title: Quality of labour neuraxial analgesia and maternal satisfaction at a tertiary care teaching hospital: a prospective observational study.
abstract: OBJECTIVE
  Current labour analgesia practices are evidence-based; however, such evidence often originates in controlled trials, the results of which may not be readily applicable in the context of day-to-day clinical practice. The objective of this study was to evaluate the effectiveness of and maternal satisfaction with the neuraxial labour analgesia regimen provided at a tertiary care teaching hospital.
  
  
  METHODS
  All women with a viable pregnancy who requested neuraxial analgesia for labour during November 2011 at our institution were approached to participate in this prospective study. Patients were managed as per departmental routine based on a patient-controlled epidural analgesia regimen with a maintenance solution of 0.0625% bupivacaine and fentanyl 2 μg·mL(-1). Demographic and obstetric data, characteristics of the neuraxial analgesia, pain scores, side effects, and complications were recorded. After delivery, patients completed a satisfaction questionnaire.
  
  
  RESULTS
  All 332 eligible women were approached, and 294 completed the study. Most women received epidural analgesia and considered its placement comfortable. A large number of women reported having experienced pain during the first or second stages of labour (38% and 26%, respectively). Although 24.4% of women required top-ups both by nurses and physicians, adjustment in the local anesthetic maintenance concentration was made in only 7.8% of the cases. Most women (92%) were satisfied with the quality of analgesia. Unintentional dural puncture occurred in three (1%) cases, and there were no cases of intravascular catheter insertion or systemic local anesthetic toxicity. Overweight women (body mass index 25-30 kg·m(-2)) (adjusted odds ratio [AOR] = 2.56; 95% confidence interval [CI]: 1.1 to 5.97), those undergoing induced labour (AOR = 2.4; 95% CI: 1.2 to 5.2), and those requiring top-ups by the anesthesiologist (AOR = 5.08; 95% CI: 2.31 to 11.11) were associated with more dissatisfaction with pain control during the first stage of labour.
  
  
  CONCLUSIONS
  Although our technique with dilute local anesthetic-opioid infusion was considered effective in previous randomized clinical trials, it did not provide sufficient labour analgesia for a large proportion of women. Nevertheless, most women were satisfied with their pain management and childbirth experience. Strategies to individualize care for labour and delivery should be readily available while providing labour analgesia.
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 781, Toronto, ON, M5G 1X5, Canada.
authors.forename: Jefferson
authors.initials: J
authors.lastname: Clivatti
authors.forename: Naveed
authors.initials: N
authors.lastname: Siddiqui
authors.forename: Akash
authors.initials: A
authors.lastname: Goel
authors.forename: Melissa
authors.initials: M
authors.lastname: Shaw
authors.forename: Ioana
authors.initials: I
authors.lastname: Crisan
authors.forename: Jose C A
authors.initials: JC
authors.lastname: Carvalho
mesh_terms: D000759:Adjuvants, Anesthesia / Q000008:administration & dosage / Q000009:adverse effects; D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D016362:Analgesia, Obstetrical / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D016058:Analgesia, Patient-Controlled / Q000009:adverse effects / Q000379:methods / Q000592:standards; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects; D001919:Bradycardia / Q000139:chemically induced; D002045:Bupivacaine / Q000008:administration & dosage / Q000009:adverse effects; D036861:Delivery, Obstetric; D004388:Dura Mater / Q000293:injuries; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000009:adverse effects; D005315:Fetal Diseases / Q000139:chemically induced; D006801:Humans; D007022:Hypotension / Q000139:chemically induced; D007747:Labor Stage, First; D008012:Lidocaine / Q000008:administration & dosage / Q000009:adverse effects; D009325:Nausea / Q000139:chemically induced; D050177:Overweight / Q000503:physiopathology; D010147:Pain Measurement; D017060:Patient Satisfaction; D011247:Pregnancy; D011446:Prospective Studies; D011537:Pruritus / Q000139:chemically induced; D014839:Vomiting / Q000139:chemically induced
chemical_list: D000759:Adjuvants, Anesthesia; D000779:Anesthetics, Local; D008012:Lidocaine; D005283:Fentanyl; D002045:Bupivacaine