Anaesth Intensive Care 2013; 41: 774-781

Effect of an anaesthesia information video on preoperative

maternal anxiety and postoperative satisfaction in elective
caesarean section: a prospective randomised trial
V. A. Eley*, T. Searles†, K. Donovan‡, E. Walters§
Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.

Summary
Video-based patient information supplementing clinician interview has been shown to reduce anxiety and
improve satisfaction in patients undergoing procedures. In Queensland more than 90% of caesarean sections
are performed under regional anaesthesia. We aimed to assess the effect of using an information video about
neuraxial blockade in patients having regional anaesthesia for elective caesarean section. Subjects were
randomised to undergo usual care (Group C), or to view a video and undergo usual care (Group V). Subjects
completed the Spielberger State-Trait Anxiety Inventory preoperatively and the Maternal Satisfaction with
Caesarean Section Score questionnaire postoperatively. Satisfaction with, and duration of the preoperative
anaesthetic interview, were noted. One-way analysis of variance (ANOVA) and Chi-squared tests were used
in statistical analysis. One-hundred and forty three subjects were randomised and 110 completed the protocol
and analysis. Group C and Group V were similar in terms demographic and anaesthesia data. There was no
difference in anxiety score (41.2 versus 39.8, P=0.50), maternal satisfaction score (118.5 versus 122.7, P=0.22)
or interview duration (16.3 versus 15.8 min, P=0.69) between the two groups. The use of an anaesthesia
information video does not reduce preoperative anxiety or increase the duration of the anaesthetic interview.
Maternal satisfaction with neuraxial blockade for elective caesarean is high and not improved by an anaesthesia
information video.
Key Words: anaesthesia, patient education, preoperative information, caesarean section

The rate of caesarean section is rising and in the
state of Queensland around 90% of these procedures
are performed under neuraxial anaesthesia1.
Neuraxial anaesthesia is believed to offer the best
maternal and neonatal outcomes. Adjunctive
sedative medication is usually avoided, however
maternal anxiety is frequently observed2. This
anxiety has clinical implications. Animal research
in the 1970s has suggested that reducing maternal
anxiety might improve intrauterine conditions for
the foetus3. Hobson et al demonstrated that lower
preoperative anxiety is associated with increased
maternal satisfaction after elective caesarean section4.
Satisfaction with anaesthesia among non-obstetric
patients is also influenced by information provided
by the anaesthetist in the preoperative period5.
Methods used to enhance patient knowledge include
written and audiovisual materials. Patients under-
going coronary angiography had lower anxiety levels
when they viewed a patient information video prior
to their procedure6.
The aim of this study was to assess the impact on
patient experience when an information video about
neuraxial anaesthesia was shown prior to anaesthesia
for elective caesarean section. The hypothesis was
that viewing the video would reduce preoperative
anxiety and improve patient satisfaction with neura-
xial anaesthesia for elective caesarean section.

MATERIALS AND METHODS

* BMedSci MBBS FANZCA, Staff Anaesthetist; Senior Lecturer, School of
Medicine, University of Queensland, Queensland, Australia.
† MBBS FANZCA, Staff Anaesthetist; Senior Lecturer, School of Medicine,
University of Queensland, Queensland, Australia.
‡ BSc, MBBS, FRCA, Senior Registrar; Associate Lecturer, School of
Medicine, University of Queensland, Queensland, Australia.
§ BSci, MBBS, Senior Registrar; Associate Lecturer, School of Medicine,
University of Queensland, Queensland, Australia.
Address for correspondence: Dr Victoria Eley, Email: va_eley@hotmail.com
Accepted for publication on August 12, 2013
Ethics approval was obtained through the Royal
Brisbane and Women's Hospital Human Research
Ethics Committee (Approval no. HREC11Q
RBW463) and the trial was registered with the
Australian New Zealand Clinical Trials Registry
(ACTRN12611001207909).
Eligible patients were identified from clinic
referrals and recruited in the maternity anaesthetic
Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013
 Effect of an anaesthetic information video in elective caesarean
section
clinic, where they provided written, informed consent.
Eligibility criteria were: age greater than 18 years;
no previous elective caesarean section; ability to
understand a questionnaire and video presented in
English and likely to be offered regional anaesthesia
for their caesarean section. Enrolled subjects who
subsequently underwent emergency caesarean
section or had a general anaesthetic as the primary
technique were excluded from analysis. Subjects
were allocated to either Group V (subjects viewed
the information video prior to undergoing usual
care, which included interviews with an anaesthetist
and a midwife) or Group C (subjects underwent
usual care only). The primary outcome measure
was the Spielberger State-Trait Anxiety Inventory7
(STAI) score measured on the day of surgery in the
holding bay. Secondary outcome measures were the
Maternal Satisfaction Scale for Caesarean Section8
measured on the first postoperative day, duration
of the anaesthetic interview and patient satisfaction
with information presented at the clinic; measured
using a seven-point Likert scale.
Figure1: Participant flow diagram. GA=general anaesthesia
Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013
775
Interventions
The video of four and a half minutes duration was
produced by the Herston Multimedia Unit, using
staff from our department. Equipment and uniforms
typical for our department were used. All staff
appearing in the video gave informed consent. The
video was shown within the maternity pre-admission
clinic for the purposes of this study only.
The video used actors and narrative to portray
a typical patient journey from the time of adminis-
tration of ranitidine in the holding bay to arrival in
the post-anaesthetic care unit. Information regarding
the surgical process was not included. Animations
were used to explain the basic anatomy of neuraxial
anaesthesia. Explanations and demonstrations were
included, covering insertion of the intravenous
cannula, patient positioning for neuraxial anaes-
thesia, insertion of the neuraxial anaesthetic and
use of patient monitoring. Descriptions of common
sensations experienced after neuraxial anaesthesia
for caesarean section were given. The risks and side-
776 V. A. Eley, T. Searles et al

effects of neuraxial anaesthesia were not included.
‘Usual care’ in the maternity pre-admission clinic
of our institution involves an appointment with
an anaesthetist, an appointment with a midwife
and a venepuncture for blood group and hold. The
appointment typically occurs within one to seven
days of surgery. The anaesthetic interview follows a
standardised proforma for history, examination and
investigation. Where regional anaesthesia is planned,
informed consent is obtained and documented.
Spielberger State-Trait Anxiety Inventory
The STAI consists of two separate, 20-point self-
report inventories; one examines state-anxiety (how
a person feels ‘right now’) and the other examines
trait-anxiety (how a person ‘generally feels’). Each
consists of a number of statements and each answer is
scored 1–4 with some inverse marking. The resulting
score has a minimum of 20 and maximum of 80, with
80 being the most anxious. The inventory has been
widely used in research and clinical practice7. The
Cronbach’s alpha coefficients (indicating reliability)
are high across several tested populations9 and the
STAI has been used extensively in pregnant women.
Both inventories were completed on the day of
surgery in the holding bay. Subjects were educated
on how to complete the questionnaire, in accordance
with the STAI manual.
The Maternal Satisfaction Scale for Caesarean Section
This questionnaire consists of 22 items, specifically
designed to assess maternal satisfaction with neuraxial
anaesthesia for elective caesarean section8. Satis-
faction with four elements is assessed; the anaesthetic,
insertion of the needle into the back, the side-effects
and the atmosphere in the theatre. Each item is
scored on a 7-point scale and the scores are added to
give a total score—minimum score 22 and maximum
score 154, a higher score representing higher satis-
faction (see Appendix). The questionnaire was
developed specifically for elective caesarean section
and has been used for research4. The first postoperative
day between the hours of 8:00am and 5:00pm was
selected for completion of the questionnaire to reduce
the effects of sleep deprivation and establishment
of breastfeeding in subsequent days. Subjects who
were in pain or feeling unwell were revisited later in
the day and withdrawn if they remained too unwell to
complete the questionnaire within the allocated time.
Two additional items were assessed on a 7-point
Likert scale on the first postoperative day, namely
the subject’s satisfaction with information given at
the anaesthetic interview and with the ability to ask
questions during the interview. These were analysed
separately to the Maternal Satisfaction Scale for
Caesarean Section8.
Baseline data collected included demographics,
obstetric and medical history, recollections from

Table 1
Demographic and clinical characteristics

Variable Control n=58 Video n=52 P-value

Age (years) 32.5 ± 5.6 31.1 ± 5.0 0.25

Nulliparous 17 (29) 15 (29) 0.98
BMI kg/m2 25.4 ± 5.3 26.1 ± 4.9 0.45
Education above high school 40 (69) 36 (69) 0.98
Previous neuraxial block or lumbar puncture 33 (56.9) 34 (65.4) 0.36
Comorbidity: mental health 8 (14) 5 (10) 0.50
Previous emergency CS 32 (55) 31 (60) 0.52
Gestation at CS (weeks) (median, interquartile range) 39 (38.5-39.5) 39 (38.5-39.5) 0.58
Support person: partner 58 (100) 49 (94) 0.18
Known foetal anomaly 5 (9) 4 (8) 0.57
Consultant interviewer 44 (76) 39 (75) 0.92
Interval between interview and surgery (days) 5.6 ± 2.5 5.7 ± 3.4 0.87
Memories from previous CS n=63 Control n=32 Video n=31
I can remember everything 10 (31) 14 (45) 0.26
I can remember some things/nothing 22 (69) 17 (55)

Data are mean ± standard deviation or number (percentage), except where labelled. BMI=body mass index,
CS=caesarean section.

Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013

 Effect of an anaesthetic information video in elective caesarean 777
section
Table 2
Anaesthetic and Delivery Data

Variable Control n=58 Video n=52 P value

Type of neuraxial anaesthesia:
CSE 55 (95) 51 (98) 0.56
Intrathecal fentanyl 55 (95) 51 (98) 0.56
Supplementation of neuraxial anaesthesia:
IV opioid 6 (10) 2 (4) 0.28
IV sedation 2 (3) 1 (2) 1.00
Inhaled nitrous oxide 2 (3) 1 (2) 1.00
Conversion to general anaesthesia 3 (5) 0 (0) 0.25
Intraoperative blood transfusion** 1 (2) 0 (0.0) 1.00
Neonate in NICU / nursery at time of follow-up 12 (21) 10 (19) 0.85

Data are number (percentage). **There were no postoperative transfusions (data collected day
1 postoperative). CSE=combined spinal epidural, IV=intravenous, NICU=neonatal intensive
care unit.

previous emergency caesarean sections, prior
experience of regional anaesthesia, educational
achievement and grade of anaesthetist in the clinic.
The booking body mass index was documented, as
described by the World Health Organization10.
Postoperatively the subjects’ medical charts
were accessed to obtain information on failure or
supplementation of neuraxial anaesthesia, blood
transfusion and newborn admission to the neonatal
intensive care unit or nursery.
A power analysis was performed, using a common
standard deviation of 13 from a prospective study in
patients undergoing caesarean section4. The sample
size of 50 per group was determined, based on
detecting an 8-point change in anxiety scores with
80% power and a significance level of 0.05. A mean
difference of 8-points in STAI scores is suggested
as clinically significant in the treatment of anxiety, as
described by Fisher11.
Block randomisation was used, with alternating
block sizes of four and six. Allocation was by means of
sequentially numbered, opaque, sealed envelopes as
described by Doig12 and the sequence was generated
by a practitioner (independent of the study) using
the restricted shuffled approach13. The allocation
ratio was 1:1 and subjects were stratified according
to history of emergency caesarean section using
the classification of the Royal College of Obstetricians
and Gynaecologists (Category 1 and 2 caesarean
section considered ‘emergency’)12.
The primary investigators were excluded from
interviewing study subjects in clinic and from
providing their anaesthetic care in theatre. Group
allocation was kept separate from data collection mat-
Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013
erials and data collectors were not aware of group
allocation.
Anaesthetists in the clinic were not aware of
group allocation. Anaesthetists had not viewed the
video, but were aware it was a video about neuraxial
anaesthesia for caesarean section. It was specified to
anaesthetists that the video did not replace informed
patient consent and that their interview should
follow the departmental proforma, with the usual
description of risks and complications. Subjects
were not specifically asked to keep their allocation
secret from the anaesthetist, as it was thought that
this could compromise their care.
All subjects were booked on a morning list,
followed the same preoperative fasting protocol and
received oral effervescent ranitidine in the holding
bay area. Choice of anaesthetic technique was not
restricted. Anaesthetists providing care on the day
of surgery were not aware of group allocation. Once
again, subjects were not asked to keep their allo-
cation from their anaesthetist, to avoid compromis-
ing their care.
Pearson Chi-square and Fisher’s exact tests were
used to compare the two groups for categorical
variables. A one-way analysis of variance was used
to detect differences between the two groups for
the primary and secondary outcome measures. The
Mann-Whitney U-Test was used to analyse non-
parametric data.
RESULTS
Subjects were recruited between March and
October 2012. Recruitment ended when sufficient
778 V. A. Eley, T. Searles et al
Table 3
Outcome measures for Control and Video groups
Variable
Trait anxietya
State anxietya
MSSCSb
Satisfaction with information (median, interquartile range)
Ability to ask questions (median, interquartile range)
Duration of interview (minutes)
Data are mean ± standard deviation except where labelled.a score 20-80 , b Maternal Satisfaction Score
for Caesarean Section: maximum score 154, 7 point Likert scale. MSSCS= Maternal Satisfaction Scale for
Caesarean Section.
numbers had completed the protocol in each group—
both groups were larger than the intended sample
size as a consequence of randomisation. Subjects
with incomplete outcome data were excluded from
the analysis. The number of incomplete subjects
was similar in both groups. Fourteen subjects were
excluded for reasons specified in the protocol, and
the other main reasons for failure to complete
data being change of schedule or early delivery.
The baseline data of subjects excluded were
compared to that of the subjects who completed
the protocol and no significant differences were
detected. Thirty-two subjects did not complete the
protocol and one was excluded from analysis due
to errors in the STAI, which meant it was unable
to be accurately scored, in accordance with the
STAI manual8 Figure 1 shows flow of participants
from enrolment to analysis. Of those subjects who
completed the protocol, Group C and Group V did
not differ significantly in demographic or clinical
characteristics (Table 1). Table 2 shows the anaes-
thesia and follow-up data.
There was only one statistically significant differ-
ence detected between the groups in terms of
the primary and secondary outcome measures,
demonstrated in Table 3. Subjects in Group C
reported lower scores for the “satisfaction with infor-
mation given in the anaesthetic interview” statement.
Post hoc sub-group analysis was performed on
two groups. Of the subjects who were having their
first caesarean section (n=47), those in Group C
reported lower satisfaction scores for the “satisfaction
with information given in the anaesthetic interview”
statement, with a median (interquartile range) of 7
(5.75–7) compared with 7 (7–7) in Group V. Of the
nulliparous subjects (n=32), there were no signif-
icant differences in the primary or secondary outcome
measures.
Control n=58 Video n=52 P value
33 ± 7.8 32 ± 7.7 0.24
41 ± 10.5 40 ± 10.8 0.49
119 ± 19.4 123 ± 16.4 0.22
7 (6-7) 7 (7-7) 0.01
7 (7-7) 7 (7-7) 0.38
16.3 ± 5.3 15.8 ± 6.5 0.69
DISCUSSION
This study found that a video about neuraxial
anaesthesia, viewed at the anaesthetic appointment
prior to elective caesarean section, did not reduce
maternal anxiety, improve postoperative satisfaction
or alter the duration of the anaesthetic interview.
Control subjects showed lower levels of satisfaction
with information received at the anaesthetic
interview. This also held true within a sub-group
analysis of subjects having their first caesarean
section. The reduction in satisfaction was not
thought to be clinically significant, as the median
scores were all high. The results are consistent with
those published by Salzwedel et al15, who found that
the use of anaesthesia information videos did not
change anxiety levels among non-obstetric patients.
Salzwedel et al also reported that using an
anaesthetic information video prior to the anaesthetic
interview increases the duration of the subsequent
interview, probably by prompting closer question-
ing of medical staff about video content13. Our study
did not find this. The neuraxial anaesthesia video used
in the study by Salzwedel et al was 8:20 minutes in
duration and focused on risk education – in contrast
our video did not include information on risks and
side-effects. Comparing studies concerning video-
assisted patient information is problematic when
the duration, purpose and content of the videos are
different.
Our study has some limitations. The exclusion
criteria (specifically, patients less than 18 years of
age and those unable to understand English) may
have lead to exclusion of those who could have
benefited most from this intervention. Selection
bias also occurred, with several patients declining
participation, citing anxiety as the reason. These
patients may have benefited from viewing the video,
if it had been presented as routine care, rather than
as part of a research study.
Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013
 Effect of an anaesthetic information video in elective caesarean
section
The inclusion of patients who had previously
undergone emergency caesarean section could be seen
as a limitation. Ryding et al documented amnesia in
women experiencing emergency caesarean section14.
They suggested this may be due to dissociation from
frightful memories, with fatigue, anxiety and the effect
of analgesic drugs contributing. In our study, the
majority of subjects who had previously undergone
an emergency caesarean section denied full memory of
the event.
The anaesthetic clinic staff included consultants
and advanced trainees, which may have affected
subject satisfaction. However, the majority of subjects
in both groups were seen by consultant anaesthetists.
The caesarean section anaesthetists caring for
study participants were also not a standardised group,
which may have introduced bias. To avoid inter-
fering with the clinician-patient relationship, anae-
sthetists in the clinic and the operating theatre were
not formally blinded to group allocation and this
was another possible source of bias. The conduct in
the clinic and theatre reflect real practice in our hos-
pital, such that the results of this study are location-
specific and may not apply to other institutions.
The subjective nature of our assessment tools
could be seen as a limitation, although the tools used
perform adequately in pregnancy. A physiological
marker of anxiety which can be objectively measured
is salivary amylase. Self-report measures are easy
to administer, economical and less threatening to
potential subjects. In addition, STAI (state) scores have
been shown to correlate with salivary amylase levels15.
Our results for preoperative maternal STAI scores
and the Maternal Satisfaction Scale for Caesarean
Section8 scores are consistent with those previously
reported4.
Patients at our institution have preoperative
anxiety but show a high level of satisfaction with
their anaesthetic for elective caesarean section.
These elements are not changed by use of an anae-
sthetic information video. It is possible that patients
already receive sufficient information from health
professionals within our institution or from exter-
nal resources such as the internet, friends and family.
While this study does not support the routine use
of an anaesthetic information video during pre-
paration for elective caesarean section, further
research may differentiate benefits for specific patient
groups, such as those who are under-age, non–English
speaking or have a history of anxiety.
ACKNOWLEDGEMENTS
The authors thank the Statistical Unit of the Queens-
land Institute of Medical Research for their assistance
with statistical analysis.
Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013
779
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Schuster MD. The effect of detailed, video-assisted anesthesia
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 780 V. A. Eley, T. Searles et al

APPENDIX 1

Speiberger State-Trait Anxiety Inventory: Form Y-1
A number of statements which people have used to
describe themselves are given below. Read each statement
and then circle the appropriate number to the right of the
statement to indicate how you feel right now, that is, at this
moment. There are no right or wrong answers. Do not spend
too much time on any one statement but give the answer
which seems to describe your present feelings best.
Speiberger State-Trait Anxiety Inventory: Form Y-2
A number of statements which people have used to
describe themselves are given below. Read each statement
and then circle the appropriate number to the right of the
statement to indicate how you generally feel.

1 2 3 4 1 2 3 4
Not At All Somewhat Moderately So Very Much So Almost Never Sometimes Often Almost Always
1. I feel calm 1 2 3 4 21. I feel pleasant 1 2 3 4
2. I feel secure 1 2 3 4 22. I feel nervous and restless 1 2 3 4
3. I am tense 1 2 3 4 23. I feel satisfied with myself 1 2 3 4
4. I feel strained 1 2 3 4 24. I wish I could be as happy as others seem to be 1 2 3 4
5. I feel at ease 1 2 3 4 25. I feel like a failure 1 2 3 4
6. I feel upset 1 2 3 4 26. I feel rested 1 2 3 4
7. I am presently worrying over possible misfortunes 1 2 3 4 27. I am “calm, cool, and collected” 1 2 3 4
8. I feel satisfied 1 2 3 4 28. I feel that difficulties are piling up so that I cannot 1 2 3 4
overcome them
9. I feel frightened 1 2 3 4
29. I worry too much over something that really 1 2 3 4
10. I feel comfortable 1 2 3 4 doesn’t matter
11. I feel self-confident 1 2 3 4 30. I am happy 1 2 3 4
12. I feel nervous 1 2 3 4 31. I have disturbing thoughts 1 2 3 4
13. I am jittery 1 2 3 4 32. I lack self-confidence 1 2 3 4
14. I feel indecisive 1 2 3 4 33. I feel secure 1 2 3 4
15. I am relaxed 1 2 3 4 34. I make decisions easily 1 2 3 4
16. I feel content 1 2 3 4 35. I feel inadequate 1 2 3 4
17. I am worried 1 2 3 4 36. I am content 1 2 3 4
18. I feel confused 1 2 3 4 37. Some unimportant thought runs through my mind 1 2 3 4
19. I feel steady 1 2 3 4 and bothers me
20. I feel pleasant 1 2 3 4 38. I take disappointments so keenly that I can’t put 1 2 3 4
them out of my mind
39. I am a steady person 1 2 3 4
40. I get in a state of tension or turmoil as I think over 1 2 3 4
my recent concerns and interests

Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013

 Effect of an anaesthetic information video in elective caesarean 781
section
APPENDIX 2

Maternal Satisfaction Scale for Caesarean Section

Strongly Neither Strongly

disagree agree agree
nor
disagree
1 2 3 4 5 6 7
I was pain free during my caesarean section
I felt the anaesthetic I received was safe for me
I felt the anaesthetic I received was safe for my baby
I had no pain when the needle was put in my back
The needle was put easily into my back
I was in a comfortable position when the needle was put into my back
During the caesarean section:
I did not experience shivering
I did not experience dry lips/mouth
I did not experience a dry throat
I did not experience a change in mood
After the caesarean section:
I did not experience back problems
I did not experience itchiness
In the operating room, during the surgery, I was able to:
Interact with my partner
Bond with my baby
Have a sense of control
Communicate with the staff
See my baby after delivery
Hold my baby after delivery
I knew what the staff were doing during the operation
I found the atmosphere in the operating room comfortable
I was able to nurse my baby after delivery
I recovered quickly after my anaesthetic

Appendix 3

Additional Questions

Strongly Neither Strongly

disagree agree agree
nor
disagree
1 2 3 4 5 6 7
I received enough information about my anaesthetic
I was able to ask questions if I was unsure about my anaesthetic

Anaesthesia and Intensive Care, Vol. 41, No. 6, November 2013

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.