|Year : 2019 | Volume
| Issue : 1 | Page : 14-17
Effect of preoperative education about spinal anesthesia on anxiety and postoperative pain in parturients undergoing elective cesarean section: A randomized controlled trial
Anila K Kalliyath1, Sara V Korula1, Anna Mathew2, Saramma P Abraham1, Mini Isac3
1 Department of Anesthesiology, MOSC Medical College, Kolenchery, Kerala, India
2 Department of Pharmacology, MOSC Medical College, Kolenchery, Kerala, India
3 Department of Obstetrics and Gynecology, MOSC Medical College, Kolenchery, Kerala, India
|Date of Web Publication||11-Apr-2019|
Dr. Sara V Korula
Department of Anesthesiology, MOSC Medical College, Kolenchery, Kerala
Source of Support: None, Conflict of Interest: None
Background: Preoperative anxiety is a common problem in all patients. The reason could be incomplete information regarding the anesthesia and surgical procedure. Cesarean section (CS) is a common surgery and treatment of postoperative pain after CS continues to be an ongoing challenge. Aim: The present study was carried out to assess if preoperative education with a handout about spinal anesthesia can reduce anxiety and postoperative pain in parturients undergoing CS under spinal anesthesia. Methods and Materials: We randomized 64 parturients into two equal groups; study (Group A) and control group (Group B). The study group was given a handout and a structured education about spinal anesthesia. The control group was given routine preoperative information. The Amsterdam preoperative anxiety and information scale (APAIS) was used to measure anxiety preoperatively and visual analogue scale (VAS) for pain at 5 h and 24 h postoperatively. Statistical Analysis: The two groups were compared using Student's t test and non-parametric Wilcoxon-Mann-Whitney U test. Result: The median difference in preoperative anxiety scores (APAIS) in the two groups was found to be 8.00 (P < 0.001), which was significant statistically. The median value of postoperative pain analyzed using VAS after giving education, at 5 h was significantly reduced in Group A (5.00) as compared to Group B (9.00). The median value of VAS score at 24 h was significantly different in both groups. It was 1.0 in Group A, whereas the same was 5.50 in Group B (P <.00). The median difference in hours in the duration of analgesia between the two groups was 0.62, which was not significant statistically (P < 0.10). Conclusion: A planned preoperative education and handout with details about spinal anesthesia can have a significant impact on reducing the preoperative anxiety and the postoperative pain in parturients undergoing elective CS under spinal anesthesia.
Keywords: Cesarean section, educational handout, postoperative pain, preoperative anxiety, spinal anesthesia
|How to cite this article:|
Kalliyath AK, Korula SV, Mathew A, Abraham SP, Isac M. Effect of preoperative education about spinal anesthesia on anxiety and postoperative pain in parturients undergoing elective cesarean section: A randomized controlled trial. J Obstet Anaesth Crit Care 2019;9:14-7
|How to cite this URL:|
Kalliyath AK, Korula SV, Mathew A, Abraham SP, Isac M. Effect of preoperative education about spinal anesthesia on anxiety and postoperative pain in parturients undergoing elective cesarean section: A randomized controlled trial. J Obstet Anaesth Crit Care [serial online] 2019 [cited 2019 Dec 9];9:14-7. Available from: http://www.joacc.com/text.asp?2019/9/1/14/255892
| Introduction|| |
In patients scheduled for surgery, preoperative anxiety has been encountered at a rate of 60%–80%, which influences the surgery, anesthesia, and consequently the postoperative healing., Studies have shown that depression and anxiety are common in parturients coming for elective cesarean section (CS). The maternal anxiety can be related to well-being of the unborn baby and also the procedure related to anesthesia and surgery. Good analgesia after CS helps in early mobilization, prevent thromboembolic complications, and improves general well-being of the mother. There is additional benefit in care of the newborn and effective breast feeding. Preoperative counseling can be used to reduce requirement of analgesics, decrease complications, and increase patient satisfaction.
Kerala is a state in south India where the women's literacy rate is high, and antenatal checkups are quite regular. This is in contrast to many other parts of the country. However, studies have shown that information about anesthetic management is usually inadequate. In most institutions in India, CS is performed under spinal anesthesia.
Hence, the present study was initiated to assess the effectiveness of planned interactive education and handout in the local language about spinal anesthesia, in allaying the anxiety in parturients undergoing elective CS and to ascertain the role of this preoperative education on postoperative pain relief.
| Methods|| |
After the Institutional Ethics Committee approval, consecutive parturients admitted for elective CS under spinal anesthesia were visited on the day prior to the surgery for a period of 2 months from April to May 2016.
Written informed consent was taken, and the patients were enrolled to the study.
Consecutive american society of anaesthesiologists (ASA) 2 parturient mothers admitted to the institution for elective CS under spinal anesthesia.
Parturients with complicated pregnancy and those who required any other procedures to be done intraoperatively such as myomectomy, breast lump excision, etc., were excluded.
The patients were randomly allocated into two groups by permuted block randomization: Group A being the interventional group and Group B being the control group. The group allocations were sealed in serially numbered opaque envelops prepared by the research coordinator, who was not involved in the study. The demographic data were collected in the case study form.
The Amsterdam preoperative anxiety and information scale (APAIS) is a validated and widely used scale for measurement of anxiety, and this scale was used to measure anxiety in this study. The visual analogue scale (VAS) was used to measure pain. In the study, a scale of 0–10 was used by asking the patients to quantify the pain by putting a mark on VAS scale, which they felt represented the degree of pain at the moment.
The planned preoperative counseling comprised of details about positioning and procedure of spinal anesthesia, side effects and recovery of spinal anesthesia, and advantages of spinal anesthesia compared to general anesthesia in CS. A patient handout titled- Mother's Information Sheet, with the same details in the local language, was also provided. Structured education and handout was given to Group A before routine preanesthetic check-up (PAC).
The parturients in Group B received the routine PAC. This included patient assessment for fitness for surgery, the anesthetist doing the PAC explained the nil per oral (NPO) timings, and the anesthesia that would be given for the procedure. The patient handout was not given prior to assessment.
The APAIS was used to measure anxiety levels, 3to 4 hours after giving the education and PAC, by an assessor blinded to the study groups. The patients in both the study arms received standard care. The anesthetists performing the spinal anesthesia were blinded to the allocation of groups. All patients were given 15 mcg fentanyl with 9 mg bupivacaine for anesthesia. All patients had adequate anesthesia. Postoperatively, they were given non steroidal anti-inflammatory drugs (NSAIDS) (Injection diclofenac 75 mg IM) and intravenous tramadol 100 mg Q8H for analgesia.
The VAS was used to measure postoperative pain by the blinded assessor at 5 h and 24 h postoperatively.
The sample size was calculated using nMaster 2.0 sample size software for non-parametric tests using the non-parametric two group Wilcoxon-Mann-Whitney U test. The sample size for 80% power and 5% alpha error is 32 subjects in Group A and 32 subjects in Group B. The continuous variables that satisfied normal distribution were assessed using mean and standard deviation, and for the variables that did not satisfy, median and interquartile range was taken. Outcome measures that satisfied normal distribution were assessed using Student's t test, and those that did not satisfy normal distribution were assessed using non-parametric Wilcoxon-Mann-Whitney Utest. A P value < 0.05 was taken to be significant, and P value < 0.001 was taken to be highly significant. The demographic variables in the two groups were compared using Chi-square test. The median APAIS and VAS scores obtained for Groups A and Group B were analyzed.
| Results|| |
A total of 64 parturients undergoing elective CS under spinal anesthesia were studied after being randomly divided into two groups – A and B. All the participants were above 18 years and below 40 years, except one, all others were post-term. They were an educated group out of which more than 70% were graduates.
The two groups did not differ significantly in demographic factors, obstetric history, and fetal lie [Table 1]. The fetal position: 82% women had cephalic lie, 15% were breech presentation, and the rest 3% were transverse lie.
The median difference in APAIS in the two groups was found to be 8.00, which was statistically significant (P < 0.001). The median value of postoperative pain analyzed using VAS after giving education, at 5 h was significantly reduced in Group A (5.00) as compared to Group B (9.00). The median of VAS score at 24 h was 1.0 in Group A when compared to Group B (5.50). This difference was also statistically significant (P <.00). The median difference in hours in the duration of analgesia between the two groups was 0.62(P < 0.10) [Table 2].
| Discussion|| |
This study was designed to assess whether a structured preoperative education and handout about spinal anesthesia can decrease preoperative anxiety in parturients undergoing CS under spinal anesthesia. The APAIS used in this study is valid and reliable in different settings. This contains 6 statements and the answers to these are used to determine patient's anxiety level. Each statement is rated on a 5-point scale, and the total score ranges from 0 to 24. It includes measurement of both anxiety (Questions 1, 2, 4, and 5) and information need (Question 3 and 6) relating to the situation of waiting for the surgery.
In the present study, the median value of preoperative anxiety, as measured by APAIS after giving a detailed information in the form of a two-way dialogue and handout, was found to be significantly reduced in Group A (2.50) as compared to Group B (10.50). The VAS pain scores at 5 h (Group A 5.00, Group B 9.00) and 24 h (Group A 1.0, Group B 5.50) postoperatively showed significant difference between the two groups. These differences demonstrate the effectiveness of the intervention. In a previous study, more than 40% of patients reported a reduction in anxiety level after they got the information from a handout.
Preoperative anxiety has a major role in postoperative pain. The women undergoing CS have a higher degree of anxiety and sometimes depression too. However, the preanesthetic visit on the day prior to surgery is sometimes the only information the patients have about the anesthetic plan. Studies have shown that the anesthetists' visits prior to surgery has time constraints and usually cannot be tailored to the patient requirement. A well structured patient handout can be of added benefit in these situations. It improves patient satisfaction regarding their knowledge about anesthesia., Our study showed similar results.
Although a review on the effect of the preoperative counseling on the postoperative pain showed that this intervention is indeed effective, there are a few studies that showed no relation between postoperative pain and preoperative education. In our study, we found a significant reduction in postoperative pain in the intervention group. One reason might be that in parturients coming for elective CS, anxiety levels are quite high. The good preoperative education gave the study group an idea about what to expect in the operating theatre, and also in the postoperative period, th e reduced anxiety levels contributed to the reduction in VAS scores. The handout in the local language helped the patients to review the information again. Although our intervention is not a substitute for adequate analgesia with pharmacological agents, it can be a good supplementary tool.
The limitations of our study were that both primigravidas and multigravidas were included in the study, and the difference in their anxiety levels was not considered. However, the number of patients with exposure to anesthesia was similar in both groups. Anesthesia is just one cause of anxiety. We did not explore the effect of other sources of anxiety. In the study, all the parturients had high school education, and more than 70% were graduates. Therefore, the impact of educational status on pain could not be analyzed.
| Conclusion|| |
This randomized control study has demonstrated that a planned preoperative education with handouts regarding the procedure of spinal anesthesia and its advantages in parturients undergoing elective CS can reduce preoperative anxiety and the postoperative pain.
We thank Mr. John Micheal from Department of Statistics, CMC Vellore who helped in the statistical analysis of the data.
Financial support and sponsorship
Indian Council of Medical Research Short Term Studentship Grant (reference ID 2016-00056).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ortiz J, Wang S, Elayda MA, Tolpin DA, Ortiz J, Wang S, et al
. Preoperative patient education: Can we improve satisfaction and reduce anxiety? Rev Bras Anestesiol 2015;65:7-13.
Caumo W, Schmidt AP, Schneider CN, Bergmann J, Iwamoto CW, Adamatti LC, et al
. Risk factors for postoperative anxiety in adults. Anaesthesia 2001;56:720-8.
Kuo S-Y, Chen S-R, Tzeng Y-L. Depression and anxiety trajectories among women who undergo an elective cesarean section. PLoSOne 2014;9:e86653.
Bayrampour H, Salmon C, Vinturache A, Tough S. Effect of depressive and anxiety symptoms during pregnancy on risk of obstetric interventions. J ObstetGynaecol Res 2015;41:1040-8.
Kerai S, Saxena KN, Taneja B. Post-caesarean analgesia: What is new? Indian J Anaesth 2017;61:200-14.
] [Full text]
Veeramachaneni R, Indurkar PS. Awareness about anaesthesia in India: A survey in southern India. Int J Res Med Sci 2016;4:499-508.
Boker A, Brownell L, Donen N. The Amsterdam preoperative anxiety and information scale provides a simple and reliable measure of preoperative anxiety. Can J Anesth 2002;49:792-8.
Moerman N, van Dam FS, Muller MJ, Oosting H. The amsterdam preoperative anxiety and information scale (APAIS). AnesthAnalg 1996;82:445-51.
Fitzgerald BM, Elder J. Will a 1-page informational handout decrease patients' most common fears of anesthesia and surgery? J SurgEduc 2008;65:359-63.
Kim JH. Preoperative evaluation of a surgical patient; preanesthetic interview by anesthesiology residents. Korean J Anesthesiol 2012;62:207-8.
Pinar G, Kurt A, Gungor T. The efficacy of preopoerative instruction in reducing anxiety following gyneoncological surgery: A case control study. World J SurgOncol 2011;9:38.
Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 2010;104:369-74.
O'Donnell KF. Preoperative pain management education: A quality improvement project. J Perianesthesia Nurs Off J Am SocPeriAnesthesia Nurses 2015;30:221-7.
Ramesh C, Nayak BS, Pai VB, Patil NT, George A, George LS, et al
. Effect of preoperative education on postoperative outcomes among patients undergoing cardiac surgery: A systematic review and meta-analysis. J Perianesthesia Nurs Off J Am SocPeriAnesthesia Nurses 2017;32:518-29.e2.
[Table 1], [Table 2]