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IDENTIFYING MAJOR COMPONENTS OF QUALITY NEURAXIAL ANALGESIA

Departments of Anesthesia, Obstetrics & Gynecology and Nursing, Sunnybrook & Women’s College HSC, 76 Grenville Street, Toronto, ON, M5S 1B2, University of Toronto; Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, 3650 Bathurst Street, Toronto, ON, M6A 2E1; Dept of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8; Dept of Anesthesia, Toronto East General Hospital, 825 Coxwell Ave, Toronto, ON, M4C 3E7; North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1

INTRODUCTION: Labour analgesia research is limited by a fragmented approach to outcome measurement which does not permit meaningful discrimination between modern drug regimens/techniques. A global quality measure of analgesia is likely to provide this level of discrimination. Valid instrument development must be guided by knowledge of parturient perceptions of "quality neuraxial analgesia" (QNA). We report preliminary research examining these issues as part of development of the Quality of Labor Analgesia (QLA) Index, a multi-attribute health index designed to measure neuraxial labor analgesia in research. This work provides the first crucial step in developing the QLA.

METHODS: Qualitative descriptive methods were used to explore parturient experiences of neuraxial analgesia. After REB approval, a purposeful sample of English-speaking parturients of mixed parity, racial, socioeconomic status and delivery mode who received neuraxial analgesia was recruited from 3 urban (1 teaching, 2 community) hospitals with a combined delivery rate of >10,000/year and a range of neuraxial analgesia practice including PCEA. Focus groups/in-depth interviews were held in hospital 72 hours of delivery using semi-structured interviews. Parturients were asked key questions with further iterative exploration until response saturation was achieved. Transcripts were independently coded by 2 researchers and inter-rater reliability was established. Thematic content analysis was performed to identify emergent themes related to QNA.

RESULTS: 27 parturients were interviewed. Emergent themes related to pain, control and fear. Labour pain decreased perceptions of control which was restored when "QNA" was achieved. Women feared both pain, factors associated with epidural insertion and analgesia side-effects. Ideal QNA was defined as safe, complete continuous pain relief, rapid in onset, with complete absence of side-effects. Dissatisfaction was associated with breakthrough pain (most highly ranked source of dissatisfaction), loss of control associated with motor block or numbness and inability to feel the urge to push or contractions. The latter led to fear related to loss of bodily indicators of labour progress and diminished participation in the birth. Dissatisfaction with other side-effects included pruritus and inability to urinate.

DISCUSSION: Preliminary work suggests that the major component scales required to measure QNA must include: pain/pain relief, control, movement, numbness, itching, and ability to urinate.

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