Assessment of satisfaction and anxiety levels of the patients who had cesarean section with general and spinal anesthesia

Abstract

The primary aim in our study is to obtain the most objective result by comparing the anesthesia satisfaction of women who had cesarean section both under general and spinal anesthesia. Our secondary aim is to assess the relation between patients’ preference of anesthesia technique and anxiety level. Total number of 94 ASA II women who hadcesarean section under general anesthesia within 5 years and scheduled to have elective cesarean section under spinal anesthesia, were included into the study. After 48 hours, all of the patients were asked to compare their previous general anesthesia experience with spinal anesthesia in regard of satisfaction and anxiety. Satisfaction scores were as “bad”, “average”, “good”, “very good” while patients were asked to use numbers from 1 to 10 to score their anxiety level. The mean age of the patients was 26.1±4.5 when they had general anesthesia and it was 29.7±4.6 when they had spinal anesthesia. When the satisfaction scores of anesthesia techniques were compared, spinal anesthesia was found to be statistically significantly high (p0.05). The patients who had cesarean section under both of the anesthesia techniques were more satisfied by spinal anesthesia. While no difference was found between preoperative anxiety levels. [Med-Science 2017; 6(2.000): 229-32]

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ORIGINAL RESEARCH
Medicine Science 2017;6(2):229-32
Assessment of satisfaction and anxiety levels of the patients who had cesarean section
with general and spinal anesthesia
Basak Altiparmak1, Sezen Bozkurt Koseoglu2
1Mugla Sitki Kocman University Training and Research Hospital, Department of Anesthesiology and Reanimation Mugla, Turkey
2Mugla Sitki Kocman University Training and Research Hospital, Department of Gynecology and Obstetrics Mugla, Turkey
Received 04 September 2016; Accepted 01 Novenber 2016
Available online 21.11.2016 with doi: 10.5455/medscience.2016.05.8544
Abstract
The primary aim in our study is to obtain the most objective result by comparing the anesthesia satisfaction of women who had cesarean section both under
general and spinal anesthesia. Our secondary aim is to assess the relation between patients’ preference of anesthesia technique and anxiety level. Total number
of 94 ASA II women who hadcesarean section under general anesthesia within 5 years and scheduled to have elective cesarean section under spinal anesthesia,
were included into the study. After 48 hours, all of the patients were asked to compare their previous general anesthesia experience with spinal anesthesia in
regard of satisfaction and anxiety. Satisfaction scores were as “bad”, “average”, “good”, “very good” while patients were asked to use numbers from 1 to 10 to
score their anxiety level. The mean age of the patients was 26.1±4.5 when they had general anesthesia and it was 29.7±4.6 when they had spinal anesthesia.
When the satisfaction scores of anesthesia techniques were compared, spinal anesthesia was found to be statistically significantly high (p<0.05). No difference
was obtained between the anesthesia techniques in regard of anxiety level (p>0.05). The patients who had cesarean section under both of the anesthesia
techniques were more satisfied by spinal anesthesia. While no difference was found between preoperative anxiety levels.
Keywords: General anesthesia, satisfaction, cesarean, spinal
Introduction
The anesthesiologists try to maintain the best health state
for both mother and fetus during cesarean section. That’s
why anesthetic management of obstetric surgery has a
different importance from other procedures [1]. Regional
anesthesia practice has increased significantly all over the
world for the last 25 years. The preference of regional
instead of general anesthesia for obstetric surgery is also
strongly recommended in the guidelines published by
American Society of Anesthesiologists [2]. However, in
the presence of any contraindications or emergency state,
general anesthesia are mains to be the most common
choice for many anesthesiologists [3].
Although regional anesthesia practice has also rapidly
increased in our country in the recent years, patient refusal
is still one of the most common contraindications leading
to lower regional anesthesia ratios [4].
There are some studies comparing regional and general
anesthesia in regard of patient satisfaction in the current
literature [5], nevertheless no study has been conducted on
the same group of patients who has experienced cesarean
section under both general and regional anesthesia, yet.
The primary aim in our study is to obtain the most
objective results by comparing the anesthesia satisfaction
of women who had cesarean section both under general
and spinal anesthesia. Our secondary aim is to assess the
relation between type of anesthesia technique and
preoperative anxiety level.
Materials and Methods
After receiving hospital ethic committee approval and
patients’ informed consent, the study was conducted in
Biga State Hospital between January 2012- December
2014 in accordance with the Helsinki declaration. Total
number of 94 ASA II women who had cesarean section
under general anesthesia within 5 years and scheduled for
elective cesarean section under spinal anesthesia, were
included into the study. The exclusion criterias were
presence of relative or absolute contraindication for
regional anesthesia, patient refusal to participate into the
study, story of first cesarean section earlier than 5 years,
unable to remember the first anesthesia experience,
additive anesthetic agent requirement intraoperatively,
story of emergency cesarean section due to fetal distress
and failed spinal anesthesia. After 48 hours, all of the
patients were asked to compare their previous general
anesthesia experience with spinal anesthesia in regard of
satisfaction and anxiety. Satisfaction scores were given as
“bad”, “average”, “good”, “very good” while patients were
asked to use numbers from 1 to 10 to score their anxiety
*Coresponding Author: Basak Altiparmak, Mugla Sitki
Kocman University Training and Research Hospital,
Department of Anesthesiology and Reanimation
E-mail: drsezenkoseoglu@gmail.com
Medicine Science
International
Medical Journal

doi: 10.5455/medscience.2016.05.8544 Med Science 2017;6(2):229-32
230
level. All of the datas were recorded. Besides, all of the
patients’ ages, comorbidities, story of gravity and parity,
psychiatric disorders and indications of first cesarean
section were also recorded.
SPSS 22.0 (Statistical Package for Social Sciences)
package program was used for the statistical analysis of the
datas (SPSS Inc., Chicago, IL, USA). Normality of the
variables were analyzed by Kolmogornow-Smirnov test.
Student’s t test and Mann Whitney U test were used to
evaluate associations between categorical and continuous
variables. Pearson correlation analysis was used to find the
correlation between variables. P values were considered
statistically significant at p<.05.
Results
The mean age of the patients was 26.1±4.5 when they had
general anesthesia and it was 29.7±4.6 when they had
spinal anesthesia (Table 1). Indications of cesarean section
with general anesthesia were listed in Table 2. The most
frequent indication of cesarean was cephalopelvic
disproportion.
When the satisfaction scores of anesthesia techniques were
compared, spinal anesthesia was found to be statistically
significantly higher than general anesthesia (p<0.05).
Patients’ responses for satisfaction were shown in Table 3.
When we look at general anesthesia, 24.4% of patients
were ‘very pleased’ with the procedure, while this ratio
was 68% with spinal anesthesia. No difference was
obtained between the anesthesia techniques in regard of
anxiety level (p>0.05). Patients’ responses for anxiety were
shown in Table 4. There was no correlation between age
and satisfaction scores and anxiety level (p>0. 05).
Table 1. The mean ages of patients according to the type of anesthesia
Anesthesia Type Age p value
General Anesthesia 26.1±4.5
0.927
Spinal Anesthesia 29.7±4.6
The data is given as mean±standart devision
Table 2.Indications of cesarean with general anesthesia
Indication Number (n) Ratio (%)
Cephalopelvic disproportion 48 51
Arrest of active labor 28 29.7
Breech presentation 18 19
Transvers presentation 6 6.3
Table 3. Satisfaction scores of patients according to the type of anesthesia
Satisfaction
level
General
Anesthesia
Spinal Anesthesia
P value
Number
(n)
Ratio
(%)
Number
(n)
Ratio
(%)
Bad 10 10.6 0 0
0.000
Average 21 22.3 3 3.1
Good 40 42.6 27 28.5
Very good 23 24.5 64 68.4
Table 4. Preoperative anxiety levels of patients according to the type of
anesthesia
Anxiety
level
General anesthesia Spinal anesthesia
p value
Number
(n)
Ratio
(%)
Number
(n)
Ratio
(%)
1 0 0 0 0
0.500
2 0 0 0 0
3 0 0 0 0
4 0 0 0 0
5 4 4.2 5 5.3
6 10 10.6 11 11.7
7 20 21.3 18 19.1
8 20 21.3 31 32.9
9 19 20.2 8 8.6
10 21 22.4 21 22.4
Discussion
The patients who had cesarean section under both of the
anesthesia techniques were more satisfied with spinal
anesthesia. While no difference was found between groups
in regard of preoperative anxiety levels.
As the anesthesiologists’ knowledge and skill improved
and new equipments were introduced into markets with
technological progression, regional anesthesia became
more preferable in the recent years [6]. General anesthesia
for obstetric surgery has maternal risks such as difficult
intubation and gastric aspiration, and it is well known to
cause lower APGAR scores of the fetus [7, 8]. Through the
end of pregnancy, mucosal edema of upper airways and
increase in breast sizes make intubation challenging.
Increased intraabdominal pressure and decrease in the
tonus of lower esophageal sphincter due to circulating
prostaglandins, increase the risk of gastroesophageal reflux
[9]. While regional anesthesia helps preventing these risks,
it has also advantages such as decreased stress response,
minimal depressant effect on fetus and early breastfeeding
[10]. In a recent study, cesarean section under regional
anesthesia was reported to provide a higher regional
cerebral oxygen saturation of newborn than general
anesthesia did [11]. Considering the favorable effects on
mother and fetus, regional anesthesia is accepted as the
gold-standard technique for obstetric surgery [12]. But
even regional anesthesia has disadvantages. The most
important one is hypotension frequently seen during spinal
anesthesia [13]. Hypotension which occurs due to
sympathetic blockage, is seen approximately 50% of
obstetric cases [14]. The sudden decrease in arterial blood
pressure causes nausea-vomiting, regurgitation and
changes in consciousness of mother [15], while it may lead
to fetal hypoxia, acidosis and newborn depression due to
corrupted uterine blood flow [16]. The presence of
complications decreases anesthesia satisfaction
significantly [17]. Despite all the advantages, regional
anesthesia ratio in our country remains lower than the
rations in the world [18, 19]. In the previous years, the
most important reason was the co-decision of surgeon,
anesthesiologist and patient, however patient’s refusal to
procedure became the most frequent reason nowadays [6].

doi: 10.5455/medscience.2016.05.8544 Med Science 2017;6(2):229-32
231
In the current study, all the patients had their first cesarean
section under general anesthesia with their own demand.
Increased preference of general anesthesia can be a result
of lower socio-cultural level and poor knowledge about
regional anesthesia in rural places. In a previous survey, it
was shown that while deciding the anesthesia technique,
patients were significantly influenced by satisfaction levels
of other patients who had the same operation previously
[20]. Whereas “satisfaction” is a subjective concept on its
own. Comparing the satisfaction levels of patients who
know only one of the choices, increases the limitation of a
study. Studies comparing anesthesia techniques for
obstetric surgery in regard of patient satisfaction were done
before, but different patient groups were selected for
different anesthesia techniques in all of these studies (5,
20]. Patients’previous experiences or knowledge about the
anesthesia techniques were not mentioned in these studies,
either. On the other hand in the current study, more
objective and realistic results were intended by assessing
the satisfaction levels of patients who experienced different
anesthesia techniques for the same operation in a short
time period. In the study of Lertakyamanee et al in 1999,
spinal, epidural or general anesthesia techniques were
compared and no significant difference was found [5].
Whereas, we found statistically significantly high scores at
spinal anesthesia group in our study. Technical progression
and innovation throughout the years in regional anesthesia
field might be the reason for this difference. New spinal
and epidural sets improved the comfort of anesthesiologist
and patient during the procedure [6]. The increase in the
anesthesiologists’ experience and skill may also explain
the increased satisfaction scores. In a study in 2013 a very
high ratio, 97%, of patients were found to be satisfied by
regional anesthesia [17]. But there was no control group in
this study.
When we look at the secondary inference of our study,
there was no difference between spinal and general
anesthesia in regard of anxiety levels. There was no
correlation between age and anxiety, either. These results
are similar with previous studies in the literature. Eley el
al. made patients undergoing cesarean watch a video type
introducing regional anesthesia and then assessed the
preoperative anxiety levels. They couldn’t find a statistical
difference [21]. Similarly, Kumar et al. reported that the
information given by health personal couldn’t decrease
anxiety of patients preoperatively [22]. In this survey it
was determined that patients were much more relaxed by
intraoperative communication and seeing the baby rather
than preoperative information [22].
The major limitation of our study is the time period
between two cesareans of the patients. We determined “5
years” as the longest duration between two cesareans to be
able to reduce this limitation and have a more standardized
sample group. And also we excluded the patients who
could not remember the first cesarean experience. However
evaluation of the cesarean under general anesthesia had be
made after a time period. This is still the major limitation
of this study.
In conclusion, we found that the patients who had cesarean
section under both of the anesthesia techniques were more
satisfied by spinal anesthesia, while no difference was
found between preoperative anxiety levels. We believe this
study provides the most objective and realistic data ever.
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