of pain relief in labor could be used as an incentive to help change reluctant behavior toward institutional delivery. It is, therefore, recommended that hospitals, especially in government settings, should include pain relief options as part of a comprehensive delivery package. Varying training levels of obstetricians also affected the level of knowledge about epidural analgesia. While an Australian study showed significantly better knowledge scores among those obstetricians with <5-year experience, a Turkish study showed better scores among those with 6–15 years of clinical experience.[8] In addition, younger female obstetricians have been shown to significantly favor epidural analgesia in comparison to their older male counterparts above 40 years.[9] The authors further concluded that 77% of obstetricians thought that epidural analgesia prolonged labor and increased incidence of instrumentation, over 84% agreed that the technique was not associated with adverse neonatal or maternal outcome, and up to 98% would prefer epidural analgesia.

CONCLUSION

The results of this study have highlighted the wide gap that exists between the desire for labor analgesia and its availability to the parturients. Parturient women in this study had poor knowledge about epidural analgesia, and this necessitates the role of doctors in disseminating appropriate and accurate knowledge regarding epidural analgesia and eliminating the fears and misconceptions of parturients to its utilization. Collaborative efforts of anesthesiologists and obstetricians are required to ensure that every delivery is painless.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.