Original article
National survey on clinical practice in obstetric analgesia in Spain
Encuesta Nacional sobre la práctica clínica en analgesia obstétrica en España
L. Hernández Gonzáleza,
, N. Broglyb, S. Manrique Muñozc, C. Suárez Castañod, G. Yerga Pozoe, M. Raynard Ortizf, E. Guasch Arévalob
Corresponding author
a Complejo Hospitalario Universitario Insular, Materno-Infantil, Gran Canaria, Spain
b Hospital Universitario La Paz, Madrid, Spain
c Hospital Vall d’Hebrón, Barcelona, Spain
d Hospital Universitario Marqués de Valdecilla, Santander, Spain
e Hospital Universitario Virgen de Rocío, Sevilla, Spain
f Hospital Universitario Dexeus, Barcelona, Spain
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Brogly, S. Manrique Muñoz, C. Suárez Castaño, G. Yerga Pozo, M. Raynard Ortiz, E. Guasch Arévalo" "autores" => array:7 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Hernández González" "email" => array:1 [ 0 => "lhergonk@gobiernodecanarias.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Brogly" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Manrique Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Suárez Castaño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "G." "apellidos" => "Yerga Pozo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Raynard Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "E." "apellidos" => "Guasch Arévalo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Complejo Hospitalario Universitario Insular, Materno-Infantil, Gran Canaria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Vall d’Hebrón, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital Universitario Virgen de Rocío, Sevilla, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Universitario Dexeus, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Encuesta Nacional sobre la práctica clínica en analgesia obstétrica en España" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0030" class="elsevierStylePara elsevierViewall">Anaesthesiologists are important members of maternal care teams in all hospital obstetric units. These units may differ at the international level and even at the national level, depending on the type of hospital and level of care provided; nevertheless, the hospital’s anaesthesiologists are responsible for providing the minimum standard of care.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 2020, the European minimum standards for obstetric analgesia were published.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In Spain, SEDAR’s Obstetrics Division published recommendations and algorithms for obstetric anaesthesiologists in 2013 (SEDAR Protocols 2013). These protocols were updated in 2017 and 2021<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> using the latest scientific evidence, and the recommendations were extended to new obstetric anaesthesiology interventions such as external cephalic version and reproductive medicine, which require specific anaesthetic procedures. The existence of national recommendations, however, does not guarantee uniform practice across Spain.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Epidural analgesia remains the most effective technique for pain control during childbirth. Several different epidural analgesia techniques have been described in the literature: direct epidural puncture followed by insertion of an epidural catheter, epidural puncture followed by dural puncture with or without administration of local anaesthetic and insertion of an epidural catheter (combined spinal epidural [CSE]), and/or administration of an initial epidural bolus.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The technique used to maintain epidural analgesia will depend on several factors, such as the availability of an anaesthesiologist round the clock in the delivery room, the availability of analgesia pumps, and the type of analgesia agent used. Several techniques have been described in recent years, including continuous epidural infusion (CEI), patient-controlled epidural analgesia (PCEA) with or without CEI, and programmed intermittent epidural boluses (PIEB), also with or without PCEA.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">If neuraxial analgesia is impossible, several other techniques are safe when performed by an anaesthesiologist, such as intravenous remifentanil.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Given the absence of information regarding obstetric anaesthesia practice in Spain, the Obstetrics Division of SEDAR designed a national survey to determine the analgesia and anaesthesia techniques currently used in obstetrics, to identify areas of uniformity and disparity in anaesthesia management, and to describe the safety measures implemented in obstetric anaesthetic units in Spain.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and method</span><p id="par0060" class="elsevierStylePara elsevierViewall">After obtaining waivers from local research ethics committees, a team of experts in obstetric anaesthesiology from SEDAR’s Obstetrics Division developed a Delphi-based survey on epidural labour analgesia.</p><p id="par0065" class="elsevierStylePara elsevierViewall">After several videoconference meetings, the experts defined a number of areas to evaluate: the organization of obstetric anaesthesia services, current trends in labour neuraxial analgesia, and obstetric anaesthesia practice.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The panel developed a 36-item questionnaire to determine the characteristics of responding health centres, the epidural technique used, the dose and method of administration of the local anaesthetic, and the use of adjuvants. The questionnaire also enquired about alternatives to epidural analgesia, and safety and humanization measures implemented during childbirth (<a class="elsevierStyleCrossRef" href="#sec0075">Appendix A</a>).</p><p id="par0075" class="elsevierStylePara elsevierViewall">A series of Delphi rounds were held to validate the questions on the basis of prevailing scientific evidence and the usual practice of panel members. The resulting questionnaire was endorsed by SEDAR’s Scientific Committee. The questionnaire was uploaded to Google Forms and sent by email to the person in charge of each obstetric unit of the 195 Spanish maternity hospitals registered in the SEDAR’s Obstetrics Division between April and September 2022. Participation was anonymous, voluntary, and unpaid. Respondents gave permission for their responses to be used in publications related to the survey. The data were downloaded into a Microsoft Excel file (Microsoft Corporation, Redmont, WA, USA) for analysis. Qualitative variables are shown as N (%) and quantitative variables as mean (SD).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 195 questionnaires were sent by email, and responses were received from 108 health centres from 16 of the 17 Autonomous Communities in Spain, representing a response rate of 55.38%. Three of the 108 responses received were incomplete and were therefore eliminated, leaving 105 responses from195 maternity hospitals (53.4%), 84.7% of which are public hospitals, 8.6% are private hospitals, and 7.6% are subsidized hospitals. Forty-nine (48.6%) hospitals offer specialized perinatal care (ACOG level 3–4).</p><p id="par0085" class="elsevierStylePara elsevierViewall">Only one of the responding hospitals did not provide round-the-clock obstetric anaesthesia vs 55.2% of hospitals in which anaesthesiologists attended both obstetric and other emergencies and 43.8% that had at least one full-time obstetric anaesthesiologist. In 23.8% of hospitals, anaesthesiologists devote more than 50% of their time to obstetric anaesthesia, while in the remaining 76.2% they combine obstetric anaesthesia with other subspecialities.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding teaching, 27.6% of hospitals do not have a resident training programme vs 72.4% that do of these, 35.2% taught their own residents, 34.3% taught both their own and external residents, and 2.9% taught only external residents.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Epidural analgesia techniques during childbirth</span><p id="par0095" class="elsevierStylePara elsevierViewall">In 69.5% of responding hospitals the epidural space is identified using the loss of resistance to saline technique vs loss of resistance to air in 23.8% and either technique in 6.6%. Only one hospital reported using the hanging drop technique for this purpose.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The use of ultrasound to locate the epidural space is only used in 20% of centres, and then only occasionally in patients with a history of difficult epidural puncture (19%) or morbid obesity (8.8%).</p><p id="par0105" class="elsevierStylePara elsevierViewall">In 22.8% of centres, epidural analgesia is performed without prior fluid therapy vs 74.3% of centres in which preloading with crystalloids is mandatory, and 1.9% (2) in which preloading with colloids is mandatory.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Start of labour analgesia</span><p id="par0110" class="elsevierStylePara elsevierViewall">In 93.3% of centres, the first choice technique is standard epidural analgesia, although 8.5% prefer the combined spinal-epidural (CSE) technique.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Regarding the test dose, 58.1% use bupivacaine plus a vasoconstrictor, 11.4% use lidocaine plus a vasoconstrictor, and 9.5% use either indistinctly. In 10.5%, the test dose is included in the induction dose, and in 9.5% another type of local anaesthetic is used as a test dose.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The induction bolus is levobupivacaine in 45.7% of centres, followed by ropivacaine in 21.9% and bupivacaine in 18.1%. The remaining centres use any of the foregoing, and follow no particular protocol.</p><p id="par0125" class="elsevierStylePara elsevierViewall">in 90.5% of centres, fentanyl is the adjuvant used in the induction bolus. Only one centre uses sufentanil, and the remaining 8.5% did not include adjuvants in the initial bolus.</p><p id="par0130" class="elsevierStylePara elsevierViewall">To maintain obstetric analgesia, 5.7% of centres prefer continuous epidural infusion (CEI), 60.9% use CEI plus PCEA, 30.5% use PIEB + PCEA, and in 1.9% of centres manual booster boluses are administered by the anaesthesiologist or by the midwife under specialist supervision.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Maintenance of analgesia during delivery</span><p id="par0135" class="elsevierStylePara elsevierViewall">Nearly half (48.6%) of the centres polled use levobupivacaine as a maintenance anaesthetic agent compared to 24.8% that use ropivacaine and 9.5% that use bupivacaine. The remaining centres use a combination of any of these agents.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The maintenance adjuvant is fentanyl in 96% of centres, compared to one centre that uses sufentanil, another that uses morphine, and two centres that do no not use maintenance adjuvants.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Management of epidural for labour and/or caesarean section and its side effects</span><p id="par0145" class="elsevierStylePara elsevierViewall">Over half (63.8%) of responding centres administer epidural analgesia in over 80% of patients.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In 50.5% of centres, more than 50% of patients undergoing intrapartum caesarean section have an existing labour epidural placed in the delivery room. In 61.9% of centres, the likelihood of administering general anaesthesia due to failure to convert the epidural block to anaesthesia was less than 5%. If a category 1 caesarean section is required in a parturient with an existing labour epidural, 13.3% of centres would perform general anaesthesia, 44.7% would convert the epidural block, 26.7% would add a hypnotic to the epidural, 3.8% would perform a second epidural, and 7.6% would combine any of the foregoing techniques.</p><p id="par0155" class="elsevierStylePara elsevierViewall">In the case of lateralized block, 60% of centres would first withdraw the catheter 1-2 cm and administer a booster epidural bolus, in 13.3% the catheter would be removed and a new one placed, and in 5.7% the catheter would be removed and CSE performed. The remaining 19% centres did not have a protocol in the event of lateralized block.</p><p id="par0160" class="elsevierStylePara elsevierViewall">In the case of maternal hypotension, 20% of centres would only administer fluids as the first option vs 50.5% that would use a vasoactive agent (ephedrine in 33.3%, phenylephrine in 12.4%, both in 4.8%) and 29.5% that would use a combination of fluid therapy and a vasoactive agent.</p><p id="par0165" class="elsevierStylePara elsevierViewall">In the case of massive postpartum haemorrhage, first line treatment in 47.6% of centres would be to examine the birth canal under the existing epidural anaesthesia vs 38.1% of centres that would perform the examination under general anaesthesia. A small percentage (2.8%) of centres would administer sedation, and in the remaining of centres any of the 3 foregoing techniques would be used, depending on the haemodynamic status of the patient.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Fifteen responding centres (14.3%) do not offer an alternative (pharmacological or non-pharmacological) to labour epidural analgesia. In 71.4%, more than 2 non-pharmacological methods were available, and in 34.3% more than 2 pharmacological methods (intravenous remifentanil is the only pharmacological alternative in 19% of centres and nitrous oxide in 15.2%).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Epidural analgesia safety</span><p id="par0175" class="elsevierStylePara elsevierViewall">In total, 24.8% of responding centres do not have or do not follow protocols for the management of obstetric patients, even though SEDAR has endorsed such protocols and made them available to SEDAR members on its website.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In 48.5% of centres, information to obtain informed consent for epidural analgesia was given to the mother during pregnancy (15.2% during group talks; 24.8% in the anaesthesiologist's office) vs 40% in which it was given immediately before performing the epidural technique, and 10% in which it was given at the time of hospital admission, before the onset of contractions.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In 69.5% of centres, this information was given by the anaesthesiologist, while in 18.1%, 1.9%, and 1.9% of centres it was given by the midwife, gynaecologist, or nurse anaesthetist, respectively. In 8.6% of centres, the provision of informed consent for epidural analgesia was not protocolized.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Only 63.8% of centres used a commercially available local anaesthetic solution or a solution prepared by the hospital's pharmacy. In 34% of centres, the solution was prepared directly by the anaesthesiologist before administering it to the patient. The midwife prepared the local anaesthetic solution only in one centre.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Only 12% of responding centres used lüer-lock connectors in the delivery room. Over half (56.2%) used yellow coding to identify epidural catheters in order to differentiate them from intravenous catheters, while only 6% used drug identification labels. Some (9.5%) did not apply measures to differentiate epidural from other catheters.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0200" class="elsevierStylePara elsevierViewall">Hospitals from all over Spain participated in this national survey on clinical practice in epidural analgesia during labour, allowing us to obtain a well-balanced, representative picture of the situation in both private and public centres in Spain. The success of the survey was due to our ability to reach out directly to the obstetricians registered with SEDAR’s Obstetrics Division.</p><p id="par0205" class="elsevierStylePara elsevierViewall">We achieved an excellent response rate compared to other studies,8 bearing in mind that participation was voluntarily and unpaid, and the responses received enabled us draw representative conclusions from our study population. These results have shown that our survey has acceptable internal validity.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The responses to our questionnaire have shown that analgesia techniques vary among hospitals, and that many centres are now using the latest evidence-based techniques such as CSE and maintenance with PIEB plus PCEA. The use of low doses and concentrations of local anaesthetics supports reports in the scientific literature, although this approach is not yet offered or promoted in many Spanish centres.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">8</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">CEI + PCEA was the most widely used technique among our respondents. Reports in the literature show that PIEB is becoming more popular because it is highly rated by patients, reduces consumption of local anaesthetics, and shortens the second phase of labour. In Spain, one of the main barriers to the use of PIEB is probably cost, specifically, difficulties accessing the pumps and perfusion systems required for this mode of administration.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Anaesthesia-related mortality is rare among pregnant patients, and there is no significant difference between regional and general techniques in this regard.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a> However, the incidence of postpartum haemorrhage, surgical wound infection, and the rate of postpartum depression is higher in patients undergoing caesarean section under general anaesthesia compared with neuraxial techniques.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">10,11</span></a> In the case of urgent caesarean section (category 1–3),<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">12</span></a> most centres prefer regional rather than general anaesthesia, as recommended in scientific guidelines.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">13</span></a> If a category 1 caesarean section is needed in a parturient with an existing labour epidural, most centres convert the epidural using fast-acting local anaesthetics, as recommended in the current scientific literature.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">According to recommendations, information about any analgesic or anaesthetic technique to be performed by an anaesthesiologist should be given by an anaesthesiologist (resident or specialist). The information given to obtain informed consent for any technique must be adapted to the cultural, personal, and psychological characteristics of the patient.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a> In some autonomous communities, this information must be given at least 24 h before the procedure, except in the case of emergencies. However, there is no such provision in Spanish law, so the information must be given with sufficient notice to allow the patient time to reflect and freely decide.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The Helsinki Declaration on Patient Safety in Anaesthesiology endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC)<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a> has promoted a Europe-wide patient safety culture. The Declaration calls on all hospitals in Europe to introduce drug labelling systems in anaesthesiology units in order to reduce administration errors. Other national<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> and international<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">18–20</span></a> organisations have recommended further safety measures (colour-coding for epidural/spinal catheters,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> the use of lüer-lock connectors, automated or third-person verification systems). The use of these protocols in obstetric anaesthesia where doses and procedures are standardized reduces intra-hospital clinical practice variability, improves patient safety, and reduces the incidence of adverse effects secondary to wrong-route errors. The results of our survey have shown that despite the acceptable compliance rate, there is still room for improvement in obstetric local anaesthesia administration.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Limitations</span><p id="par0235" class="elsevierStylePara elsevierViewall">Only hospitals with an obstetric anaesthesiologist registered with SEDAR’s Obstetric Division participated in the survey. The only requirement for entry in this register is to be a member of SEDAR. Registry is open, voluntary, and has been available since 2021. Hospitals providing obstetric anaesthesia services that do not have a representative registered with SEDAR’s obstetrics division did not receive the questionnaire.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0240" class="elsevierStylePara elsevierViewall">This is the first survey to provide us with up to date information on clinical practice in obstetric anaesthesiology in public and private hospital in Spain, following the creation of a national network of obstetric hospitals.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The results show a predilection for the use of low-dose analgesia techniques with fentanyl and a more wide-spread use of PCEA systems. In patients requiring caesarean section, regional techniques are prioritized over general anaesthesia. Most hospitals follow current evidence-based recommendations in all areas of obstetric anaesthesiology practice. Some centres, however, maintain obsolete practices, do not offer any alternatives to labour epidural, and have not drawn up their own care protocols to homogenise clinical practice at the local level.</p><p id="par0250" class="elsevierStylePara elsevierViewall">Implementing and updating evidence-based strategies, treatments and techniques in obstetrics will allow hospitals to improve care quality and patient safety and achieve excellence in the care of pregnant women. Further surveys are needed to evaluate existing practices and propose improvements.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:18 [ 0 => array:3 [ "identificador" => "xres2268601" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1891717" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2268600" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1891718" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0010" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Epidural analgesia techniques during childbirth" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Start of labour analgesia" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Maintenance of analgesia during delivery" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Management of epidural for labour and/or caesarean section and its side effects" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Epidural analgesia safety" ] 12 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 13 => array:2 [ "identificador" => "sec0055" "titulo" => "Limitations" ] 14 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion" ] 15 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 16 => array:2 [ "identificador" => "xack780565" "titulo" => "Acknowledgements" ] 17 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-04-27" "fechaAceptado" => "2024-07-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1891717" "palabras" => array:4 [ 0 => "National survery" 1 => "Obstetric anaesthesia" 2 => "Obstetric analgesia" 3 => "Obstetric safety" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1891718" "palabras" => array:4 [ 0 => "Encuesta nacional" 1 => "Analgesia obstétrica" 2 => "Anestesia obstétrica" 3 => "Seguridad obstétrica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A national survey was conducted among maternity hospitals nationwide to understand the variability in clinical practice for obstetric analgesia and to reach a consensus on optimal care in the future in Spain.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Spanish experts in obstetric anesthesiology designed a survey on the practice of obstetric analgesia during childbirth, following a Delphi process. The survey was sent to 195 Spanish maternity hospitals between April and September 2022 using Google Forms. A descriptive study of the results was performed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Responses were obtained from 108 centres (55.4%), of which 88 (83.8%) were public hospitals. The most commonly used technique was epidural analgesia in 97 (92.4%) centres. Nine (8.6%) centres used the combined spinal-epidural (CSE) technique, 5 (4.8%) used spinal analgesia, and 3 (2.9%) used dural puncture epidural (DPE) analgesia. The most commonly used local anaesthetic was levobupivacaine 0.1−0.25% in 82 (78.1%) centres. Fentanyl or sufentanil were added to the local anaesthetic in 96 (91.4%) centres. Epidural maintenance was performed with continuous epidural infusion (CEI) + patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB) + PCEA in 64 (60.9%) and 33 (30.5%) centres, respectively. Fifteen (14.3%) centres lacked alternative techniques to epidural analgesia and 25 (23.8%) did not follow obstetric analgesia protocols.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the variability in clinical practice for obstetric analgesia in Spain, the vast majority of centres follow recommendations in this field. There is room for improvement, which should be considered a fundamental strategy for progressing towards excellence.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se llevó a cabo una encuesta nacional entre las maternidades del territorio español para conocer la variabilidad de la práctica clínica en analgesia obstétrica y consensuar un óptimo cuidado futuro en España.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Expertos españoles en anestesiología obstétrica, diseñaron una encuesta sobre la práctica de la analgesia obstétrica durante el parto, siguiendo un proceso Delphi. La encuesta fue enviada a 195 maternidades españolas entre abril y septiembre de 2022 utilizando Googleform. Se realizó un estudio descriptivo de los resultados.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se obtuvieron respuestas de 108 centros (55.4%), de los que 88 (83.8%) fueron hospitales públicos. La técnica más utilizada fue la analgesia epidural en 97 (92,4%) centros. Nueve (8,6%) centros usaban la técnica espinal-epidural combinada (CSE), 5 (4,8%) la analgesia espinal y 3 (2,9%) la analgesia epidural con punción dural (DPE). El anestésico local más empleado fue la levobupivacaína 0,1–0,25% en 82 (78,1%) centros. El fentanilo o el sulfentanilo eran añadidos al anestésico local en 96 (91,4%) centros. Se realizaba el mantenimiento epidural con infusión epidural continua (CEI) + bolos epidurales controlados por la paciente (PCEA) o bolos epidurales intermitentes programados (PIEB) + PCEA en 64 (60,9%) y 33 (30,5%) centros respectivamente. Quince (14,3%) centros carecían de técnicas alternativas a la analgesia epidural y 25 (23.8%) no seguían protocolos de analgesia obstétrica.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A pesar de la variabilidad en la práctica clínica en la analgesia obstétrica en España, la gran mayoría de los centros siguen recomendaciones en este campo. El margen de mejora es posible y debería considerarse como estrategia fundamental para una evolución hacia la excelencia.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0270" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "National survey on clinical practice in obstetric analgesia in Spain" "identificador" => "sec0075" ] ] ] ] "multimedia" => array:2 [ 0 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. In which autonomous community is your hospital located?: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. What type of funding does your hospital receive: Public Hospital/Private Hospital/Subsidised Hospital/Other:__ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. What level of perinatal care does your centre offer?: Level 1 Level 2 Level 3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Does your hospital have its own resident programme? Yes/No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Does your maternity ward have its own obstetric anaesthesiologists? (do they devore more than 50% of their time to obstetric anaesthesia?) Yes/No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. In your hospital, is there always (round the clock) an anaesthesiologist available for patients in labour? Yes/No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7. What is the average number of deliveries per year in your hospital? <500/500−1500/ 1501–3000/ 3000−5000/ > 5000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8. Percentage of women receiving neuraxial analgesia in your hospital : <50%/50%–80%/>80% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9. Percentage of urgent (unscheduled) caesarean sections performed in a parturient with an existing labour epidural? ____ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.Percentage of parturients in your centre requiring general anaesthesia due to failed conversion from epidural analgesia? ______ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11. In a parturient with an existing functioning epidural catheter who requires category 1 caesarean section (immediate threat to the life of a woman or foetus), what technique do you usually use?: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The existing epidural catheter/Intradural anaesthesia/General anaesthesia/Epidural catheter + intravenous hypnotics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12. What technique do most anaesthesiologists in your centre use to identify the epidural space? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Loss of resistance to air/Loss of resistance to saline/Hanging drop/Other: ______ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13. In your centre, do you use ultrasound to guide epidural administration? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Usually/Sometimes/Never \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14. If you use ultrasound, in which patients do you use it?: ________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15. What neuraxial technique(s) do anaesthesiologists in your hospital usually use for labour analgesia? (Indicate the percentage per technique) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Epidural/Combined spinal-epidural (CSE)/Dural puncture epidural (DPE)/Spinal/Other:___ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16. What test dose do you use in your centre? _____________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17. What local anaesthetic do you usually use in your centre for epidural induction? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bupivacaine/Levobupivacaine/Ropivacaine/Other:___________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18. What is the concentration of the epidural induction dose? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0.0625% / 0.125% / 0.25% / 0.1% / 0.16% / 0.2% / 0.75% /Other______________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.- In addition to the local anaesthetic, what adjuvant(s) do you add to the induction dose? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None/Fentanyl/Sufentanil/Morphine/ Buprenorphine/Clonidine/Other:_____________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20. How is epidural analgesia usually maintained in your hospital? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Continuous infusion only/Continuous infusion + PCA/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Continuous infusion + boluses administered by the midwife/anaesthesiologist/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Programmed intermittent epidural bolus (PIEB)/programmed intermittent epidural bolus (PIEB) + PCA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCA only/boluses administered by midwife/anaesthesiologist only/Other:____________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21. What local anaesthetic do you usually use in your centre to maintain epidural analgesia? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bupivacaine/Levobupivacaine/Ropivacaine/Other:___________________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22. What is the concentration of the epidural maintenance anaesthetic? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0.0625% / 0.125% / 0.25% / 0.1% / 0.2% / 0.75% /Other \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23. In addition to the local anaesthetic, what adjuvant(s) do you add to the maintenance anaesthetic? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1 mcg/ml fentanyl/2 mcg/ml fentanyl/0.5 mcg/ml sufentanil/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0.05 mg/ml morphine/0.01 mg/ml buprenorphine/clonidine/Others: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24. What are the most frequent epidural-related adverse effects in your hospital?: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maternal hypotension without foetal impact/Maternal hypotension with foetal impact/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post-dural puncture headache/High sensory block/Motor block/Patched or lateralized analgesia/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pruritus/Nausea/vomiting/Blood puncture/Local anaesthetic toxicity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25. In the event of lateralized or patchy analgesia, how do you usually resolve the problem? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I withdraw the catheter one or two centimetres and administer a new bolus/I remove the catheter completely and place a new one \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I modify the dose or volume of local anaesthetic/I leave it as it is and inform the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26. In the event of postpartum haemorrhage, would you consider using: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>the existing epidural catheter/ general anaesthesia directly \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27. In addition to epidural analgesia, does your hospital offer any other type of labour analgesia?: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Continuous infusion of remifentanil/Continuous infusion of remifentanil + boluses/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Only remifentanil boluses/Nitrous oxide/Pethidine/Other \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28. Does your hospital use any other non-pharmacological analgesia? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bath/Shower/Water bath/Music therapy/Colour therapy/Aromatherapy/Homeopathy/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Accompaniment during delivery/Birthing ball/Other:_______ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29. When are patients given the written informed consent form for epidural analgesia in your hospital? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>During pregnancy, in a consultation arranged for this purpose. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>During pregnancy, during an information group meeting. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>During pregnancy, during an information group meeting + specific consultation for complex cases. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>At the time of hospital admission, before entering the delivery room. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In the delivery room, immediately before performing the analgesia technique. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30. Who gives the informed consent information? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Midwife/Gynaecologist/Anaesthesiologist/Other:____________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31. Does your hospital have labour analgesia management protocols? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes, all anaesthesiologists follow them \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes, but some follow them and others do not. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No, we don’t have our own protocols, but we follow SEDAR protocols. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No, we don’t have our own protocols, anaesthesiologists treat patients at their discretion. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32. When you perform labour analgesia, who helps you? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A specific nurse anaesthetist/A midwife/A nursing assistant/Nobody/Other______ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33. Where is the epidural analgesia solution prepared? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>It is prepared and delivered by the hospital pharmacy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>It is prepared before the epidural is administered \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>We use a commercial solution and add the adjuvants \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other:______________ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34. Does your hospital have specific epidural catheter connectors (luer-lock)? Yes/No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35. Safety measures and risks. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Which of the following safety measures do you use in your centre? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Specific automatic PCA pumps (not manual boluses). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anaesthesia nurses administer or monitor regional anaesthesia (epidural/spinal). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vital signs monitoring (SatO2, HR, NIBP) during the epidural technique. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Foetal CTG monitoring during the technique. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The technique is performed in a specific room that meets aseptic criteria. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The technique is performed at the patient’s bedside. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The technique is performed using sterile drapes, gloves and gown (all three). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Respirator available in the area where the epidural technique is performed. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lipid emulsion is available in the area where the technique is performed. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A crash trolley is available in the area where the technique is performed and is regularly checked. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The catheter is identified with a yellow label. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Can another member of staff (not an anaesthesiologist) make changes to the labour analgesia (the midwife/gynaecologist can stop the pump without warning, give extra boluses without consulting, etc.)? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36. Would you like to provide us with contact details so that you can receive information directly from the Obstetrics Division? (provide your name and email) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3685434.png" ] ] ] ] ] 1 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Key concepts</span><p id="par2005" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0010" class="elsevierStylePara elsevierViewall">National survey on obstetric anaesthesia practice in Spain.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0015" class="elsevierStylePara elsevierViewall">Most commonly used analgesic and anaesthetic techniques.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Safety mechanisms used in each obstetric anaesthetic unit.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0025" class="elsevierStylePara elsevierViewall">Monitoring of scientific evidence.</p></li></ul></p></span></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a safe practice of Anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.W. 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