Robin Russell

Long term backache after childbirth: prospective search for causative factors

Abstract Objectives: To assess in a prospective randomised study the association between motor block resulting from high and low dose epidural infusions of bupivacaine in labour and the incidence of long term backache after childbirth, and to compare the incidence of backache in women not receiving epidural analgesia. Design: Women requesting epidural analgesia in labour between October 1991 and March 1994 were randomised to receive infusions of either bupivacaine alone or low dose bupivacaine with opioid. Data were collected during labour and the immediate postpartum period from these women and from women recruited at random over the same time from those who had laboured without epidural analgesia. A postal questionnaire about symptoms was sent three months after childbirth to all women. Further data were collected one year after childbirth from those who had reported new backache at three months. Setting: St Thomass Hospital, London. Subjects: 599 women were recruited, of whom 450 (75%) replied to a follow up questionnaire. Results: 152 women (33.8% of responders) reported backache lasting three months after delivery and, of these, 33 (7.3%) had not previously suffered with backache. There were no significant differences between the treatment groups in the incidence of postnatal backache overall or of new backache or any symptoms after childbirth. Among all demographic, obstetric, and epidural variables examined the only factors significantly associated with backache after childbirth were backache before and during pregnancy. Conclusions: The incidence of new long term backache was not significantly increased in women who received epidural analgesia in labour. Motor block resulting from epidural local anaesthetic administration was not a significant factor in the development of backache. Key messages About half of all women suffer backache during pregnancy, but many forget this when questioned retrospectively A prospective study showed that the incidence of new postpartum backache is 7.3 The use of epidural analgesia in labour had no effect on the incidence of postpartum backache In a randomised trial motor block in labour was not associated with an increase the incidence of backache

Is opioid loading necessary before opioid/local anaesthetic epidural infusion? A randomized double-blind study in labour

The effects of two different epidural loading doses administered before starting an opioid/low dose local anaesthetic infusion were examined in a randomized double-blind study during labour. Forty mothers were given either 10 ml 0.25% plain bupivacaine or 10 ml 0.125% plain bupivacaine containing 5 mcg of sufentanil followed in all cases by epidural infusion of 0.08% plain bupivacaine containing 0.2 mcg/ml of sufentanil, which was continued into the second stage. The quality of analgesia did not differ significantly between the groups in either the first or the second stage of labour: in each group 75% of women required 0 or 1 top-up during labour and verbal numerical pain scores were similar. Over 80% of women in each group reported a pain free second stage of labour. There were no differences in the mode of delivery between the groups with 60% of women in each group having a spontaneous vaginal delivery. The proportion of women with motor block increased with the duration of the epidural infusion, with no difference between the groups. There was no difference in the degree of maternal satisfaction assessed 24 hours after delivery, with 80% of women in each group awarding the maximum verbal numerical score for their satisfaction with epidural analgesia. The incidence of maternal side effects (nausea, vomiting, drowsiness and pruritus) was similar in the 2 groups as was neonatal outcome, assessed by Apgar and neurological and adaptive capacity scores and umbilical artery and vein pH. We conclude that opioid loading before opioid/low-dose bupivacaine epidural infusions is unnecessary.

2 Long-term effects of epidural analgesia

Summary Backache and neurological sequelae of childbirth are often attributed to epidural analgesia. Though local tenderness at the site of epidural insertion is commonly encountered, there is no good evidence to support a causal relationship between epidural analgesia and generalized backache. Backache is common before and after delivery and prospective studies show no difference in the incidence of new backache between epidural and non-epidural populations. Headache from accidental or deliberate dural puncture is usually short lived but occasionally becomes a long-term problem possibly because of persistent leakage of spinal fluid or for other reasons. Various neurological problems may follow childbirth with compressive peripheral lesions being probably the most common. Neurological sequelae of regional analgesia are exceedingly uncommon in the obstetric population provided the contraindications to regional analgesia are observed correctly and gross mistakes are not made. Bladder disturbances are not uncommon following childbirth and can only be truly attributed to regional analgesia if it allows bladder over-distension to be ignored, which again is an error of management. British mothers and their carers have an amazing capacity to attribute all manner of postnatal symptoms to epidural analgesia which is markedly detrimental as every attribution tends to become a self-fulfilling prophecy.

Obstetric Anaesthesia 2017: Brussels

As the official journal of the Obstetric Anaesthetists’ Association (OAA), the International Journal of Obstetric Anesthesia (IJOA) is proud to publish the best abstracts submitted to Obstetric Anaesthesia 2017. This year the meeting, which is to be held in Brussels, is jointly hosted by the OAA, Club Anesthésie Réanimation en Obstérique (CARO) and the Belgian Association for Regional Anesthesia (BARA). By the closing date in January, 275 abstracts had been submitted. This represents a 20% increase from last year; primarily a consequence of greater interest from outside the UK. Such an international flavour is most welcome. Even though our politicians struggle to reach agreement, at least we are able to share our experiences of the management of labour and delivery and the care of high-risk pregnancy. Furthermore, nearly 80% of the abstracts were submitted by trainee anaesthetists, which bodes well for the future of obstetric anaesthesia. Each submission underwent peer-review by four senior obstetric anaesthetists with the best 190 abstracts selected for presentation at the Brussels meeting. The top 10 are to be presented orally in the Felicity Reynolds Prize and a further 180 presentations are to be made in one of the two e-poster sessions. As always, I am extremely grateful to those assessors who gave up their valuable time to help with marking. This year, an extra submission category was introduced, namely Quality Improvement. When reviewing previous years’ submissions, it became clear that many authors have found it difficult to decide into which category their project fits. This is especially true for those projects that have previously been labelled as audit or service evaluation and hence the decision to include an extra category. Difficulties with categorisation are, however, likely to remain, questioning whether the process requires further refinement or is, indeed, strictly necessary. In defence of the current system, it helps divide abstracts into manageable groups for marking and, hopefully, reminds authors of the need to ensure that their work has the appropriate approval. Certainly, it is reassuring that the number of projects rejected for not seeking approval or consent continues to fall. Despite such progress, confusion remains in the UK regarding who should approve projects; arguably a simpler system would be one more akin to that used in North America where projects are assessed by the local institutional review board. An interesting observation from this year’s submissions was that only 25% of projects submitted as original research came from UK institutions: in all other categories, the vast majority of submissions were UK-based. In recent years, for a variety of reasons it has become more difficult to conduct research in the UK. Time will tell whether this is a cause for concern. With such a large number of submissions, unfortunately there is not sufficient time for all to be presented at the meeting: nor is it possible to provide individual feedback to unsuccessful authors. Once again, authors should be aware that not following the instructions on how to prepare and submit their work invariably leads to a loss of marks during the scoring process. This can make the difference between having an abstract accepted or rejected. There is, however, still much about which we can be positive. This year the number of submissions has increased, there is a significant international component with abstracts from across Europe and around the world and the vast majority of presentations are from trainees. So, please take time to study the abstracts, not only at the meeting but also on-line and in this supplement. A great deal of work has gone into their preparation and much useful information is contained therein.

Obstetric Anaesthesia 2015: Torquay

Welcome to the 2015 Supplement of the International Journal of Obstetric Anesthesia (IJOA). As the official journal of the Obstetric Anaesthetists’ Association (OAA), IJOA is again delighted to publish the best abstracts submitted to the OAA’s Annual Scientific Meeting, which this year visits Torquay in the South-West of England. A total of 225 submissions were received by January’s closing date and, on behalf of the organising committee, I would like to thank all those who took the time to prepare and submit their work. Each submission was marked by four senior obstetric anaesthetists. The 10 top-scoring abstracts have been selected for oral presentation during two free-paper sessions at the meeting. In addition, 170 projects are to be discussed at two e-posters sessions. Overall, 80% of submissions have been accepted for presentation in some form at the Torquay meeting. The oral presentations cover a variety of subjects including anaesthesia for caesarean section, equipment and patient monitoring, postoperative analgesia and complications. The posters have been grouped so that the various e-poster boards deal with common themes. Of note, there are a number of projects examining enhanced recovery programmes and anaesthetic workload; two areas of particular current interest. Other poster sessions focus on labour analgesia, critical care, surveys of practice and interesting cases. Governance in research and audit remains an important issue. The Abstract Committee’s aim to ensure that all projects submitted for presentation undergo some form of peer review by an ethics or audit committee or Caldicott Guardian appears to be working. This year very few abstracts had not received local approval before submission. Furthermore, the vast majority of case reports had the patient’s consent to presentation; a necessity for inclusion at an international meeting and publication in the IJOA Supplement. Sadly, not all submissions could be accepted. With such a large number of abstracts, it is not possible to give individual feedback and so unsuccessful authors are asked to seek advice from senior members of their departments to explore areas in which their work could be improved. By doing so, future submissions are likely to be more successful. One easy way to increase the likelihood of acceptance is simply to read and follow the instructions. As in previous years, it was disappointing to see how many authors failed to do so. The enthusiasm for obstetric anaesthesia is evident from the number and quality of submissions to the OAA’s Annual Scientific Meetings. This continued support is extremely welcome and hopefully the abstracts at the Torquay meeting will stimulate discussion leading to positive changes that improve the care of both mothers and babies.

Obstetric Anaesthesia 2014: Dublin

In its role as the official journal of the Obstetric Anaesthetists’ Association (OAA), the International Journal of Obstetric Anesthesia (IJOA) is pleased to publish the best 112 abstracts submitted to the 2014 Annual Scientific Meeting in Dublin. By the closing date for submissions back in January, the meeting had attracted over 280 abstracts covering all areas of obstetric anaesthetic practice. Each abstract was marked by at least three experienced obstetric anaesthetists from a team of 12 volunteers. Marks were awarded for originality, relevance, methodology (significance for case reports) and presentation. The scores were collated, after which decisions were made on which were to be selected for oral and poster presentation during the Dublin meeting. As in previous years, authors were asked to categorise their work during the submission process into one of five groups: original research, survey, audit, service evaluation or case report. Such categorisation made allocation to assessors more straight-forward ensuring that similar projects were marked by the same teams. In addition, it also emphasized to the authors the requirement to seek appropriate approval for their projects (research ethics committee, Trust audit board, Caldicott guardian or patient consent). It is reassuring that the number of abstracts rejected for failure to seek the necessary approval was significantly down when compared to previous years. Following delegate feedback from last year’s conference in Bournemouth, all authors of posters accepted for the Dublin meeting are to be given the opportunity to present their work. The 100 top-scoring posters, which are included in this Supplement together with the 12 oral presentations, are to be presented in the e-poster session on Thursday afternoon. The remainder are to be shown and discussed at other times during the meeting. Unfortunately, not all abstracts can be accepted for presentation. With such a large number of submissions, it is not possible to give individual feedback to those authors whose projects were not accepted. Unsuccessful authors are advised to contact members of their own departments with experience in publication who will hopefully be able to offer suitable and constructive advice on how to improve their work. Given the frequency of certain mistakes in this year’s submissions, some general advice can, however, be offered. The simplest way to decrease the chance of an abstract being accepted is not to follow the instructions for authors. Journal Editors are all too familiar with authors failing to heed this advice, and with 25% of marks for this year’s abstracts awarded for presentation, it was disappointing to observe how frequently these instructions were ignored: an oversight that could make the difference between an abstract being accepted or rejected. Furthermore, some authors failed to use the spellchecker with the result that their abstracts contained basic spelling errors for which marks were lost. Finally, many references contained mistakes and authors are reminded of the need to check references carefully both for format and accuracy. Having spent many hours editing the abstracts, I would like, as a cathartic experience, to share five specific issues that appeared with monotonous regularity. By doing so, they might not be repeated in future years benefiting both the Editor in Chief, whose workload will be reduced, and authors who, by avoiding these common pitfalls, may score higher marks. (1) Data are plural, datum being the singular form. It was difficult to keep count of the times that the two words ‘‘data was’’ were included. (2) Apgar is not an acronym. Virginia Apgar was an anaesthetist who worked in New York and so her name should not appear in block capitals. (3) The generic name of a drug does not require a capital letter; however, trade names most certainly do. (4) Somewhat more controversially, caesarean does not require a capital letter as it has nothing to do with the roman emperor. The name comes from the Latin caedare which means to cut out. (5) Finally, the abbreviation LSCS was commonly used. Although the vast majority of caesarean sections (or caesarean deliveries, a controversy for another day) are performed through the lower uterine segment, some are not. Consequently, it is perhaps better to omit the initials LS especially when reporting the findings of large retrospective studies where surgical technique has not been part of the data collection. So having got that off my chest I can now look forward to the scientific programme in Dublin and the numerous presentations of interesting and important new work.

Assessing Long Term Backache After Childbirth

OBJECTIVESnTo investigate the factors associated with long term backache after childbirth, to assess all women reporting new onset long term backache, and to investigate any relation with pain relief in labour.nnnDESIGNnData collected from obstetric records and postal questionnaires or telephone interviews on morbidity after childbirth from all women delivering their first baby between March 1990 and February 1991, followed by analysis of data collected from outpatient consultations.nnnSETTINGnSt Thomass Hospital, London.nnnSUBJECTSnQuestionnaires were sent to 1615 women who had delivered their first baby in the defined period; 1015 either replied by post or were contacted by telephone.nnnRESULTSn299 women (29.5% of responders) reported backache lasting more than six months and of these 156 (15.4%) said they had had no back problems previously. Those women who had received epidural analgesia in labour were significantly more likely to report new onset backache (17.8%; 95% confidence interval 14.8% to 20.8%) than those who did not (11.7%; 8.6% to 14.8%). Younger women, unmarried women, and those reporting other antenatal symptoms were significantly more likely to report new long term backache. The 156 women reporting new backache were asked to attend an outpatient clinic and 36 (23%) did so. The majority had a postural backache which was not severe. Psychological factors were present in 14 women.nnnCONCLUSIONSnThough new long term backache is reported more commonly after epidural analgesia in labour, it tends to be postural and not severe. There were no differences in the nature of the backache between those who had or had not received epidural analgesia in labour.