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Interprofessional provider attitudes toward the initiation of epidural analgesia in the laboring patient: are we all on the same page?

Published:August 20, 2018DOI:https://doi.org/10.1016/j.ijoa.2018.08.007

      Highlights

      • Different provider groups vary in comfort when managing labor epidural analgesia.
      • Willingness to advocate for epidural placement may depend on the cervical dilation.
      • Providers consider patient-specific factors when determining suitability.

      Abstract

      Background

      The timing of initiation of neuraxial labor analgesia should ultimately depend on patient preference although obstetricians, anesthesiologists and nurses may influence decision-making. We hypothesized that provider groups would have similar attitudes toward the timing of epidural placement, but some identifiable differences could be used to improve understanding and communication among providers.

      Methods

      Anesthesiologists, nurses and obstetricians completed a survey assessing their knowledge and attitudes on the timing of epidural placement in specified clinical circumstances.

      Results

      Anesthesiologists (100%) and nurses (86.2%) reported being more familiar with epidural management than obstetricians (43.3%, P <0.01). The willingness of providers to advocate epidural placement based on the magnitude of cervical dilation was similar, although at 10 cm dilatation obstetricians (73.3%) were significantly more likely to advocate neuraxial block compared to both nurses (27.6%, P <0.01) and anesthesiologists (36.7%, P <0.01). The impact of patient factors and clinical circumstances on the timing of neuraxial block placement showed significant differences among provider groups in five of 24 areas assessed, including patient desire for an epidural, primigravid patients without membrane rupture, oxytocin infusion initiated, labor epidural in a previous pregnancy, and a difficult airway.

      Conclusions

      There were differences between providers in factors that may impact the timing of epidural placement and in their self-perceived familiarity with epidural management. These present an opportunity for furthering interprofessional education and collaboration.

      Keywords

      Introduction

      Neuraxial labor analgesia is commonly requested, with rates in the United States of 66–82%.
      • D’Angelo R.
      • Smiley R.M.
      • Riley E.T.
      • Segal S.
      Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology.
      • Traynor A.J.
      • Aragon M.
      • Ghosh D.
      • et al.
      Obstetric Anesthesia Workforce survey: a 30-year update.
      Analysis of open-ended patient survey responses reflects the importance of effective and timely neuraxial labor analgesia to many parturients.
      • Attanasio L.
      • Kozhimannil K.B.
      • Jou J.
      • McPherson M.E.
      • Camann W.
      Women’s experiences with neuraxial labor analgesia in the listening to mothers II survey: a content analysis of open-ended responses.
      The most recent practice guidelines by the American Society of Anesthesiologists (ASA), American College of Obstetricians and Gynecologists (ACOG), and other published reports support offering neuraxial analgesia early in labor, independent of cervical dilation, and that maternal request alone is a sufficient indication for initiating labor analgesia.
      • Practice Guidelines for Obstetric Anesthesia
      An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology.
      • Committee on Practice Bulletins-Obstetrics
      Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia.
      • Sng B.L.
      • Leong W.L.
      • Zeng Y.
      • et al.
      Early versus late initiation of epidural analgesia for labour.
      • Wong C.A.
      • Scavone B.M.
      • Peaceman A.M.
      • et al.
      The risk of cesarean delivery with neuraxial analgesia given early versus late in labor.
      • Wong C.A.
      • McCarthy R.J.
      • Sullivan J.T.
      • Scavone B.M.
      • Gerber S.E.
      • Yaghmour E.A.
      Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial.
      • Wang F.
      • Shen X.
      • Guo X.
      • Peng Y.
      • Gu X.
      Labor Analgesia Examining Group. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial.
      • Wassen M.M.
      • Zuijlen J.
      • Roumen F.J.
      • Smits L.J.
      • Marcus M.A.
      • Nijhuis J.G.
      Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review.
      • Wang T.T.
      • Sun S.
      • Huang S.Q.
      Effects of epidural labor analgesia with low concentrations of local anesthetics on obstetric outcomes: a systematic review and meta-analysis of randomized controlled trials.
      It is uncertain if these guidelines are being followed in clinical practice, or if historical biases that epidural placement should be delayed, due to concerns about prolongation of labor or increased cesarean delivery rates, still exist.
      Assuming no contraindications are present, labor epidural analgesia should ultimately depend on patient preference, although provider attitudes and biases may also influence the patient’s decision-making. Given the severity of labor pain
      • Brownridge P.
      The nature and consequences of childbirth pain.
      and the time taken for a patient to become comfortable after epidural initiation,
      • Barker H.M.
      • Simmons S.W.
      • Hiscock R.J.
      • Cyna A.M.
      • McDonald S.
      Time to get comfortable with a labour epidural.
      interprofessional co-operation and timely communication are paramount.
      • Lyndon A.
      • Zlatnik M.G.
      • Wachter R.M.
      Effective physician-nurse communication: a patient safety essential for labor and delivery.
      Interdisciplinary attitudes toward the timing of epidural placement would ideally be congruent, however it is uncertain if different providers prioritize different factors when counseling patients. For example, obstetricians may give greater consideration to interventions that they perform, such as amniotomy or oxytocin initiation,
      • Petersen A.
      • Poetter U.
      • Michelsen C.
      • Gross M.M.
      The sequence of intrapartum interventions: a descriptive approach to the cascade of interventions.
      and may advise labor epidural placement prior to amniotomy. Anesthesiologists may be more aware of patients with a potentially difficult airway and be more likely to advocate for early epidural placement,
      • Practice Guidelines for Obstetric Anesthesia
      An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology.
      while nurses may give greater priority to a patient’s desire to ambulate early in labor when offering patients advice about the timing of epidural placement.
      There is little information about the attitudes of different provider groups towards the timing of epidural placement. We surveyed providers on how patient factors or circumstances may affect their decision-making, and hypothesized that provider groups would have generally similar attitudes about the timing of epidural placement, but that there would be differences identified that could be used to improve understanding, communication and focus multidisciplinary education efforts in providing patient-centered care.

      Methods

      The study was approved by the Ohio State University Institutional Review Board (#2016E0251). Data were obtained from a written survey (Appendix) administered to anesthesia providers who work on the labor and delivery (L and D) unit at least once per month, and to residents postgraduate year (PGY)-3 and above, L and D nurses, and obstetricians (PGY-1 and above, fellows, and attending obstetricians). A convenience sample of 30 providers per group was chosen because it represented a maximum number that could be recruited based on the size of our institution. Trainees were included, since otherwise the sample size would have been very small, and our belief that the practice patterns of resident and attending physicians would be similar enough to justify their inclusion.
      The survey first asked demographic information about age, years in practice, number of days per month working on the L and D unit, and self-perceived familiarity with epidural analgesia management (1–5 scale). “Familiarity” was defined as management within that provider group’s scope of practice. Self-reported familiarity with the management of labor epidural analgesia was assessed on a Likert scale (1 = very uncomfortable, 5 = very comfortable; Fig. 1). In our institution the primary neuraxial technique for laboring patients is an initial bolus of 0.125% bupivacaine and fentanyl 2 µg/mL (10 mL in divided doses) followed by a continuous maintenance infusion of 0.0625% bupivacaine and fentanyl 2 µg/mL with patient-controlled epidural analgesia (6 mL, 15 min lockout).
      Figure thumbnail gr1
      Fig. 1Provider familiarity with labor epidurals
      The participant was asked to assess their likelihood of advocating epidural placement (on a 1–5 scale), other factors notwithstanding, for a laboring patient whose cervix was <4 cm dilated, >4 cm but less than fully dilated, or fully dilated.
      The survey then asked participants to rate the importance of how 24 patient-specific factors would influence their decision to advocate for initiation of epidural placement in a laboring patient with a cervix <4 cm dilated. The answers available were “less likely”, “no impact”, and “more likely”. These factors were chosen by a consensus of the author group, which included an obstetrician and obstetric anaesthesiologists.
      For all sections of the survey participants were instructed that “advocating” should be interpreted as recommending initiation of epidural labor analgesia for a particular patient, given the information available and within that particular provider’s scope of practice. The primary outcome was the difference in proportions of responses among the three provider groups, in the responses to the 24 patient-specific factor survey items.
      A sample size of 90 participants constituted this study cohort. Descriptive statistics were used to summarize demographic characteristics and survey responses, stratified by healthcare-role group (anesthesiologist, nurse or obstetrician). Demographic data were compared among groups using either a Chi-square test or a one-way analysis of variance, where appropriate. For the likelihood of or comfort with epidural placement based on questions related to cervical dilation, responses were categorized into three groups (‘less likely/uncomfortable’, ‘no impact/neutral’, and ‘more likely/comfortable’). These data, along with those of the 24 patient-specific factor items, were described with proportions and were compared among health-care role groups by Fisher’s exact test. When the overall three-group comparison was significant, pairwise comparisons were evaluated at an adjusted significance level of 0.05/2 = 0.025, to account for the multiple comparisons of the three groups. If participants omitted an answer the items were excluded from analysis. All analyses were performed using SAS/STAT software, version 9.4 of the SAS system for Windows (SAS Institute, Inc., Cary, NC).

      Results

      Provider demographic assessment showed no significant differences between the mean age of the anesthesiologists and obstetricians or anesthesiologists and nurses (Table 1). The nurse cohort reported more years in practice than both the anesthesiologists (13.38 vs 7.52, P <0.01) and the obstetricians (13.38 vs 6.28, P <0.01). Both the obstetricians and nurses reported working more days per month on the L and D unit than their anesthesia counterparts (12.35 vs 4.72 days, P <0.01; and 10.98 vs 4.72 days, P <0.01, respectively). Anesthesiologists and nurses reported being more familiar with epidural management than obstetricians (100%, 86.2%, and 43.3%, respectively, P <0.0001, Table 2). There was no significant difference between anesthesiologists and nurses with respect to familiarity in epidural management.
      Table 1Provider demographics
      RoleVariableNMean
      AnesthesiologistAge

      Years in practice

      Days per month
      29

      30

      30
      34.21

      7.52

      3.42
      NurseAge

      Years in practice

      Days per month
      27

      30

      28
      38.00

      13.38

      10.98
      ObstetricianAge

      Years in practice

      Days per month
      30

      30

      30
      33.03

      6.28

      12.35
      Table 2Provider comfort and likelihood of advocating for epidural placement based on patient’s cervical dilatation
      Cervical DilationTotal ResponsesAnesthesiologistObstetricianNurseP-value
      nn (%)n (%)n (%)
      Familiarity
       Unfamiliar80 (0.0)5 (16.7)3 (10.3)<.0001
       Neutral130 (0.0)12 (40.0)1 (3.5)
       Familiar6729 (100.0)13 (43.3)25 (86.2)
      <4 cm
       Less likely207 (23.3)5 (16.7)8 (27.6)0.5610
       No impact4317 (56.7)14 (46.7)12 (41.4)
       More likely266 (20.0)11 (36.7)9 (31.0)
      >4 cm
       Less likely52 (6.7)2 (6.7)1 (3.5)0.2499
       No impact1810 (33.3)4 (13.3)4 (13.8)
       More likely6618 (60.0)24 (80.0)24 (82.8)
      10 cm
       Less likely287 (23.3)6 (20.0)15 (51.7)0.0005
       No impact2012 (40.0)2 (6.7)6 (20.7)
       More likely4111 (36.7)22 (73.3)8 (27.6)
      The providers were surveyed on the impact that the patient’s cervical dilatation, in the absence of other information, might have on the timing of neuraxial labor analgesia in a hypothetical patient (Table 2). To retain consistency with the other survey responses, responses of 1 and 2 on the Likert scale were combined and scored as “less likely”, 3 was scored as “no impact”, and 4 and 5 were combined and scored as “more likely” for statistical analysis. There were no significant differences among the three groups in their willingness to advocate epidural placement in a laboring parturient <4 or >4 cm dilated (Table 2, Fig. 2, Fig. 3). Given a laboring patient at 10 cm cervical dilatation however, obstetricians were significantly more likely to advocate epidural placement (73.3%) compared to both nurses (27.6%, P <0.01) and anesthesiologists (36.7%, P <0.01) (Table 2, Fig. 4).
      Figure thumbnail gr2
      Fig. 2Provider likelihood of advocating epidural placement if the patient’s cervical dilatation is less than 4 cm
      Figure thumbnail gr3
      Fig. 3Provider likelihood of advocating epidural placement if the patient’s cervical dilatation is greater than 4 cm
      Figure thumbnail gr4
      Fig. 4Provider likelihood of advocating epidural placement if the patient’s cervix is fully dilated
      For the remaining survey questions the participants were asked to describe their willingness to advocate epidural placement in a laboring parturient <4 cm dilated, using “less likely”, “more likely”, or “no impact”, given an additional piece of patient-specific information (Table 3). Five of the 24 questions showed significant differences in attitudes among the three groups. For the patient who wants epidural analgesia (question (Q)1), pairwise comparison revealed that anesthesiologists (93.3%) were more likely to advocate epidural analgesia than nurses (65.5%, P <0.02) and obstetricians (63.3%, P <0.01) (Fig. 5). For women receiving an oxytocin infusion (Q3), anesthesiologists (56.7%) were more likely than the obstetricians (23.3%, P <0.02) to advocate epidural analgesia (Fig. 6). For primigravid women with unruptured membranes (Q13, Fig. 7), nurses (36.7%) were less likely to advocate epidural analgesia than obstetricians (6.9%, P <0.04). For patients with a history of a difficult or an anticipated difficult airway (Q18) anesthesiologists (86.7%) were more likely than both nurses (53.3%, P <0.01) and obstetricians (65.5%, P=0.01) to advocate epidural placement (Fig. 8). Obstetricians were also more likely than nurses to advocate epidural placement given this information (P=0.02).
      Table 3Provider likelihood of advocating for epidural placement given patient-specific factors
      QuestionsTotal ResponsesAnesthesiologistObstetricianNurseP-value
      nn (%)n (%)n (%)
      Q1Patient desires an epidural0.0034
       Less likely31 (3.3)0 (0.0)2(6.9)
       No impact201 (3.3)11 (36.7)8 (27.6)
       More likely6628 (93.3)19 (63.3)19 (65.5)
      Q2Patient does not desire an epidural0.6915
       Less likely8329 (96.7)27 (90.0)27 (90.0)
       No impact71 (3.3)3 (10.0)3 (10.0)
       More likely00 (0.0)0 (0.0)0 (0.0)
      Q3Oxytocin infusion has been started0.0326
       Less likely00 (0.0)0 (0.0)0 (0.0)
       No impact5413 (43.3)23 (76.7)18 (62.1)
       More likely3517 (56.7)7 (23.3)11 (37.9)
      Q4Oxytocin infusion has not been started0.3265
       Less likely177 (23.3)3 (10.0)7 (24.1)
       No impact2423 (76.7)27 (90.0)22 (75.9)
       More likely00 (0.0)0 (0.0)0 (0.0)
      Q5Patient is primigravid0.0619
       Less likely175 (16.7)3 (10.0)9 (30.0)
       No impact5822 (73.3)23 (76.7)13 (43.3)
       More likely153 (10.0)4 (13.3)8 (26.7)
      Q6Patient is multigravid0.1552
       Less likely51 (3.3)1 (3.3)3 (10.0)
       No impact5115 (50.0)22 (73.3)14 (46.7)
       More likely3414 (46.7)7 (23.3)13 (43.3)
      Q7Prolonged labor expected0.1951
       Less likely153 (10.0)4 (13.3)8 (26.7)
       No impact3916 (53.3)15 (50.0)8 (26.7)
       More likely3611 (36.7)11 (36.7)14 (46.7)
      Q8Patient is primigravid and induced with oxytocin0.1844
       Less likely71 (3.3)2 (6.9)4 (13.8)
       No impact4814 (46.7)20 (69.0)14 (48.3)
       More likely3315 (50.0)7 (24.1)11 (37.9)
      Q9Patient is primigravid in spontaneous labor0.7121
       Less likely32 (6.7)0 (0.0)1 (3.3)
       No impact6021 (70.0)20 (69.0)19 (63.3)
       More likely267 (23.3)9 (31.0)10 (33.3)
      Q10Patient is multigravid and induced with oxytocin0.5334
       Less likely10 (0.0)0 (0.0)1 (3.3)
       No impact4715 (50.0)18 (62.1)14 (46.7)
       More likely4115 (50.0)11 (37.9)15 (50.0)
      Q11Patient is multigravid in spontaneous labor0.3378
       Less likely82 (6.7)1 (3.5)5 (16.7)
       No impact4515 (50.0)18 (62.1)12 (40.0)
       More likely3613 (43.3)10 (34.5)13 (43.3)
      Q12Patient is primigravid and membranes are ruptured0.5516
       Less likely10 (0.0)0 (0.0)1 (3.3)
       No impact5416 (53.3)19 (65.5)19 (63.3)
       More likely3414 (46.7)10 (34.5)10 (33.3)
      Q13Patient is primigravid and membranes are not ruptured0.0049
       Less likely229 (30.0)2 (6.9)11 (36.7)
       No impact6321 (70.0)23 (79.3)19 (63.3)
       More likely40 (0.0)4 (13.8)0 (0.0)
      Q14Patient is multigravid and membranes are ruptured0.2198
       Less likely30 (0.0)1 (3.5)2 (6.9)
       No impact4316 (53.3)17 (58.6)10 (34.5)
       More likely4214 (46.7)11 (37.9)17 (58.6)
      Q15Patient is multigravid and membranes are not ruptured0.2415
       Less likely92 (6.7)1 (3.6)6 (20.7)
       No impact6724 (80.0)22 (78.6)21 (72.4)
       More likely114 (13.3)5 (17.9)2 (6.9)
      Q16Patient had prior caesarean0.9215
       Less likely20 (0.0)1 (3.5)1 (3.3)
       No impact124 (13.3)3 (10.3)5 (16.7)
       More likely7526 (86.7)25 (86.2)24 (80.0)
      Q17Patient is morbidly obese0.1262
       Less likely10 (0.0)0 (0.0)1 (3.3)
       No impact4412 (40.0)13 (44.8)19 (63.3)
       More likely4418 (60.0)16 (55.2)10 (33.3)
      Q18Patient has history of or anticipated difficult airway0.0150
       Less likely21 (3.3)0 (0.0)1 (3.3)
       No impact263 (10.0)10 (34.5)13 (43.3)
       More likely6126 (86.7)19 (65.5)16 (53.3)
      Q19Patient has pre-eclampsia0.1064
       Less likely65 (16.7)0 (0.0)1 (3.3)
       No impact4512 (40.0)15 (51.7)18 (60.0)
       More likely3813 (43.3)14 (48.3)11 (36.7)
      Q20Patient is currently comfortable0.6377
       Less likely5519 (63.3)16 (55.2)20 (66.7)
       No impact319 (30.0)12 (41.4)10 (33.3)
       More likely32 (6.7)1 (3.5)0 (0.0)
      Q21Patient is currently uncomfortable0.7267
       Less likely00 (0.0)0 (0.0)0 (0.0)
       No impact196 (20.0)5 (17.2)8 (26.7)
       More likely7024 (80.0)24 (82.8)22 (73.3)
      Q22Patient has previously labored without epidural0.5903
       Less likely3713 (43.3)10 (33.3)14 (46.7)
       No impact5216 (53.3)20 (66.7)16 (53.3)
       More likely11 (3.3)0 (0.0)0 (0.0)
      Q23Patient has previously labored with epidural0.0044
       Less likely31 (3.3)0 (0.0)2 (6.7)
       No impact6516 (53.3)23 (76.7)26 (86.7)
       More likely2213 (43.3)7 (23.3)2 (6.7)
      Q24Patient has twin gestation0.2083
       Less likely10 (0.0)1 (3.3)0 (0.0)
       No impact163 (10.0)5 (16.7)8 (27.6)
       More likely7227 (90.0)24 (80.0)21 (72.4)
      Figure thumbnail gr5
      Fig. 5Responses by Provider to Question 1 (Q1): Patient desires epidural analgesia
      Figure thumbnail gr6
      Fig. 6Responses by Provider to Question 3 (Q3): Oxytocin infusion has been initiated
      Figure thumbnail gr7
      Fig. 7Responses by Provider to Question 13 (Q13): Primigravid patient with unruptured membranes
      Figure thumbnail gr8
      Fig. 8Responses by Provider to Question 18 (Q18): History of or anticipated difficult patient airway
      A similar relationship was found among the three provider groups for patients who were described as having previously labored successfully with epidural analgesia (Q23). Anesthesiologists (43.3%) were more likely than both nurses (6.7%, P <0.01) and obstetricians (23.3%, P <0.01) to advocate placement of an epidural, while obstetricians were more likely than nurses (P <0.02) (Fig. 9). For all other questions regarding a laboring patient with a cervix <4 cm dilated, there were no differences between groups (Table 3).
      Figure thumbnail gr9
      Fig. 9Responses by Provider to Question 23 (Q23): Patient who has previously labored with epidural analgesia

      Discussion

      All three provider groups showed similar attitudes towards the timing of epidural placement, but demonstrated some differences, which were consistent with our hypothesis, based on patient-specific conditions. Not surprisingly anesthesiologists reported being more comfortable than obstetricians in the management of labor epidurals, a finding shared with the nurses. In our sample, the nurses reported greater time in practice than both the anesthesiologists and obstetricians, which may have contributed to this greater level of confidence. Likewise, nurses are more often present at the bedside than obstetricians during consent, placement and management of neuraxial labor analgesia. An anesthesiologist’s willingness to advocate for epidural analgesia was increased by the patient’s wishes for it, the status of an oxytocin infusion, anticipation of a difficult airway, and whether the patient had previously used labor epidural analgesia. In contrast, the presence of unruptured membranes in the primigravid patient led to nursing reluctance to advocate for epidural analgesia when compared to their medical colleagues. The reason is uncertain, although there is evidence that amniotomy may increase the rate of labor and therefore labor-associated pain.
      • Gross M.M.
      • Fromke C.
      • Hecker H.
      The timing of amniotomy, oxytocin, and neuraxial analgesia and its association with labor duration and mode of birth.
      • Wei S.
      • Wo B.L.
      • Qi H.P.
      • Xu H.
      • Luo Z.C.
      • Roy C.
      • Fraser W.D.
      Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care.
      • Conell-Price J.
      • Evans J.B.
      • Hong D.
      • Shafer S.
      • Flood P.
      The development and validation of a dynamic model to account for the progress of labor in the assessment of pain.
      Perhaps, prior to amniotomy, nurses anticipate less pain and give greater priority to allowing the patient to ambulate.
      There was little difference in attitude among the groups about epidural placement in relation to cervical dilatation, including for patients in early labor. This is reassuring, as it suggests that nurses, obstetricians, and anesthesiologists are comfortable with the practice of early epidural placement if the patient wishes, a practice supported by evidence that early epidurals are not associated with untoward effects such as an increased incidence of cesarean delivery.
      • Practice Guidelines for Obstetric Anesthesia
      An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology.
      • Committee on Practice Bulletins-Obstetrics
      Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia.
      • Sng B.L.
      • Leong W.L.
      • Zeng Y.
      • et al.
      Early versus late initiation of epidural analgesia for labour.
      • Wong C.A.
      • Scavone B.M.
      • Peaceman A.M.
      • et al.
      The risk of cesarean delivery with neuraxial analgesia given early versus late in labor.
      • Wong C.A.
      • McCarthy R.J.
      • Sullivan J.T.
      • Scavone B.M.
      • Gerber S.E.
      • Yaghmour E.A.
      Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial.
      • Wang F.
      • Shen X.
      • Guo X.
      • Peng Y.
      • Gu X.
      Labor Analgesia Examining Group. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial.
      • Wassen M.M.
      • Zuijlen J.
      • Roumen F.J.
      • Smits L.J.
      • Marcus M.A.
      • Nijhuis J.G.
      Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review.
      • Wang T.T.
      • Sun S.
      • Huang S.Q.
      Effects of epidural labor analgesia with low concentrations of local anesthetics on obstetric outcomes: a systematic review and meta-analysis of randomized controlled trials.
      If there are historical biases against early epidural placement, they were not evident in this survey. For those patients described as being fully dilated, obstetricians reported being more likely than both other provider groups to advocate for epidural placement. It is possible that the obstetricians consider that patients may labor for a while at maximum cervical dilatation and so may benefit from neuraxial analgesia, while nurses and anesthesiologists may have interpreted this question as indicating that delivery was imminent.
      It is a limitation of the survey that it did not allow free responses, through which participants may have clarified their thought process, and it is therefore possible that each provider group interpreted the questions differently due to their different roles in patient care. This may have influenced the results in a systematic way. This survey demonstrated that attitudes on the timing of epidural placement are not totally consistent for patient-specific factors, emphasizing the need for interprofessional co-operation. For example, anesthesiologists advocated early epidural placement if a difficult airway was anticipated, and it is important that nurses and obstetricians are aware of and understand the rationale for this attitude. We acknowledge that this survey represents the attitudes of providers at a single center alone and recognize that some practices and attitudes are institution-specific, so the results may not be generalizable to other institutions. Another limitation is that “patient advocacy” is a subjective term that has been shown to have several interpretations.
      • Munday J.
      • Kynoch K.
      • Hines S.
      Nurses’ experiences of advocacy in the perioperative department: a systematic review.
      • Vaartio H.
      • Leino-Kilpi H.
      • Salantera S.
      • Suominen T.
      Nursing advocacy: how is it defined by patients and nurses, what does it involve and how is it experienced?.
      In conclusion, surveying obstetric patient provider groups about attitudes toward the timing of neuraxial labor analgesia demonstrated some important differences that can be used to focus efforts in interprofessional education and communication in the future.

      Declarations of interest

      None.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:

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