Spinal or epidural anaesthesia for elective caesarean section? A Swedish experience. Combined spinal epidural anaesthesia for caesarean section: a randomised comparison of Oxford, lateral and sitting positions. Anaesthetic technique for elective caesarean section and neurobehavioural status of newborns. Effect of delayed supine positioning after induction of spinal anaesthesia for caesarean section. Neurologic activity of infants following anesthesia for cesarean section. Lumbar wedge versus pelvic wedge in preventing hypotension following combined spinal epidural anaesthesia for caesarean delivery. Hypotension following combined spinal-epidural anaesthesia for Caesarean section. Left lateral position vs. tilted supine position. Subarachnoid versus epidural bupivacaine 0.5% for caesarean section. Prevention of hypotension during spinal anaesthesia for caesarean section.
Ninety seven women undergoing elective lower segment caesarean section were randomly divided into two groups, group 1 received spinal anaesthesia with hyperbaric bupivacaine and group 2 received mepivacaine 20 mg/ml with adrenaline 5 microg/ml via an epidural catheter. All patients were given a preload of Ringer acetate and Macrodex prior to onset of anaesthesia. Ephedrine 5 mg was given if the systolic blood pressure fell below 100 mmHg. There was a small (<30%) but significant (P<0.01) fall in blood pressure in both groups of women. Six women in the epidural group required supplemental analgesics during the operation compared to only 1 patient in the spinal group (P<0.01). Muscle relaxation was judged to be inadequate in 3 patients in the spinal group and in 5 patients in the epidural group. One patient in the spinal group had a characteristic post-spinal headache lasting 3 days. The injection-delivery time was shorter (P<0.01) in the spinal group compared to the epidural group. The Apgar scores at 1 and 5 min were similar in both groups. The results from our study suggest that spinal anaesthesia is a good alternative to epidural anaesthesia for elective caesarean section. A fall in blood pressure, which is equally possible in both groups of patients, should be prevented by adequate fluid preload and treated immediately by intravenous ephedrine. Maternal position during induction of intrathecal anaesthesia for caesarean section influences block height and haemodynamic stability. In a randomised study of 90 women presenting for elective caesarean section using combined spinal-epidural anaesthesia, three positions were compared--the Oxford position (group O), the right lateral to supine wedged (group R) and the sitting to supine wedged (group S). Hyperbaric bupivacaine 12.5 mg with fentanyl 12.5 microg was injected intrathecally using a needle-through-needle CSE technique. Intravenous ephedrine 6 mg was given every minute that systolic blood pressure fell below 80% of baseline. Time required for block height to reach T5 as assessed by light touch, was similar in the three groups. There were no significant differences in blood pressure although ephedrine requirements were less in group R. There were no significant differences in the incidence of maternal nausea and vomiting or in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis. Although the study failed to show any significant differences in block height between the groups, no women in group O had a block above T2 compared with three in group R and three in group S. Ninety healthy parturients undergoing elective caesarean section were randomly allocated to receive either general (n = 30), epidural (n = 30) or spinal (n = 30) anaesthesia. Acid-base status, Apgar score and neurobehavioural status, using the neurologic and adaptive capacity scoring (NACS) system, were studied in the newborn. Apgar scores and acid-base parameters were similar in all the three groups. NACS testing revealed significantly more vigorous babies in the spinal anaesthesia group than in the other two groups at 15 min and 2 h interval after delivery, despite a higher incidence of maternal hypotension. We conclude that newborns tend to have a better neurobehavioural status in the early post-delivery period if their mothers receive spinal anaesthesia rather than general or epidural anaesthesia for caesarean section. The study tested the hypothesis that the incidence of hypotension during spinal anaesthesia for caesarean section is less in parturients who remain in the sitting position for 3 min compared with parturients who are placed in the modified supine position immediately after induction of spinal anesthesia.
                Spinal anaesthesia was induced with the woman in the sitting position using 2.8 ml hyperbaric bupivacaine 0.5% at the L(3-4) or L(2-3) interspace. Ninety-eight patients scheduled for elective caesarean section under spinal anaesthesia were randomised to assume the supine position on an operating table tilted 10 degrees to the left (modified supine position) immediately after spinal injection (group 0, n=52) or to remain in the sitting position for 3 min before they also assumed the modified supine position (group 3, n=46). Isotonic saline 2-300 ml was given intravenously over 15 min before spinal injection followed by 15 ml/kg over 15-20 min after induction of spinal anaesthesia. If the systolic blood pressure decreased to less than 70% of baseline or to less than 100 mmHg or if there was any complaint of nausea, ephedrine was given in 5 mg boluses intravenously every 2 min.
                The blood pressure decreased significantly in both groups following spinal injection (P<0.001). Blood pressure variations over time differed significantly between the two groups (P<0.05). However, the incidence of maternal hypotension before delivery was similar in the two groups. The difference was caused by the time to the blood pressure nadir being significantly shorter in group 0 compared with group 3 (9.1+/-4.5 min vs. 11.7+/-3.7 min, P<0.01). Similar numbers of patients received rescue with ephedrine before delivery: 35 (67%) in group 0 vs. 26 (57%) in group 3 (NS). The mean total dose of ephedrine before delivery was 10.9 mg in group 0 vs. 9.2 mg in group 3 (NS). There were no differences in neonatal outcome between the two groups.
                At elective caesarean section, a 3-min delay before supine positioning does not influence the incidence of maternal hypotension after induction of spinal anaesthesia in the sitting position with 2.8 ml of bupivacaine 0.5% with 8% dextrose. Elective cesarean section was performed in a consecutive series of 30 patients with full-term pregnancies who were not in labor. Epidural (lidocaine, 1.5 per cent, with epinephrine, 1:200,000) and general anesthesia (thiopental, nitrous oxide-oxygen, succinylcholine infusion) was used alternately. Neonatal acid-base values and Apgar scores showed no significant difference between the two anesthetic groups, and most infants were vigorous at birth. The neurologic recoveries of the infants showed no significant difference between the two groups. In the group receiving epidural anesthesia, there was a significant correlation between maternal hypotension and weak rooting and sucking reflexes of the infants during the first two days. All infants of high-risk obstetric patients in the series, independent of anesthetic technique used, had abnormal neurologic activity, as evidenced by either depression of muscle tone and the reflexes or all the tested variables. Neurologic assessment as followed in this series is a sensitive indicator of the effects of fetal stress factors acting during cesarean section. Aortocaval compression is a major cause of maternal hypotension. A randomised controlled clinical trial was designed to compare two wedged supine positions for prevention of hypotension following combined spinal epidural anaesthesia for caesarean delivery. Sixty parturients undergoing elective caesarean delivery were randomly assigned to two different wedged supine positions. After the completion of subarachnoid injection, parturients were placed with either a wedge under the right pelvis (group P pelvic wedge) or under the right lumbar region (group L, lumbar wedge). Systolic blood pressure and heart rate were recorded every minute for 20 minutes from the subarachnoid injection. Hypotension, defined as systolic blood pressure <100 mmHg or 80% of the baseline, was treated with intravenous ephedrine 5 mg. The incidence of hypotension, ephedrine use and neonatal Apgar scores and umbilical arterial pH were recorded. The incidence of hypotension was significantly higher in group P than that in group L (23/30 [77%] vs. 14/30 [47%], P=0.016). Systolic blood pressure decreased significantly in both groups at seven, eight and nine minutes (P < 0.001); moreover it was lower at seven, eight and nine minutes in group P than in group L (P < 0.01). Heart rate did not change significantly in either group. There were no significant differences between the two groups for Apgar score and umbilical arterial pH. A lumbar wedge is more effective than a pelvic wedge in preventing hypotension following combined spinal epidural anaesthesia for caesarean delivery, although it does not eliminate hypotension. Eighty-seven pregnant mothers undergoing elective Caesarean section were randomly allocated either to the full left lateral position (n = 45) or to the supine position with 12 degrees left lateral tilt (n = 42) after a combined spinal-epidural (CSE) in the sitting position and an initial 2 min in the full right lateral position. Fewer mothers were hypotensive while in the study position [29 (64%) in lateral group vs. 38 (90%) in the tilted supine group; p = 0.03]. Mothers in the lateral group tended to become hypotensive after turning them back to the tilted supine position immediately before surgery; hence the number of mothers who were hypotensive from the insertion of the CSE until delivery were similar [36 (80%) vs. 38 (90%)]. Mothers in the lateral group needed a lower dose of ephedrine to treat their hypotension while in their study position (median (interquartile range [range]) 6 (0-12 [0-36]) mg vs. 12 (6-18 [0-36]) mg, respectively; p = 0.04) but ephedrine requirements were similar overall (12 (6-12 [0-36]) mg vs. 12 (6-18 [0-36]) mg), respectively. The full left lateral position reduces the incidence of early hypotension compared with the tilted supine position with tilt, and makes it easier to treat. In order to compare subarachnoid (spinal) and epidural block for caesarean section, 40 women were randomly allocated to spinal or epidural analgesia with bupivacaine. The median dose of bupivacaine was 13 mg in the spinal group versus 155 mg in the epidural group. The mean time from induction to delivery was 32 min shorter in the spinal group (P less than 0.001). In the spinal group one woman was excluded because of spontaneous labour. Three patients in the spinal and one in the epidural group failed to develop adequate analgesia to initiate surgery. For the remaining patients both techniques provided good analgesia during operation. Postoperatively, epidural block provided better pain relief. The patients in the epidural group had a lower pain score during the first 4 h after the operation (P less than 0.01). In spite of similar haemodynamic changes in the two groups, the mean base deficit in umbilical cord blood at delivery was higher in the spinal group (P less than 0.05). Twenty-six parturients scheduled to receive spinal anaesthesia for caesarean section were randomized to receive either isotonic saline 750 ml plus 20 ml/kg (group A) or 750 ml plus 500 ml (group B) before subarachnoid administration of bupivacaine 13 mg. Ephedrine 0.15 mg/kg i.v. followed by an infusion 0.4 mg.kg(-1) h(-1) were then administered in group B. In both groups ephedrine 10 mg/min i.v. was given if the mean arterial blood pressure decreased more than 10 mmHg. Despite the fluid preload and large doses of ephedrine noted {median (range), group A 30 mg (10-80), group B 92 mg (25-194)}, hypotension, sometimes accompanied by nausea, still occurred. Mean maternal arterial was significantly lower in group A than in group B 5-10 min after induction of spinal anaesthesia (P < 0.05). There was no difference in the frequency of nausea or vomiting, Apgar score, or pH in umbilical cord blood. One neonate in group A and 2 in group B were acidotic. In conclusion, a reduced volume loading could be compensated with an increased ephedrine administration after induction of spinal anaesthesia, without increasing the incidence of hypotension or other maternal or neonatal complications. However, the fluid volumes and/or ephedrine doses used were not sufficient to prevent hypotension altogether.
Both spinal and epidural techniques are shown to provide effective anaesthesia for caesarean section. Both techniques are associated with moderate degrees of maternal satisfaction. Spinal anaesthesia has a shorter onset time, but treatment for hypotension is more likely if spinal anaesthesia is used. No conclusions can be drawn about intraoperative side-effects and postoperative complications because they were of low incidence and/or not reported.