Obstetric anaesthesia in Hungary

International Journal of Obstelric Anesthesia (1997) 6235-238 0 1997 Pearson Professional Ltd

ORIGINAL ARTICLE

Obstetric anaesthesiain Hungary A. Beke, Gy. Takhs, I. Sziller, L. Fed&k, Z. Papp Department of Obstetrics and Gynaecology, Semmelweis University Medical School, Budapest, Hungary

A nation-wide survey of pain relief in childbirth in Hungary was carried out in 1993. Information was provided on 104 137 deliveries in 98 units. The frequencies of different methods of pain relief for vaginal delivery were as follows: systemic opiates in 7387 cases (8.3%), epidural analgesia in 4611 cases (5.2%) and inhalational analgesia (nitrous oxide) in 4470 cases(5%). Epidural analgesia was available in 36 units (36.7%). For 71 744 vaginal deliveries (80.5%) no pain relief was provided at all. For caesareansection (n = 13 240) the rate of spinal or epidural anaesthesiawas 36.7%. It was concluded that despite an increasing rate of pain relief in labour elsewhere,the numbers of epidurals are still rather low in Hungary. SUMMARY.

INTRODUCTION

RESULTS

The nature and extent of obstetric anaesthesiaservices vary greatly from one country to another. Effective pain relief in labour in the form of epidural analgesia has been used increasingly in the western world in the last 30 years. The extent to which it is used dependson local resourcesand on the views of mothers and their carers. The purpose of this study was to assessthe current practice of obstetric anaesthesiain Hungary, with special referenceto pain relief during labour and anaesthesiafor caesareansection.

Out of 120 units, 98 replied to the questionnaire. The study was based on 104 137 deliveries. According to the Hungarian birth registry, there were around 116 000 deliveries in 1993; the study therefore covers 9 0 % of the original target population. In the m a jority of hospitals in the survey, fewer than 1000mothers were delivered annually (Table 1). In Table 2 the frequencies of spontaneous deliveries, caesarean sections, forceps and vacuum extractions are listed. In F ig. 1, frequencies of different methods of pain relief in spontaneousvaginal delivery are shown. O p iates, the most popular, were used in only 8.3% of all spontaneousdeliveries.As many as 30 obstetric units used pethidine and nalbuphine, but no

PATIENTS AND METHODS In 1993, a questionnaire was sent to all of the 120 obstetrics and gynaecology units in Hungary. The questionnaire was addressed to the chairman or director of the obstetric unit. The questionnaire (see Appendix) was designed to enquire into the methods of pain relief during labour and delivery, anaesthetic management of forceps and vacuum deliveries and anaesthesiafor caesareansections used in that year. To obtain a better review of the use of regional anaesthesia we included not only the analysis of obstetric anaesthesiabut also the data for gynaecological laparotomy and vaginal hysterectomy. Atir

Table 1. Annual delivery rates in the 98 hospitals in the survey Number of hospitals 3 7 28 60

Annual delivery rate >3000 2001-3000 100-2000
Table 2. Types of delivery in 98 obstetrical units in Hungary

Number of deliveries Spontaneous vaginal deliveries Vacuum deliveries (84 units) Forceps deliveries (24 units) Caesarean sections

Beke, Gy. TakBcs, I. Sziller, L. FedBk, Z. Papp,

Department of Obstetrics and Gynaecology, Semmelweis University Medical School, Baross utca 27., H-1088 Budapest, Hungary (Director: Zoltan Papp M D PhD DSC) Correspondence to: Artur Beke MD. 235

n

%

104 137 89 079 1587 231 13 240

100 85.54 1.52 0.22 12.71

236 International Journal of Obstetric Anesthesia method of pain relief was used in 80.5% of vaginal deliveries. Nitrous oxide and epidural analgesia were used with similar frequency (see Fig. 1). In Hungary 33 obstetric units used nitrous oxide regularly, sometimes in a high proportion of parturients. Other methods, such as electroanalgesia (TENS), administration of sedative and/or anxiolytic and/or spasmolytic combinations, hypnosis or acupuncture were used less than 1%. In Hungary only about one-third of all obstetric units used epidural analgesia for pain relief (Fig. 2). The epidural rate exceeded 5% in only 12 hospitals, in five of which frequencies between 20 and 40% were achieved. For the most part these were the privileged institutions where education has been introduced for those who are interested in this method. The anaesthetic techniques used for caesarean

z;

80.5%(71744) I I

1

70%+-j 6O%+j 50%--

830,(7387,

40%-5.2%(4611)

30%--

s.Oo/p(44701 1.0%(867)

20%--

lO%-0%7

No pain relief

Epidurrl

n,r---,V’

Opiate

Other

Fig. 1 Pain relief in spontaneous vaginal deliveries.

501

40 30

L-4 12(12.2%)

12(12.2%)

12(12.2%)

k

L-4

204

Yi:

%v/a


l-5%

nwer

Fig. 2 Number of the hospitals where epidural analgesia is used for pain relief in labour.

63.3%(8372)

Spinal anaesthesin

Epidoral maesthair

Fig. 3 Type of anaesthesia at caesarean sections.

General earesthesi8

Fig. 4 Rate of regional anaesthesia (RA) at caesarean sections in Hungarian hospitals.

Table 3. Anaesthetists and nurses

Anaesthetists Nurses

Anaesthetic unit

Independent obstetrical anaesthetic unit

277 398

44 64

section are given in Fig. 3. Most were carried out under general anaesthesia. As Fig. 4 shows, one-third of all institutions performed neither epidural nor spinal anaesthesia due to lack of anaesthetic services or because of local attitudes. In almost all deliveries performed by vacuum extraction or forceps, regional analgesia or general anaesthesia was used. Table 3 shows the number of the physicians and assistants (nurses) able to provide obstetric anaesthesia. In anaesthetic units there were 277 anaesthetists and 398 nurses, and in independent obstetric anaesthetic units 44 anaesthetists and 64 nurses. ‘Independent’ means that the obstetric anaesthetic unit is independent from the anaesthetic unit and belongs to the obstetric unit. The majority of gynaecological laparotomies (n = 18 219) were performed under general anaesthesia and only 1.9% with regional anaesthesia. For vaginal hysterectomy (n = 2758) the rate of regional anaesthesia was 43.2%, of which 7@-90% was spinal anaesthesia in more than 20 hospitals. DISCUSSION Although the level of pain experienced during labour and delivery may often be quite severe,‘J according to our data 80.5% of vaginal deliveries in Hungary were performed without any kind of pain relief. Even nitrous oxide was little used. Nitrous oxide has been favoured for pain relief in labour for a few decades now, in many parts of the world. Intermittent inhalational analgesia using a mixture of 50% N,O in oxygen is inexpensive, may provide

Obstetric anaesthesia in Hungary good analgesia and has a remarkable safety record. According to British data, in the UK 60% of women used N,O and it was the first choice for the majority of parturients who obtained some information about the possibilities of pain relief.’ The product Entonox (a stable 50-50 mixture of nitrous oxide and oxygen in a single cylinder) is convenient and has contributed to the safety of the agent. It is generally found to be more effective than pethidine, I,* the most widely used opioid in labour. Nevertheless opioids, despite their shortcomings,‘m3were the most popular means of analgesia in Hungary, though even they were little used. The extent of use of analgesia in labour varies between hospitals as well as between countries, and not always for any reason other than tradition.4 Schneider et al found that in Switzerland the use of epidural analgesia in labour was associated with the language area.s Thus, in the French speaking part, as in France, use of epidural analgesia was higher than in German and Italian speaking areas. A very important issue in obstetric anaesthesia, with a special bearing on its development, is the availability of suitably trained physicians. Undoubtedly, ready availability of a highly qualified, knowledgeable anaesthetist is a prerequisite for improving the level of service and achieving the safety standards required by parturients. According to Table 3 a total of 321 anaesthetists with the help of 462 nurses perform anaesthesia in Hungary. Clearly this number of anaesthetists is insufficient to provide a comprehensive obstetric anaesthesia service, given the number of deliveries in Hungary. In most Hungarian hospitals the annual delivery rate did not exceed 1000. Data from a nation-wide UK survey indicated that in 1990 about one-half of all women delivered in large hospitals with 2000-4000 deliveries per year.’ In Switzerland, the delivery rate was below 600 per year in more than 50% of the units.5 In the smaller Hungarian hospitals it is difficult to

237

provide good anaesthetic service, which is one possible reason for the low epidural rate. In 1994, the Hungarian Obstetric and Perinatologic Anaesthesiologic Society was founded. This society provides information for pregnant women on different methods of pain relief in labour. By defining standards of care, increasing the number of obstetric anaesthetists and fostering changes in the attitude, an ongoing development of obstetric anaesthesia as an important subspecialty will, we hope, be encouraged. But such a body must surely ask: ‘Should the use of epidural analgesia be encouraged in Hungary, for the sake of its value in the high-risk parturient,4x6or should it be regarded as an unwarrantable expense when there may be other priorities for a country emerging from communism?‘. ACKNOWLEDGEMENTS

The authors express their thanks to the directors of the 98 obstetrical hospital units for providing statistical data and unlimited help. REFERENCES 1. Chamberlain G, Wraight A, Steer P Pain and its relief in childbirth. The Results of a National Survey Conducted by the National Birth Trust. Edinburgh: Churchill Livingstone, 1993. 2. Holdcroft A, Morgan M. An assessment of the analgesic effect in labour of pethidine and 50 % nitrous oxide in oxygen (Entonox). Br J Obstet Gynaecol 1974; 81: 603-607. 3. Olofsson C, Ekblom A, Ekman-Ordeberg G, Hjelm A, Irestedt L. Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. Br J Obstet Gynaecol 1996; 103: 968-972. 4. Reynolds F. Pain relief in labour. Br J Obstet Gynaecol 1990; 97: 757-759. 5. Schneider M, Graber J, Thorin D, Castelanelli S. A survey of current obstetric anaesthesia practice in Switzerland. International Journal of Obstetric Anesthesia 1995: 4: 207-213. 6. Karovits J, Szekeres L, Juhasz Gy et al. The effect of epidural anaesthesia on catecholamine level changes during labour. Recent Prog in Perinat Med 1987; 5: 1755180.

238 International Journal of Obstetric Anesthesia APPENDIX

ObstetricaVGynaecological (data requested

Anaesthesiological

relating to the whole of 1993) . .. . ... .. . .. .. .. .. .. .. . ... . .. .. .. .. .. .. . .. .. .. .. . .. .. .. .. .. .. . ... .. . .. .. .. .. .. .. . .. .. .. .. .. .. . ... . .. .. .. .. .. .. .. . ... .. . .. .. .. .. .. . .. .. .. .. . ... . .. .. .. .. . ... .. . ... . .. .. .. .. . ... .. . .. .. .

Name of the Hospital, Department:

Date:

questionnaire

. . . . . . . . . . . . . . . . 1994

Number of hospital beds (obstetrical and gynaecological

together

Number of obstetricians: . .. .. .. . ... . .. . Number of obstetric anaesthetists: Number of obstetric

Obstetric

.. . ... .. . .. .. .. . ...

without neonatological):

anaesthetic assistants (nurses):

.. . .. .. .. .. . ... . . . ..*.........

(working (working

at anaesthetic department) at obstetric department)

.. . .. .. .. . ... .. . . .. .. .. . ... .. .

(working (working

at anaesthetic department) at obstetric department)

anaesthesia

Total number of deliveries:

. . .. .. .. .. . .

Without

Epidural

N,O

pain relief

Opiates What types: .. .. ... ... .. ... .. .. ... ... .. .. ... .. .. .. . (.... %)

Other

Total

What types: ... ... ... .. .. .... .. .. .. ... .. .. .... .. .. . . . .(.... %)

. ..(lOO%)

Spontaneous vaginal deliveries Vacuum deliveries

. . ..( . . %)

. . . .(.... %)

. . . . (.... %)

*... (.... %)

. . . . (.... %)

. . . .(.... %)

(.... %)

. (.... %)

. ..(lOO%)

Forceps

. . . . (.... %)

. . . . (.... %)

. . . .(.... %)

. . . .(.... %)

. . (.... %)

. ..(lOO%)

Spinal . . . . (.... %)

Epidural . (.... %)

deliveries

Caesarean

section

Gynaecological

Total . ..(lOO%)

anaesthesia

Laparotomies Vaginal hysterectomies

Narcosis . . . .(.... %) . . . . (.... %)

. .. . ... .. . ... . .. .. .. .. . ... .. . .. .. .. . ... . .. .. .. .. .. .. .. . .. .. .. ..

Chairman,

lntratracheal narcosis . . . .(.... %)

Director

Epidural . . . .(.... %) . . . .(.... %)

Spinal . . . .(.... %) . . . .(.... %)

Total . . ..(lOO%). . . ..(lOO%)