Nocebo language in anaesthetic patient written information

Recent evidence suggests that how anaesthesia information is presented may influence patient treatment outcomes. We conducted an observational study of anaesthetic-based patient information leaflets across NHS Trusts in England for their nocebo terms vs. therapeutic terms, and how adverse effects were presented. In this study, 'nocebo' is wording that may predispose the patient to expect adverse events such as pain or nausea. Data were extracted and analysed for word frequency, weighted proportion and thematic analysis. In total, 42 patient information leaflets from 61 NHS Trusts were analysed. 'Pain' was the second most common word across the leaflets, median (IQR [range]) 0.82 (0.50-1.0 [0.12-1.47]) per 100 words, second only to 'anaesthesia'. In comparison, 'safe' was the most common positively valanced word which featured eight times less frequently than 'pain' 0.10 (0.07-0.18 [0.0-0.84]) and 'comfort' featured 16.5 times less than 'pain' 0.02 (0.0-0.05 [0.0-0.13]). Multiple examples of phrasing that could have potential nocebo effects included, 'you will need strong painkillers' suggesting 'strong pain' and the need for 'painkillers' rather than using therapeutic terms focusing on 'comfort', 'healing' and 'recovery'. Our results suggest a dominance of phrases with negative content in the presentation of anaesthesia information provided to patients. Clinicians need to be aware of inadvertent generation of nocebo-weighted vs. comfort-weighted communication with patients. Our study findings suggest an opportunity for more emphasis to be placed on therapeutic outcomes and effective mitigation strategies of anaesthesia risks to avoid potential unintended nocebo effects of anaesthesia information leaflets or websites.

Subcutaneous fentanyl for labour analgesia: a retrospective case note review

BACKGROUND

In 2017, a South Australia Perinatal Practice Guideline was introduced state-wide for the use of subcutaneous fentanyl for labour analgesia as a replacement for intramuscular pethidine. We retrospectively reviewed the implementation of this practice change in our institution.

METHODS

A retrospective review of maternal and neonatal case notes for the first 100 women administered subcutaneous fentanyl in labour at a single tertiary referral centre for maternity care, between February and June 2017.

RESULTS

Of the 102 women administered subcutaneous fentanyl, the majority (55%) were primipara, with an average maternal age of 29 years and body mass index of 27 kg/m². The median total fentanyl dose administered was 200 µg and the average time from last dose to birth was 3 h. The majority of women (70%) did not require additional rescue labour analgesia and 80% had a spontaneous vaginal birth. All neonates had a 5-min Apgar score >7. The median Apgar score at 1 and 5 min was 9. No neonate had an arterial cord blood pH <7.1. The mean arterial and venous cord blood pH was 7.3. The average time for neonates to establish breathing was 1 min and the median postnatal length of stay was two days.

CONCLUSIONS

Subcutaneous fentanyl for labour analgesia appears effective and has a low incidence of adverse events.

Risks of Regional Anaesthesia for Caesarean Section: Women's Recall and Information Sources

Recall and information sources regarding the risks of regional anaesthesia in women having lower segment caesarean section have not been adequately assessed previously. We aimed to survey women's recall of their pre-anaesthesia risk discussion and determine where women, presenting for lower segment caesarean section under regional anaesthesia, obtain risk information. Following a small pilot survey, women's responses were recorded for “spontaneous” or “prompted” recalled risks, the information source and its reliability. One-hundred and fifty women were surveyed following caesarean section. Seventy women (46.7%) had an elective procedure and 80 (53.3%) had an emergency procedure. Overall, 142 women (94.6%) recalled at least four risks (44.6% spontaneously; 66% prompted). Of those women giving at least four spontaneous responses, 41 (58.6%) had elective and 26 (32.5%) had emergency lower segment caesarean section (P=0.001). The majority of women stated that anaesthetists were the main, and most reliable, source of their information regarding risks of regional anaesthesia for caesarean section. This report identifies the risks associated with regional anaesthesia for caesarean section that women most frequently recall, namely headache, paralysis, nerve damage and inadequate block.

Suggestion, Hypnosis and Hypnotherapy: A Survey of Use, Knowledge and Attitudes of Anaesthetists

Clinical hypnosis is a skill of using words and gestures (frequently called suggestions) in particular ways to achieve specific outcomes. It is being increasingly recognised as a useful intervention for managing a range of symptoms, especially pain and anxiety. We surveyed all 317 South Australian Fellows and trainees registered with ANZCA to determine their use, knowledge of, and attitudes towards positive suggestion, hypnosis and hypnotherapy in their anaesthesia practice. The response rate was 218 anaesthetists (69%). The majority of respondents (63%) rated their level of knowledge on this topic as below average. Forty-eight per cent of respondents indicated that there was a role for hypnotherapy in clinical anaesthesia, particularly in areas seen as traditional targets for the modality, i.e. pain and anxiety states. Nearly half of the anaesthetists supported the use of hypnotherapy and positive suggestions within clinical anaesthesia. Those respondents who had experience of clinical hypnotherapy were more likely to support hypnosis teaching at undergraduate or postgraduate level when compared with those with no experience.

A survey of the sequelae of memorable anaesthetic drug errors from the anaesthetist's perspective

Drug errors amongst anaesthetists are common. Although there has been previous work on the system factors involved with drug error, there has been little research on the sequelae of a drug error from the anaesthetist's perspective. To clarify this issue, we surveyed anaesthetists regarding their most memorable drug error to identify associated factors and personal sequelae regarding their professional practice after the event. An online survey was sent anonymously to 989 Australian and New Zealand College of Anaesthetists (ANZCA) Fellows in March 2016 and the results were collected over the following two months. There were 295 completed surveys (29.8% response). The majority of respondents were male consultants, aged over 45 years. Reported drug errors occurred most frequently during normal working hours, and the most common drugs involved were non-depolarising muscle relaxants. In 34% of the errors, another anaesthetist was present, and their presence was felt to have contributed in 40.7% of these cases. About 20% of respondents reported that they did not receive adequate support after the event. Sleep patterns were affected in 14.4% of respondents, although very few found that the error had affected their capacity to function at work. These findings suggest that memorable drug errors can be significant enough to have adverse sequelae to anaesthetists, even if no patient harm occurs.

Consent for Labour Epidural Analgesia: An Observational Study in a Single Institution

There is a wide range of practice amongst obstetric anaesthetists when obtaining consent for women requesting labour epidural analgesia. This is the first prospective observational study recording the number and types of risks mentioned and whether the risk was quantified. Statements of benefits and alternatives to the procedure were also noted. Fourteen anaesthetists, each consulting a single patient, were recorded during the process of obtaining consent and inserting the epidural. The most commonly mentioned risks (median 7) were headache/dural puncture, failure/difficulty with insertion, nerve damage, bleeding/haematoma and infection/epidural abscess. There was no difference between consultants and trainees, although consultants showed greater variance. It was uncommon for anaesthetists to state a benefit (21%) or mention an alternative option (21%), but there was usually a quantitative statement of risk (71%). Data showed a deviation from the Australian and New Zealand College of Anaesthetists guidelines and these findings may encourage anaesthetists to reflect on their own practice and guide future research.

Chronic pain after caesarean delivery: an Australian cohort

We investigated the incidence of and risk factors for persistent pain after caesarean delivery. Over a 12-month period, women having caesarean delivery were recruited prospectively at an Australian tertiary referral centre. Demographic, anaesthetic and surgical data were collected and at 24 hour follow-up, women were assessed for immediate postoperative pain and preoperative expectations of pain. Long-term telephone follow-up was conducted at two and 12 months postoperatively. Complete data were obtained from 426 of 469 women initially recruited (90.6%). The incidence of persistent pain at the abdominal wound at two months was 14.6% (n=62) but subsequently reduced to 4.2% (n=18) at 12 months. At two months, 33 patients (7.8%) experienced constant or daily pain. At 12 months, five patients (1.1%) continued to have constant or daily pain which was mild. There was no apparent increase in incidence of persistent pain associated with general versus regional anaesthesia (relative risk [RR] 0.89, 95% confidence interval [CI] 0.49 to 1.6); emergency vs elective procedure (RR 0.65, 95% CI 0.39 to 1.07); higher acute pain scores (RR 1.1, 95% CI 0.69 to 1.75); or history of previous caesarean delivery (RR 0.81, 95% CI 0.50 to 1.33). Persistent pain, usually of a mild nature, is reported by some women two months after their caesarean delivery, but by 12 months less than 1% of women had pain requiring analgesia or affecting mood or sleep. All declined a pain clinic review. Clinicians and patients can be reassured that caesarean delivery is unlikely to lead to severe persistent pain in the long-term.

Hypnosis antenatal training for childbirth: a randomised controlled trial

OBJECTIVE

To determine the use of pharmacologic analgesia during childbirth when antenatal hypnosis is added to standard care.

DESIGN

Randomised controlled clinical trial, conducted from December 2005 to December 2010.

SETTING

The largest tertiary referral centre for maternity care in South Australia.

POPULATION

A cohort of 448 women at >34 weeks of gestation, with a singleton pregnancy and cephalic presentation, planning a vaginal birth. Exclusions were: the need for an interpreter; pre-existing pain; psychiatric illness; younger than 18 years; and previous experience of hypnosis for childbirth.

METHODS

All participants received usual care. The group of women termed Hypnosis + CD (hypnotherapist guided) were offered three antenatal live hypnosis sessions plus each session's corresponding audio CD for further practise, as well as a final fourth CD to listen to during labour. The group of women termed CD only (nurse administered) were played the same antenatal hypnosis CDs as group 1, but did not receive live hypnosis training. The control group participants were given no additional intervention or CDs.

MAIN OUTCOME MEASURE

Use of pharmacological analgesia during labour and childbirth.

RESULTS

No difference in the use of pharmacological analgesia during labour and childbirth was found comparing hypnosis + CD with control (81.2 versus 76.2%; relative risk, RR 1.07; 95% confidence interval, 95% CI 0.95-1.20), or comparing CD only with control (76.9 versus 76.2%, RR 1.01, 95% CI 0.89-1.15).

CONCLUSIONS

Antenatal group hypnosis using the Hypnosis Antenatal Training for Childbirth (HATCh) intervention in late pregnancy does not reduce the use of pharmacological analgesia during labour and childbirth.

A survey of aseptic precautions and needle type for paediatric caudal block in Australia and New Zealand

This cross-sectional survey was designed to evaluate the current practice of anaesthetists in Australia and New Zealand with regard to aseptic technique and needle type during the performance of single-shot caudal blocks. Professional bodies suggest that full aseptic precautions be taken during the administration of caudal or epidural blocks. It has been suggested that using an intravenous cannula or a styletted needle may obviate the occurrence of epidermoid tumours. A total of 202 members of the Society for Paediatric Anaesthesia in New Zealand and Australia were invited to participate in this internet-based survey. Eighty-four responses were received. Most respondents used some form of antiseptic handwash (81%), wore sterile gloves (85.7%), used antiseptic skin preparation (100%) and draped the site (57.1%). When performing caudal blocks, 43.1% used unstyletted needles, 27.2% used styletted spinal needles and 29.6% used intravenous cannulas. However, 11.9% did not wash hands, 10.7% did not wear gloves and 42.9% did not drape the site. Three respondents reported neither handwashing, wearing gloves or draping, instead only using an alcohol swab for skin preparation. The majority of respondents in our region appear to use some level of aseptic precautions, albeit to a variable degree. Published recommendations may either be perceived as overly cautious or as ambiguous in that they do not specify caudal practice as distinct from other epidural blocks. There is a need for clearer professional guidance to support a minimum level of aseptic precaution for single-shot caudal epidural blocks.

Assessment of block height for satisfactory spinal anaesthesia for caesarean section

We investigated block heights that anaesthetists considered adequate for caesarean section to proceed under spinal anaesthesia. During 3 months, 15 obstetric anaesthetists recorded block height to touch, pinprick or cold when spinal anaesthesia was considered satisfactory for caesarean section to proceed. Median (IQR [range]) block height for touch, pinprick, first cold and icy were: T10 (T7-T12 [T3-L1]); T5 (T4-T6 [C7-L1]); T5 (T4-T6 [C7-L1]); and T3 (T2-T4 [C7-L1]), respectively. Modalities were significantly correlated for: touch and cold, p = 0.0001; touch and icy, p = 0.0007; touch and pinprick, p = 0.0018; cold and icy, p < 0.0001; cold and pinprick, p = 0.0001; icy and pinprick, p < 0.0001. Pairwise comparisons showed differences between all modalities (p < 0.001) apart from pinprick and first cold (p = 0.94). All women had satisfactory anaesthesia despite 76 (81%) having a block to touch below T6. Single modality assessment of block height, particularly using touch, may erroneously indicate inadequate anaesthesia for caesarean section.

A comparison of epidural and cerebrospinal fluid glucose in parturients at term: an observational study

BACKGROUND

Detecting inadvertent dural puncture during labour epidural insertion can be difficult when using a loss of resistance to saline technique. Testing fluid for glucose that leaks from a Tuohy needle may confirm the presence of cerebrospinal fluid and infer inadvertent dural puncture. This study compared the glucose content of intrathecal fluid obtained during spinal anaesthesia for elective caesarean delivery with that of fluid from a Tuohy needle or epidural catheter when establishing epidural analgesia for labour.

METHODS

Women aged ≥18 years undergoing elective caesarean delivery and labouring parturients who requested epidural analgesia were recruited prospectively in a tertiary referral centre over a three-month period. Fluid was collected into a sterile container either during spinal anaesthesia or from a labour epidural needle. Glucose content was evaluated using a bedside blood glucometer and laboratory colorimetric analyzer.

RESULTS

Of the 118 women approached, 115 participated. All 40 women having spinal anaesthesia and 2/75 (2.7%) women having epidural analgesia, in whom inadvertent dural puncture was subsequently confirmed, had fluid samples testing positive for glucose. Median [range] laboratory glucose readings were 2.9 [1.3-5.1] mmol/L for cerebrospinal fluid and <0.3 mmol/L in fluid that leaked from a Tuohy needle (P=0.0001).

CONCLUSION

When using a loss of resistance to saline technique for epidural catheter placement, bedside glucometer testing of fluid leaking from the epidural needle may be of value in the early detection of inadvertent dural puncture.

Use of invasive placebos in research on local anaesthetic interventions

Placebos play a vital role in clinical research, but their invasive use in the context of local anaesthetic blocks is controversial. We assessed whether recently published randomised controlled trials of local anaesthetic blocks risked harming control group patients in contravention of the Declaration of Helsinki. We developed the 'SHAM' (Serious Harm and Morbidity) scale to assess risk: grade 0 = no risk (no intervention); grade 1 = minimal risk (for example, skin allergy to dressing); grade 2 = minor risk (for example, subcutaneous haematoma, infection); grade 3 = moderate risk (with or without placebo injection) (for example, neuropraxia); and grade 4 = major risk (such as blindness, pneumothorax, or liver laceration). Placebo interventions of the 59 included trials were given a SHAM grade. Nine hundred and nineteen patients in 31 studies, including six studies with 183 children, received an invasive placebo assessed as SHAM grade ≥ 3. A high level of agreement (78%, κ = 0.80, p < 0.001) for SHAM grades 0-4 increased to 100% following discussion between assessors. More than half of the randomised controlled study designs subjected patients in control groups to risks of serious or irreversible harm. A debate on whether it is justifiable to expose control group patients to risks of serious harm is overdue.

Labour Management of a Woman with Carnitine Palmitoyl Transferase Type 2 Deficiency

Carnitine palmitoyl transferase (CPT) type 2 deficiency is a disorder of mitochondrial fatty acid oxidation. In situations where energy stores are inadequate, such as may occur during labour, women with CPT type 2 deficiency are at risk of rhabdomyolysis. There is limited experience in the management of women with this condition in labour. We report a case of successful labour management of a woman with CPT type 2 deficiency, together with a brief review of the published case reports and a discussion of the issues surrounding anaesthetic management.

Communication during induction of paediatric anaesthesia: an observational study

We aimed to identify and categorise advanced communication skills used by experienced consultant paediatric anaesthetists to facilitate the induction of paediatric anaesthesia. The communication techniques were both verbal and non-verbal. Communications with potentially negative effects were also noted. Eighty-three inductions were observed over a three-month period. The 12 anaesthetists observed were all senior consultants at a tertiary referral paediatric centre. The mean age of patients was 6.1 years SD+/-4.8. There were 53 males (63.9%) and 30 females (36.1%). A first anaesthetic was administered to 43 patients (56%) and sedative premedication to six (8%). Inhalational inductions were observed in 59 patients (71%). The remainder received an intravenous induction. Anaesthesia was induced in the operating room on 68 occasions (82%), in the induction room on 11 (13%) and in the radiology department on 4(5%). The most common communication techniques used were: voice change in 60 (72%); distraction in 49 (59%); direct commands in 39 (47%); repetition in 34 (41%); imagery in 21 (25%) and focused attention 21 (25%). Other techniques used were seeding of ideas, utilisation, non-verbal cues, double-binds, story-telling, indirect suggestion, dissociation and reversed effect. Sabotage by parents or staff such as inadvertent negative suggestions, was observed on 14 occasions (17%). Paediatric anaesthetists utilise a wide range of communication techniques in a highly flexible manner when inducing anaesthesia in children. Many of these communications can be characterised as hypnotherapeutic. Our observations suggest that formal structured training in communication skills and further research is warranted.

Immediate management of inadvertent dural puncture during insertion of a labour epidural: a survey of Australian obstetric anaesthetists

Immediate management of inadvertent dural puncture during insertion of an epidural needle during labour is controversial and evidence to guide clinical practice is limited. We surveyed Australian obstetric anaesthetists by anonymous postal questionnaire. Of the 671 surveys sent, 417 (62%) were returned. Following dural puncture, 265 respondents (64%) indicated that they "would usually remove the Tuohy needle and resite". The most common reason for this decision was concern regarding the safety of intrathecal catheters (ITC) (n = 236, 89%), in particular, the risk of misuse (n = 182, 70%). The most frequently reported reason for "usually inserting an ITC" was that this reduced the incidence (n = 120, 84%) and severity (n = 110, 77%) of post dural puncture headache. Increased frequency of ITC insertion was reported by respondents who practised more frequent sessions of obstetric anaesthesia, had fewer years of experience as a consultant anaesthetist and worked in a public hospital. The more widespread use of ITCs seems to be limited by safety concerns.

Effect of communication on pain during intravenous cannulation: a randomized controlled trial

BACKGROUND

Clinicians frequently warn patients of discomfort before potentially painful procedures, despite the lack of evidence that such communications are helpful. We aimed to compare two communications (one with, and the other without, a warning of a 'sting') immediately before i.v. cannulation in order to measure differences in perceived pain by patients during the procedure.

METHODS

Randomly assigned patients awaiting elective surgery received a communication immediately before i.v. cannulation consisting of either 'I am going to apply the tourniquet and insert the needle in a few moments. It's a sharp scratch and it may sting a little' (Group S) or 'I am going to apply the tourniquet on the arm. As I do this many people find the arm becomes heavy, numb and tingly. This allows the drip to be placed more comfortably' (Group NS). Cannulation pain was measured by a 0-10 verbal numerical rating score (VNRS) and five-point Likert scale.

RESULTS

Of 101 participants, 49 were allocated to Group S and 52 to Group NS. Median VNRS pain scores with inter-quartile ranges (IQR) were 1 and 2, respectively, for both groups. Median Likert scores were 3 in Group S and 2 in Group NS with an IQR of 1 for both groups (P = 0.13). Six participants vocalized pain in Group S and none in Group NS (P = 0.01). Three participants withdrew their arm spontaneously in Group S and none in Group NS (P = 0.11).

CONCLUSIONS

Warning patients of a 'sting' before i.v. cannulation may not be helpful.

Combined spinal-epidural versus epidural analgesia in labour

BACKGROUND

Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation, and increased incidence of instrumental vaginal delivery. The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia, which could contribute to increased maternal satisfaction.

OBJECTIVES

To assess the relative effects of CSE versus epidural analgesia during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2006).

SELECTION CRITERIA

All published randomised controlled trials involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the trials identified from the searches for inclusion and extracted the data.

MAIN RESULTS

Nineteen trials (2658 women) met our inclusion criteria. Twenty-six outcomes in two sets of comparisons involving CSE versus traditional epidurals and CSE versus low-dose epidural techniques were analysed. Of the CSE versus traditional epidural analyses only three outcomes showed a difference. CSE was more favourable in relation to need for rescue analgesia and urinary retention, but associated with more pruritus. For CSE versus low-dose epidurals, four outcomes were statistically significant. CSE had a faster onset of effective analgesia from time of injection but was associated with more pruritus. CSE was also associated with a clinically non-significant lower umbilical arterial pH. No differences between CSE and epidural were seen for maternal satisfaction, mobilisation in labour, modes of birth, incidence of post dural puncture headache or blood patch and maternal hypotension. It was not possible to draw any conclusions with respect to maternal respiratory depression, maternal sedation and need for labour augmentation.

AUTHORS' CONCLUSIONS

There appears to be little basis for offering CSE over epidurals in labour with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and less pruritus with epidurals. There is no difference in ability to mobilise, obstetric outcome or neonatal outcome. However, the significantly higher incidence of urinary retention and rescue interventions with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section

BACKGROUND

Maternal hypotension, the most frequent complication of spinal anaesthesia for caesarean section, can be associated with severe nausea or vomiting which can pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis and neurological injury).

OBJECTIVES

To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2005).

SELECTION CRITERIA

Randomised controlled trials comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed eligibility and methodological quality of studies, and extracted data.

MAIN RESULTS

We included 75 trials (a total of 4624 women). Crystalloids were more effective than no fluids (relative risk (RR) 0.78, 95% confidence interval (CI) 0.60 to 1.00; one trial, 140 women, sequential analysis) and colloids were more effective than crystalloids (RR 0.68, 95% CI 0.52 to 0.89; 11 trials, 698 women) in preventing hypotension following spinal anaesthesia at caesarean section. No differences were detected for different doses, rates or methods of administering colloids or crystalloids. Ephedrine was significantly more effective than control (RR 0.51, 95% CI 0.33 to 0.78; seven trials, 470 women) or crystalloid (RR 0.70, 95% CI 0.50 to 0.96; four trials, 293 women) in preventing hypotension. No significant differences in hypotension were seen between ephedrine and phenylephrine (RR 0.95, 95% CI 0.37 to 2.44; three trials, 97 women) and phenylephrine was more effective than controls (RR 0.27, 95% CI 0.16 to 0.45; two trials, 110 women). High rates or doses of ephedrine may increase hypertension and tachycardia incidence. Lower limb compression was more effective than control (no leg compression) (RR 0.69, 95% CI 0.53 to 0.90; seven trials, 399 women) in preventing hypotension, although different methods of compression appeared to vary in their effectiveness. No other comparisons between different physical methods such as position were shown to be effective, but these trials were often small and thus underpowered to detect true effects should they exist.

AUTHORS' CONCLUSIONS

While interventions such as colloids, ephedrine, phenylephrine or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension during spinal anaesthesia for caesarean section. No conclusions can be drawn regarding rare adverse effects due to the relatively small numbers of women studied.

Complementary and alternative therapies for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of alternative and complementary therapies for pain management in labour.

OBJECTIVES

To examine the effects of complementary and alternative therapies for pain management in labour on maternal and perinatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and CINAHL (1980 to February 2006).

SELECTION CRITERIA

The inclusion criteria included published and unpublished randomised controlled trials comparing complementary and alternative therapies (but not biofeedback) with placebo, no treatment or pharmacological forms of pain management in labour. All women whether primiparous or multiparous, and in spontaneous or induced labour, in the first and second stage of labour were included.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed using relative risks for dichotomous outcomes and mean differences for continuous outcomes. The outcome measures were maternal satisfaction, use of pharmacological pain relief and maternal and neonatal adverse outcomes.

MAIN RESULTS

Fourteen trials were included in the review with data reporting on 1537 women using different modalities of pain management; 1448 women were included in the meta-analysis. Three trials involved acupuncture (n = 496), one audio-analgesia (n = 24), two trials acupressure (n = 172), one aromatherapy (n = 22), five trials hypnosis (n = 729), one trial of massage (n = 60), and relaxation (n = 34). The trials of acupuncture showed a decreased need for pain relief (relative risk (RR) 0.70, 95% confidence interval (CI) 0.49 to 1.00, two trials 288 women). Women taught self-hypnosis had decreased requirements for pharmacological analgesia (RR 0.53, 95% CI 0.36 to 0.79, five trials 749 women) including epidural analgesia (RR 0.30, 95% CI 0.22 to 0.40) and were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.15 to 4.71, one trial). No differences were seen for women receiving aromatherapy, or audio analgesia.

AUTHORS' CONCLUSIONS

Acupuncture and hypnosis may be beneficial for the management of pain during labour; however, the number of women studied has been small. Few other complementary therapies have been subjected to proper scientific study.

Antenatal self-hypnosis for labour and childbirth: a pilot study

In our institution we have used antenatal training in self-hypnosis for over three years as a tool to provide relaxation, anxiolysis and analgesia for women in labour. To assess the effects of hypnotherapy, we prospectively collected data related to the use of hypnosis in preparation for childbirth, and compared the birth outcomes of women experiencing antenatal hypnosis with parity and gestational age matched controls.

METHODS

Prospective data about women taught self-hypnosis in preparation for childbirth were collected between August 2002 and August 2004. Birth outcome data of women using hypnosis were compared with routinely collected retrospective data from parity and gestational age matched women delivering after 37 weeks gestation during 2003.

RESULTS

Seventy-seven antenatal women consecutively taught self-hypnosis in preparation for childbirth were compared with 3,249 parity and gestational age matched controls. Of the women taught antenatal self-hypnosis, nulliparous parturients used fewer epidurals: 36% (18/50) compared with 53% (765/1436) of controls (RR 0.68 [95%CI 0.47-0.98]); and required less augmentation: 18% (9/50) vs 36% (523/1436) (RR 0.48 [95%CI 0.27-0.90]).

CONCLUSIONS

Our clinical findings are consistent with recent meta-analyses showing beneficial outcomes associated with the use of hypnosis in childbirth. Adequately powered, randomized trials are required to further elucidate the effects of hypnosis preparation for childbirth.

Issues of consent for regional analgesia in labour: a survey of obstetric anaesthetists

Anaesthetists are legally obliged to obtain consent and inform patients of material risks prior to administering regional analgesia in labour. We surveyed consultant members of the Australian and New Zealand College of Anaesthetists with a special interest in obstetric anaesthesia, in order to identify and compare which risks of regional analgesia they report discussing with women prior to and during labour. We also asked about obstetric anaesthetists' beliefs about informed consent, the type of consent obtained and its documentation. Of 542 questionnaires distributed, 291 responses (54%) were suitable for analysis. The five most commonly discussed risks were post dural puncture headache, block failure, permanent neurological injury, temporary leg weakness and hypotension. Obstetric anaesthetists reported discussing a mean of 8.0 (SD 3.8) and 10 (SD 3.8) risks in the labour and antenatal settings respectively. Nearly 20% of respondents did not rank post dural puncture headache among their top five most important risks for discussion. Seventy percent of respondents indicated that they believe active labour inhibits a woman's ability to give 'fully informed consent'. Over 80% of respondents obtain verbal consent and 57 (20%) have no record of the consent or its discussion. Obstetric anaesthetists reported making a considerable effort to inform patients of risks prior to the provision of regional analgesia in labour. Verbal consent may be appropriate for labouring women, using standardized forms that serve as a reminder of the risks, and a record of the discussion. Consensus is required as to what are the levels of risk from regional analgesia in labour.

Subacute airway obstruction from a tracheal mucosal flap

We report the case of a 15-year-old girl with a near fatal obstructive tracheal lesion following tracheal intubation. The patient developed stridor and acute respiratory distress 29 h following tracheal extubation, after 35 h intubation in the intensive care unit. The failure of conventional management of stridor, including re-intubation, to provide a satisfactory airway prompted an urgent bronchoscopy, which revealed a tracheal mucosal flap causing 80% obstruction of the subglottic trachea. The fibreoptic bronchoscope allowed careful placement of a tracheal tube distal to the obstruction. The patient eventually made a full recovery. The low incidence of similar lesions and the lack of distinguishing clinical features from other causes of post-extubation stridor make diagnosis and appropriate management of this life-threatening condition difficult. We discuss how early consideration of the diagnosis and optimal initial management reduce the risk of an adverse outcome.

Challenges that opioid-dependent women present to the obstetric anaesthetist

A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.

Hypnosis for pain relief in labour and childbirth: a systematic review

BACKGROUND

In view of widespread claims of efficacy, we examined the evidence regarding the effects of hypnosis for pain relief during childbirth.

METHODS

Medline, Embase, Pubmed, and the Cochrane library 2004.1 were searched for clinical trials where hypnosis during pregnancy and childbirth was compared with a non-hypnosis intervention, no treatment or placebo. Reference lists from retrieved papers and hypnotherapy texts were also examined. There were no language restrictions. Our primary outcome measures were labour analgesia requirements (no analgesia, opiate, or epidural use), and pain scores in labour. Suitable comparative studies were included for further assessment according to predefined criteria. Meta-analyses were performed of the included randomized controlled trials (RCTs), assessed as being of "good" or "adequate" quality by a predefined score.

RESULTS

Five RCTs and 14 non-randomized comparisons (NRCs) studying 8395 women were identified where hypnosis was used for labour analgesia. Four RCTs including 224 patients examined the primary outcomes of interest. One RCT rated poor on quality assessment. Meta-analyses of the three remaining RCTs showed that, compared with controls, fewer parturients having hypnosis required analgesia, relative risk=0.51 (95% confidence interval 0.28, 0.95). Of the two included NRCs, one showed that women using hypnosis rated their labour pain less severe than controls (P<0.01). The other showed that hypnosis reduced opioid (meperidine) requirements (P<0.001), and increased the incidence of not requiring pharmacological analgesia in labour (P<0.001).

CONCLUSION

The risk/benefit profile of hypnosis demonstrates a need for well-designed trials to confirm the effects of hypnosis in childbirth.

Avoiding inadvertent epidural injection of drugs intended for non-epidural use

Inadvertent administration of non-epidural medications into the epidural space has the potential for serious morbidity and mortality. The aim of this study was to collate reported incidents of this type, describe the potential mechanisms of occurrence and identify possible solutions. We searched medical databases and reviewed reference lists of papers retrieved, covering a period of 35 years, regarding this type of medication incident. The 31 reports of 37 cases found is likely to represent a gross underestimation of the actual number of incidents that occur. "Syringe swap", "ampoule error", and epidural/intravenous line confusion were the main sources of error in 36/37 cases (97%). Given that no effective treatment for such errors has been identified, prevention should be the main defence strategy. Despite all the precautions that are currently undertaken, accidents will inevitably occur. We have identified areas for systemwide change that may prevent these types of incidents from occurring in future.

Complementary and alternative therapies for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of alternative and complementary therapies for pain management in labour.

OBJECTIVES

To examine the effectiveness of complementary and alternative therapies for pain management in labour on maternal and perinatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2002), MEDLINE (1966 to July 2002), EMBASE (1980 to July 2002) and CINAHL (1980 to July 2002).

SELECTION CRITERIA

The inclusion criteria included published and unpublished randomised controlled trials comparing complementary and alternative therapies with placebo, no treatment or pharmacological forms of pain management in labour. All women whether primiparous or multiparous, and in spontaneous or induced labour, in the first and second stage of labour were included.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed using relative risks for dichotomous outcomes and weighted mean differences for continuous outcomes. The outcome measures were maternal satisfaction, use of pharmacological pain relief and maternal and neonatal adverse outcomes.

MAIN RESULTS

Seven trials involving 366 women and using different modalities of pain management were included in this review. The trials included one involving acupuncture (n = 100), one involving audio-analgesia (n = 25), one involving aromatherapy (n = 22), three trials of hypnosis (n = 189) and one trial of music (n = 30). The trial of acupuncture decreased the need for pain relief (relative risk (RR) 0.56, 95% confidence interval (CI) 0.39 to 0.81). Women receiving hypnosis were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.55 to 4.71). No differences were seen for women receiving aromatherapy, music or audio analgesia.

REVIEWER'S CONCLUSIONS

Acupuncture and hypnosis may be beneficial for the management of pain during labour. However, few complementary therapies have been subjected to proper scientific study and the number of women studied is small.

Combined spinal-epidural versus epidural analgesia in labour

BACKGROUND

Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation, and increased incidence of instrumental vaginal delivery. The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia.

OBJECTIVES

To assess the relative effects of combined spinal-epidural versus epidural analgesia during labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register (July 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to June 2002) and EMBASE (1974 to June 2002).

SELECTION CRITERIA

All published randomised controlled trials involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour.

DATA COLLECTION AND ANALYSIS

Trials identified from searching were assessed for inclusion by the same two reviewers independently. Review Manager software was used for calculation of the treatment effect represented by odds ratios (OR) and weighted mean difference (WMD) using a fixed effects model with 95% confidence intervals (CI).

MAIN RESULTS

Fourteen trials (2047 women) met our inclusion criteria. Of the 25 outcomes analysed from these studies CSE shows a reduced time from first injection to effective maternal analgesia WMD -5.50 minutes (95% CI -6.47 to -4.52; four trials), an increased incidence of maternal satisfaction OR 4.69 (95% CI 1.27 to 17.29; three trials), and an increased incidence of pruritus OR 2.79 (95% CI 1.87 to 4.18; nine trials). No difference was found between CSE and epidural techniques with regards to maternal mobility, rescue analgesia requirements, the incidence of post dural puncture headache (PDPH) or blood patch, hypotension, urinary retention, mode of delivery, or admission of the baby to the neonatal unit.

REVIEWER'S CONCLUSIONS

There is no standard CSE or epidural technique. Compared with epidural, CSE provides faster onset of effective pain relief from the time of injection, and increases the incidence of maternal satisfaction. However, CSE women experience more itch. There is no difference between CSE and epidural techniques with respect to: the incidence of forceps delivery, maternal mobility, PDPH, caesarean section rates or admission of babies to the neonatal unit. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.

Aseptic precautions for inserting an epidural catheter: a survey of obstetric anaesthetists

We performed a postal survey of Fellows of the Australian and New Zealand College of Anaesthetists with a special interest in obstetric practice, about their beliefs regarding aseptic precautions for insertion of an epidural catheter in the labour ward. Of the 435 consultant anaesthetists surveyed, 367 responded (84%), revealing a wide variation in practice. It was not thought to be essential practice to remove a watch before washing hands by 51 respondents (14%), to wear a facemask by 105 (29%) or to wear a sterile gown by 45 (12%). Three anaesthetists (1%) did not believe sterile gloves were essential. However, all respondents indicated that an antiseptic skin preparation was essential. Our results raise questions regarding an acceptable standard of aseptic practice for the insertion of an epidural catheter in labour and we propose a minimal standard of essential precautions.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section

BACKGROUND

Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. Most workers define hypotension as a maternal systolic blood pressure below 70-80% of baseline recordings and/or an absolute value of < 90 - 100mmHg. Hypotension is often associated with nausea and vomiting and, if severe, poses serious risks to mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis and neurological injury). Several strategies are currently used to prevent or minimise hypotension but there is no established ideal technique.

OBJECTIVES

To assess the relative efficacy and side effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register (January 2002) and the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001).

SELECTION CRITERIA

All published or unpublished randomised controlled trials comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section.

DATA COLLECTION AND ANALYSIS

Trials identified from searching are assessed for inclusion by the same two reviewers independently. Studies are excluded from review where: hypotension is not an outcome measure or clearly defined prior to administering a rescue treatment; randomisation is unsatisfactory; the spinal anaesthetic technique or dose of local anaesthetic is not controlled-for; and the intervention is implemented in response to a fall in blood pressure rather than for prevention. Review Manager software is used for calculation of the treatment effect, represented by relative risks and proportional and absolute risk reductions.

MAIN RESULTS

Twenty-five trials (1477 women) meet our inclusion criteria. Four of fifteen interventions reviewed reduce the incidence of hypotension under spinal anaesthesia for caesarean section: (1) crystalloid versus control, relative risk (RR) 0.78 (95% confidence interval (CI) 0.63, 0.98); (2) pre-emptive colloid administration versus crystalloid, RR 0.54 (95% CI 0.37, 0.78); (3) ephedrine versus control, RR 0.69 (95% CI 0.57, 0.84); and (4) lower limb compression versus control, RR 0.70 (95% CI 0.59, 0.83). Ephedrine is associated with dose-related maternal hypertension and tachycardia, and fetal acidosis of uncertain clinical significance.

REVIEWER'S CONCLUSIONS

No intervention reliably prevents hypotension during spinal anaesthesia for caesarean section. No conclusions are drawn regarding rare adverse effects of interventions due to their probable low incidence and the small numbers of women studied. Further trials are recommended, in particular assessing a combination of the beneficial interventions, ie colloid or crystalloid preloading, ephedrine administration and leg compression with bandages, stockings or inflatable boots.

A survey of Australasian obstetric anaesthesia audit

In order to develop a minimal obstetric anaesthesia dataset based on current Australasian clinical audit best practice, we carried out a postal survey of 69 Australasian anaesthetic departments covering an obstetric service. We asked about data being collected, specifically concerning the high risk obstetric patient, epidural analgesia and postoperative anaesthetic review. Examples of any data collection forms were requested. Of the 66 responses, 35 departments (53%) were not collecting any audit data. Twenty-six of the 31 departments (84%) performing obstetric anaesthesia audit responded to our follow-up telephone survey. Eighteen departments believed that there had been an improvement in patient care as a result of their audit and 13 felt that the benefits outweighed the costs involved. However, only six departments (9%) had performed an audit cycle. The importance of feedback to patients or hospital staff and the incidence of post dural puncture headache (PDPH) were cited by some as priorities for obstetric anaesthesia audit. There was however no consistency as to what data should be collected. Many responses suggested a perceived need to collect clinical data without knowing what to do with it. Our survey has highlighted confusion between three distinct objectives; a dataset for obstetric anaesthesia record keeping, data required for continuing patient management in hospital and, a specific minimal dataset for clinical audit purposes. We conclude that current Australasian obstetric anaesthesia audit strategies are inadequate to develop a minimal dataset for cost-effective clinical audit.