Practice of Labor Analgesia among Anesthesiologists Across India: Cross-sectional Study

Abstract

Background:

The practice of labor analgesia is an essential part of standard obstetric care. There are many guidelines and programs, which have been setup in labor pain management, in the developed country. In India, the practice of labor analgesia is not very popular. The role of labor analgesia providers lies in educating the parturients about the need of labor analgesia and also to develop comprehensive programs and guidelines in providing it.

Aim:

The aim of our study was to assess knowledge and practice of labour analgesia among anaesthesiologists across India.

Methods:

Survey was carried out using SurveyMonkey, an online internet website. Questionnaires were sent by mail to 11,986 anesthesiologists. The questions were based on methods of labor analgesia practice, regional analgesia techniques, commonly used drugs, complications and myths surrounding labor analgesia.

Statistical Analysis:

Responses were compiled and data was analysed. Results were expressed as percentages.

Results:

There were 1351 responses to the survey. Labor analgesia was practiced mainly by anesthesiologists across India (71.34%, n = 945). Regional analgesia techniques were the most common techniques followed in providing labor analgesia (69.61%, n = 940) and among regional analgesia techniques, epidural analgesia (43.52%, n = 588) was the most common method. Bupivacaine was considered the drug of choice (64.10% n = 866) and Fentanyl was the standard adjuvant used (83.34% n = 1126). Majority of the respondents did not believe in myths surrounding labor analgesia.

Conclusion:

Epidural analgesia is the most common technique practiced, bupivacaine the commonly used local anaesthetic, fentanyl common adjuvant used in practice of labour analgesia by anaesthesiologists across India.

INTRODUCTION

Delivering a child is often referred to as a rebirth for mothers. The pain experienced in this process is beyond words can explain. This pain can result in a deviation from normal obstetric course and be potentially dangerous to both mother and fetus. Labor analgesia has evolved from 18^th century with the use of ether to present day practice of regional techniques incorporating modern technology. An array of regional techniques, nonpharmacological methods, systemic analgesia have remodeled pain management in parturient resulting in better satisfaction.[1] To begin with, obstetricians were the ones commonly involved in providing labor analgesia. With the introduction of regional techniques, anesthesiologists became part of labor pain management.

There is still lack of knowledge and awareness among majority of the parturients from India about the acceptance of labor analgesia. This can be mitigated by conducting comprehensive labor analgesia programs involving obstetricians, anesthesiologists, and other health care providers engaged in obstetric care. In the past, there have been numerous surveys and studies regarding obstetricians perspective toward the practice of labor analgesia but none involving anesthesiologists. Hence, the objective of this survey was to evaluate knowledge, perspective, and practice of labor analgesia among anesthesiologists across India which would contribute in building comprehensive labor analgesia programs.

METHODS

Ethical committee clearance was obtained from Institutional ethical committee, Miller's anaesthesia and Chestnut's Obstetric Anesthesia Principles and Practice[2,3] were taken as reference for survey questions. The questions were compiled under different domains to gather information regarding demographic profile of participants, methods of labor analgesia practice, regional analgesia techniques, drugs commonly used, complications of regional analgesia, and finally myths surrounding labor analgesia [Appendix I]. Questions were initially designed by two of the anesthesiologists who were involved in the study and later validated and refined by one of the senior anesthesiologists. An online pilot study involving faculty members from our department was carried out and their views and suggestions were taken regarding the content and ease of completion of the study. A final draft was prepared and the questions were E-mailed to members of Indian society of Anaesthesiologists through “Survey Monkey” website (surveymonkey.com) and a link was provided for the questionnaire. Anonymity was maintained throughout the study and submitting completed questionnaire would imply consent to participate in the study. Survey monkey software was programmed in such a way that it allowed the survey to be taken just once and allowed answering the questions logically to meet the objectives of the survey. Two reminder notices were sent in 2 weeks interval for those who had not responded and to those who had partially responded to the survey. An option to opt out of the survey was also provided.

Statistical analysis

Results were evaluated and statistical analysis was performed using Microsoft^® Excel (2007) and spreadsheet. Data was summarized descriptively using frequency distribution and was expressed as absolute numbers and percentages.

RESULTS

E-mails were sent to 11,986 anesthesiologists throughout the country. 1981 mails were received of which 327 did not practice labor analgesia and 303 respondents had partially replied in spite of reminders. Response rate was 16.47%. 1351 participants who had completed the survey and practiced labor analgesia were included for analysis. Demographic data of the respondents is shown in Table 1.

Table 1.

Demographic data

Hospital setup

The highest rate of labor analgesia practice was seen in private (32.35%) and corporate hospitals (31.16%) followed by private medical college (21.10%) and least by government medical colleges (12.44%), and government hospitals (2.96%) [Figure 1].

Figure 1.

Labor analgesia practice in various hospital setup. Data expressed as percentage

Labor analgesia practice

According to 1351 respondents, labor analgesia was mainly practiced by anesthesiologists (71.34%, n = 945) followed by both anesthesiologists and obstetricians (27.27%, n = 368) and least by obstetricians only (1.39%, n = 18). About 69.61% (n = 940) respondents were of the opinion that regional analgesia was the most common method of labor analgesia practiced in their setup. Moreover, for 27% (n = 364) respondents, it was systemic analgesia and for 3.39% (n = 47); it was nonpharmacological methods [Table 2]. 70.36% (n = 950) of respondents replied that they were aware of methods of labor analgesia practiced by obstetricians in their setup in contrast to 29.64%(n = 401) who were not aware.

Table 2.

Labor analgesia techniques practiced in India

Labor analgesia practice by obstetricians

Of the respondents 997 replied to questions on drugs and mode of administration of drugs by the obstetricians. They mentioned that tramadol (45%, n = 424) was the most common opioid analgesic used followed by fentanyl (20%, n = 197) pentazocine (18%, n = 174), and meperidine (16%, n = 155) [Table 3]. Intravenous boluses with intermittent dosing (75.33%, n = 715) were the common mode of administration and least was parturient controlled intravenous analgesia (8.59%, n = 81), and for some respondents (16.08%, n = 154), it was both. Regarding inhalational techniques, 238 (17%) responded, among them 151 (63%) replied that Entonox was the most common inhalational agent used by obstetricians and for 84 (35.29%) respondents, it was N20 plus Oxygen and for 28 (11.76%) respondents, it was sevoflox.

Table 3.

Drugs used by obstetricians for labor analgesia

Regional analgesia techniques, drugs, and monitoring

Regarding indication to start labor analgesia, maternal request was the most common indication according to 1005 (74.38%) respondents. According to 124 (9.17%) respondents, it was preexisting medical disorders and hypertensive disorders of pregnancy as the common indication. The rest was shared by multiple pregnancies, previous cesarean sections, prolonged labor, and deterioration in fetal well-being as the most common indications for labor analgesia.

Epidural analgesia with intermittent boluses was the most common regional technique according to 588 (43.52%) respondents followed by continuous infusion with intermittent boluses which was answered by 512 (37.89%) respondents. The rest was shared by single-shot spinal analgesia, combined spinal-epidural analgesia, and parturient-controlled epidural analgesia. The least was continuous spinal with microcatheters and pudendal and paracervical blocks [Table 4].

Table 4.

Regional analgesia techniques practised by anesthesiologists for labor analgesia

Bupivacaine ranked first as local anesthetic to be used in labor analgesia according to 866 (64.10%) respondents followed by ropivacaine which was considered by 356 (26.35%) respondents. The least was levobupivacaine and lignocaine [Figure 2]. Fentanyl was the most common adjuvant according to 1126 (83.34%) respondents. Moreover, for 117 (8.66%) respondents, it was clonidine and for 56 (4.14%) respondents; it was epinephrine [Figure 3].

Figure 2.

Local anesthetics used in regional analgesia. Data expressed as percentages

Figure 3.

Adjuvants used in regional analgesia. Data expressed as percentages

For combined spinal-epidural analgesia and single-shot spinal analgesia, both local anesthetics and opioid adjuvants were favored by a majority of the respondents.

Majority of the respondents, i.e., 1283 (95%) considered using pulse oximetry, noninvasive blood pressure, and fetal monitoring during conduct of regional analgesic techniques.

Complications

Regarding complications associated with regional analgesia techniques, hypotension was the most common complication followed by pruritis and bradycardia. The rest was shared by dural puncture, backache, urinary retention, and postdural puncture headache. The least was high block, epidural hematoma, and abscess.

Recent advances and myths surrounding Labour epidural analgesia

Regarding usage of imaging techniques,108(8%) of the respondents considered using ultrasound while placing epidural and computer integrated parturient controlled analgesia. Walking epidural was considered by 905 (67%) of the respondents. Majority of the respondents did not believe in myths surrounding labor analgesia [Table 5]. Finally, majority of respondents agreed epidural analgesia techniques was considered the most effective form of labor analgesia with greater maternal satisfaction.

Table 5.

Myths surrounding labor analgesia

DISCUSSION

Safe practice of labor analgesia in parturients applies to obstetricians and anesthesiologists. In India, practice of labor analgesia is wavering. Barely 23% of parturients accept labor analgesia according to the previous survey done in Delhi and Chennai.[4,5] This is an alarming issue when compared to other countries. In most of the developed nations providing pain-less labor for women during childbirth has become one of the main health agendas and national programs and curriculums have been implemented and developed over the last two decades.

Labor analgesia practice

The result of our survey showed most of the respondents who practiced labor analgesia were from corporate hospitals (31.16%) and private nursing homes (32.34%) followed by private medical colleges (21.10%). The least were from government medical colleges (12.44%) and government hospitals (2.96%). This implies that labor analgesia is available for parturients from upper and middle strata of the society. In Government medical colleges and hospitals, where there are more number of patients from rural and lower income group and where more number of deliveries take place, the practice of labor analgesia is sparse. The reasons attributed for such low rate may be owing to large number of patients, lack of staff and facilities, and lack of knowledge of parturients in availing labor analgesia. In the United States of America, a recent survey reported labor epidural analgesia service was available 24 × 7 in 84% of the hospitals which conducted more than 1500 deliveries per annum and 15% of the hospitals which conducted <500 deliveries per annum.[6]

According to our survey, 70% of the responders replied that labor analgesia is mainly administered by the anesthesiologists. This can be related by the fact that anesthesiologists are the ones who practice regional techniques. A survey done in India and Turkey about practice of labor analgesia showed that labor analgesia would be best provided by anesthesiologists.[7,8]

Nearly 70% of the respondents agreed that regional analgesia was the most common methods practiced among labor analgesia and similar results have been observed in the United States.[6] Systemic analgesia is used as an adjuvant along regional techniques or used solely in early stages of labor. Our survey showed systemic analgesia is practiced by 27% of the respondents and mostly in places where regional techniques were not available. Its repeated dosage, poor efficacy, maternal and fetal complications, and lesser satisfaction among parturients has made it less popular when compared to regional techniques. Similarly only 3.47% of respondents agreed for using nonpharmacological methods. There is lack of evidence about efficacy but still can be considered in places where there are no resources for regional techniques.

Labor analgesia techniques among obstetricians

Tramadol is the most commonly used systemic opiod among obstetricians followed by fentanyl. Low cost, administration by both intramuscular and intravenous route, its availability in most of the government hospitals in India, and lesser side effects has made it more popular when compared to others. However, its efficacy is poor compared to pethidine which is popular worldwide[1] Pethidine ranked fourth in our survey may be due to availability of better opioids like fentanyl in most of the private setups and tramadol in government hospitals. Morphine, ketamine, and nalbuphine were not chosen by many of our respondents.

Regarding use of inhalational agents only 17% of the respondents replied. Among the inhalational agents, entonox was the most commonly used inhalational agents by obstetricians. The reason might be because of ease of administration and its availability compared to other agents such as sevoflox. Literature gives conflicting results regarding its analgesic efficacy but better when compared to placebo.[9,10,11]

Regional analgesia practice

Neuraxial techniques have been the gold standard technique among labor analgesia. They provides great maternal satisfaction, complete, and uninterrupted analgesia to the parturients. Later, if required they can be converted to surgical anesthesia. In the United States, a survey conducted in 2011 showed 70% of them used neuraxial analgesia when compared to 61% in 2001 in majority of the hospitals.[6] In United Kingdom, regional analgesia rate was 20.08% according to national obstetric anesthesia data for 2012.[12] In our survey, 70% of them considered providing neuraxial analgesia for labor pains as stated before.

Among regional analgesia techniques, epidural analgesia with intermittent boluses (44%) was chosen by the responders as the most common method followed by continuous infusions (38%). The reason might be the duration and flexibility it offers when compared to spinal techniques. In England, a survey on epidural analgesia showed that continuous epidurals infusions (54.1%) are more common than intermittent boluses (47.4%).[12] Combined spinal-epidural analgesia and patient-controlled epidural analgesia are less popular as they have been recently introduced and still, there is lack of acceptance among anesthesiologists across India. These new techniques have been vastly practiced and accepted in developed countries, and nearly 40% of parturients opt for patient-controlled epidural analgesia in England.[12] Single-shot spinal analgesia and spinal catheters were least chosen by our respondents due to practical difficulties and its limited duration to provide analgesia. However, it can be used as an alternative in facilities, which have limited facilities for epidural analgesia.

Maternal request (74.38%) has been found as the most common indication for the initiation of neuraxial analgesia techniques in our survey which correlates with the literature search.[13,14,15] The obstetricians can take a decision in a few situations such as late stages of labor, preexisting hypertensive, and medical disorders which was also agreed by 9.17% of the respondents.

The results of our survey showed that 64% of the respondents agreed with bupivacaine have the common local anesthetic for neuraxial analgesia which has been used conventionally all over the world. Similarly, a survey conducted in Czech republic showed that 80% of the anesthesiologists used bupivacaine followed by levobupivacaine for neuraxial analgesia.[16] Ropivacaine was chosen the second most common local anesthetic used by 26.65% respondents, and studies have shown that ropivacaine being equally effective in providing labor analgesia like bupivacaine.[17,18,19] Fentanyl is the common adjuvant used while administering labor analgesia according to 83.34% respondents. The reason being its short duration and safe for both fetus and mother.[20,21,22]

Using lesser concentration of local anesthetics with opioids have led to lesser complications of epidural analgesia preventing the motor block and allowing the parturients walk out of bed. In our survey, 67% of the anesthetist agreed that they would let parturients mobilize while having epidural analgesia. Similarly, a survey in England showed that nearly 40% of obstetric units considered mobilizing parturients while receiving epidural analgesia.[12]

Myths surrounding epidural labor analgesia

Nearly 57.88% of the anesthesiologists in our survey agreed that labor epidural analgesia did not have any impact on cesarean rate and instrumental delivery. The Cochrane database systemic trials have shown that there is no statistical difference between epidural analgesia and cesarean rates.[23] Similarly, there is conflicting findings in literature about the epidural analgesia and its association between instrumental delivery.[24]

Regarding prolongation of first and second stage of labor, 56.35% of the anesthesiologists agreed there was no prolongation of first and second stage of labor. Studies have shown that effective neuraxial analgesia can prolong second stage of labor; however, no effect on first stage.[25] In our survey, majority of the anesthesiologists did not believe that epidural analgesia would result in maternal pyrexia, backache, impaired breast feeding or associated with low APGAR score. There is lack of evidence between epidural analgesia and any of the factors mentioned above in the literature.

Limitations and further scope of the study. Obstetricians were not involved in our study. Since it is a cross-sectional study, chances of bias cannot be ruled out. We recommend to involve obstetricians along with anesthesiologists and also to consider involving organizations like Indian society of anesthesiologists and Indian society of obstetricians in future surveys.

CONCLUSION

It is concluded that among the 1351 anaesthesiologists responded to our survey, we found out that majority of them practice continuous epidural analgesia using bupivacaine with fentanyl as intermittent boluses or continuous infusion as a form of labour analgesia. It was also found out that there was no increase in the number of caesarean sections or prolongation of labour after epidural labour analgesia. More number of anaesthesiologists in private hospitals practice labour analgesia compared to Government Hospitals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Questionnaire on practice of labor analgesia

Questions

Demographic details

1. Age >40 years <40 years

2. Gender Female Male

3. Years of experience in Anesthesia <5, 5– 10 years 10–20 years 20–30 years >30 years

4. Designation:

   • (a)
     Consultant/Professors
   • (b)
     Registrars/Assistant/Associate/Residents
   • (c)
     Post Graduates/Trainees

5. Hospital setup:

   • (a)
     Govt medical College
   • (b)
     Govt Hospitals
   • (c)
     Private Medical College
   • (d)
     Corporate hospitals
   • (f)
     Private hospitals/Nursing homes/Free Lancer

6. Labor Analgesia Practiced by (a) Obstetricians (b) Anesthesiologist (c) Both

7. If practiced by Obstetricians are you aware of the same (a) Yes (b) No

Methods of Pain Relief IN Labor

Methods followed in your Hospital/College/Nursing Home

1. Non-Pharmacological Methods

2. Systemic Analgesia

3. Regional Analgesia

Non pharmacological methods practiced in Obstetric units in the hospital

1. Emotional support

2. Touch and Massage

3. Therapeutic Use of Heat and Cold

4. Hydrotherapy

5. Vertical Position

6. Biofeedback

7. Transcutaneous Electrical Nerve Stimulation

8. Acupuncture/Acupressure

9. Hypnosis.

Pharmacological methods practiced in Obstetric units in the hospital

II Inhalational Agents:

1. Entonox 2) N2O 3) Sevoflurane 4) Others

Regional Analgesia

I What would be the common indication for you to start labor neuraxial analgesia

Tick from most common to least

1. Maternal request

2. Hypertensive disorders of pregnancy

3. Preexisting medical disease

4. Multiple pregnancies

5. Previous cesarean section

6. Prolonged labor

7. Deterioration in fetal well-being

II Techniques: Most commonly used to least

1. Epidural analgesia with Intermittent Boluses

2. Continuous epidural Infusion with Intermittent Boluses

3. Continuous spinal with microcatheters

4. Single-shot spinal analgesia

5. Combined spinal epidural analgesia

6. Parturient controlled epidural analgesia

7. Paracervical and pudendal blocks.

III Drugs

1. Epidural with intermittent boluses

Local Anesthetics: Tick from most commonly used to least

Bupivacaine, Levobupivacaine, Ropivacaine, Lignocaine

Adjuvants: Tick from most commonly used to least

Epinephrine, Morphine, Meperidine, Fentanyl, Sufentanil, Clonidine, Dexamethasone, Midazolam, Neostigmine

2. Single Shot Spinal Analgesia

 a. Only Local Anesthetics b) Only Opioids c) Both

3. Combined Spinal Epidural analgesia

Spinal drug used

 a. Opioids only b) Only Local Anesthetics c) Both

IV: Monitoring during Regional analgesia

• Pulse oximetry

• NIBP

• ECG

• Fetal Monitoring

V: Most common complications you have encountered -tick from most common to least

• Hypotension

• Bradycardia

• Accidental Dural puncture

• Post Dural puncture headache

• Respiratory Depression

• Pruritis

• Backache

• Urinary retention

• Epidural Hematoma

• Epidural abscess

• High Block

• Fetal bradycardia

VI: Recent Advances In Labor Analgesia: Do you practise

1. Use of Ultrasound while placing epidural Yes No

2. Walking epidural Yes No

3. Computer-integrated patient-controlled epidural analgesia Yes No

VII: Myths Surrounding Labor Epidurals and intrathecal opioids:

Increase cesarean and instrumental delivery Yes No Don't know

Delay First and Second stage of labor Yes No Don't know

Impairs breastfeeding Yes No Don't know

Associated with maternal Pyrexia Yes No Don't know

Associated with Future backache Yes No Don't know

Low Apgar Score Yes No Don't knowYes No Don't know

VIII: The most effective form of Labor analgesia with great maternal satisfaction