|Year : 2018 | Volume
| Issue : 1 | Page : 31-34
Anesthesia for emergency cesarean section: A comparison of spinal versus general anesthesia on maternal and neonatal outcomes
Vitus Okwuchukwu Obi1, Odidika Ugochukwu J. Umeora2
1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Nigeria
2 Department of Obstetrics and Gynaecology, Federal Teaching Hospital; Department of Obstetrics and Gynaecology, Ebonyi State University, Abakaliki, Nigeria
|Date of Web Publication||2-Jul-2018|
Vitus Okwuchukwu Obi
Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki
Source of Support: None, Conflict of Interest: None
Background: Despite the relative safety of cesarean section (CS), increasing CS rate is a cause for concern to obstetricians and anesthetists because of the attendant increased health risk one of which is the risk of anesthesia. The choice of anesthesia for cesarean section depends on the indication for the surgery, the urgency of intervention required, the maternal and/or fetal status, and the patient's desires. Despite the paradigm shift toward spinal anesthesia, general anesthesia is still commonly administered in our facility for some specific indications. Objective: This study was aimed to evaluate the maternal and neonatal outcomes in patients who had emergency CS under spinal anesthesia compared with those who had general anesthesia. Materials and Methods: This was a retrospective study comparing the obstetric outcome of patients who had emergency CS under spinal anesthesia compared with those who had the surgery under general anesthesia. Data analysis was done using statistical Epi Info version 7.2.1. Results: The most common indication for surgery in the spinal group was cephalopelvic disproportion while that for the general anesthesia group was antepartum hemorrhage/placenta previa. Patients who had spinal anesthesia had less intraoperative blood loss compared with those who had general anesthesia (814 ± 124 vs. 842 ± 324; P = 0.0007). There was a significant difference in the intraoperative blood loss >1000 ml among women who had spinal anesthesia relative to women who had general anesthesia (odds ratio [OR]: 0.6832, 95% confidence interval [CI]: 0.3390–0.9779; P = 0.0005). Spinal anesthesia was associated with a reduced risk of having a 1st-min Apgar score <7 (OR: 0.6096, 95% CI: 0.4066–0.9140; P = 0.016). There was no significant difference in the 5th-min Apgar score in both groups. There was also no significant difference in the number of neonates admitted into the Intensive Care Units. The maternal and perinatal mortality was not different in both groups. Conclusion: Spinal anesthesia was associated with reduced risk of blood loss and reduced risk of low Apgar score in the 1st min. There was no difference in the 5th-min Apgar score and maternal and neonatal mortality.
Keywords: Emergency cesarean section, general anesthesia, spinal anesthesia
|How to cite this article:|
Obi VO, J. Umeora OU. Anesthesia for emergency cesarean section: A comparison of spinal versus general anesthesia on maternal and neonatal outcomes. Afr J Med Health Sci 2018;17:31-4
|How to cite this URL:|
Obi VO, J. Umeora OU. Anesthesia for emergency cesarean section: A comparison of spinal versus general anesthesia on maternal and neonatal outcomes. Afr J Med Health Sci [serial online] 2018 [cited 2019 Feb 22];17:31-4. Available from: http://www.ajmhs.org/text.asp?2018/17/1/31/235735
| Introduction|| |
Although majority of women deliver vaginally, cesarean section is a necessary surgical alternative when indicated. It is the most common major obstetric surgical procedure carried out on pregnant women for maternal and/or fetal indications., In recent times, there had been an increase in the rate of cesarean section (CS) globally.,, With the advent of potent antibiotics, safe anesthesia, and improved surgical skill, CS had become only marginally more risky compared with vaginal delivery. Despite the relative safety of CS, increasing CS rate is a cause for concern to obstetricians and anesthetists because of the attendant increased health risks, one of which is the risk of anesthesia.
The choice of anesthesia for cesarean section depends on the indication for the surgery, the urgency of intervention required, the maternal and/or fetal status, and the patients' desires. In most developed countries, spinal or epidural anesthesia is the recommended obstetric anesthesia. The major reasons for this recommendation are the risk of aspiration of gastric content and the fear of failed intubation associated with general anesthesia., There is limited evidence that general anesthesia is associated with an increase in blood loss during CS, and delay with neonatal delivery may cause neonatal respiratory depression, thereby increasing the need for neonatal resuscitation.
The use of general anesthesia for CS has declined while that of spinal techniques has increased. General anesthesia is the quickest anesthesia method in an emergency; it may be indicated when the woman refuses regional techniques in failed regional attempts or when regional is contraindicated such as in coagulopathy or spinal abnormalities.
Despite the paradigm shift toward spinal anesthesia, general anesthesia is still commonly administered in our facility for some specific indications. This study, therefore, aims to evaluate the safety and the maternal and neonatal outcomes in patients who had emergency CS under spinal anesthesia compared with those who had general anesthesia.
| Materials and Methods|| |
This was a retrospective study comparing the obstetric outcome of patients who had emergency CS under spinal anesthesia compared with those who had the surgery under general anesthesia. The case files of women who had emergency CS were retrieved, and maternal and neonatal outcomes were extracted. Clinical data were extracted from a study pro forma. Data obtained included maternal age, parity, indication for CS, and type of anesthetic used. Neonatal birth weight, 1st- and 5th-min Apgar scores, neonatal special care unit admission, and perinatal deaths were recorded.
Before spinal anesthesia preload with isotonic solution is done. The spine is then cleaned with antiseptic solution; the imaginary line joining L4–L5 is then noted. Following infiltration of this area with 1% xylocaine, intrathecal administration of 3 ml of 3% bupivacaine is then achieved for the spinal anesthesia. After the surgery, the action of spinal anesthesia reverses gradually and spontaneously.
Standard rapid sequence induction of general anesthesia was achieved with propofol or thiopentone. A premedication is usually given in the form of intravenous atropine sulfate 0.4. Induction is performed with a sleeping dose of 200–300 mg intravenous thiopentone and muscle paralysis is achieved with suxamethonium. Endotracheal intubation is then performed and anesthesia is maintained with nitrous oxide and oxygen. D-tubocurarine is given as a long-acting skeletal muscle relaxant. At the end of the procedure, neostigmine is given to reverse the action of the muscle relaxant. Extubation is carried out only when the patients' reflexes are active and after careful aspiration of any secretions in the naso- and oropharynx.
Data analysis was done using Epi Info software (7.2.1 CDC, Atlanta, Georgia). Categorical variable was expressed in frequency and percentages, while continuous variables were expressed as mean and standard deviation. Association between categorical data was done using Chi-square/Fisher's exact test, and Z-test was used to compare means. A difference with P < 0.05 was considered statistically significant.
Permission to carry out this research was sought and obtained from the Research and Ethical Committee of the hospital.
| Results|| |
Over the 2-year study period, there were 4903 deliveries, while the total number of CS was 1176; thus, the CS rate over the study period was 24.0%. Majority of the CSs were emergency CS, 80.7% (949/1176), while 19.3% were elective. About 83.4% of the emergency CSs were under regional anesthesia; while 81.1% (770/949) had spinal anesthesia, 1.3% (12/949) had epidural anesthesia. Twenty-three patients who had initial spinal anesthesia were later converted to general anesthesia. The remaining 17.6% (167/949) had general anesthesia. Complete records were only available for 871 patients who had emergency CS (131 – GA and 752 – spinal).
The indication for the surgery in patients who had spinal anesthesia is shown in [Table 1]. The most common indications are cephalopelvic disproportion, one previous scar with another indication and abnormal lie/presentation.
The indication for the surgery in patients who had general anesthesia is shown in [Table 2]. The most common indication for general anesthesia was antepartum hemorrhage/placenta previa. Other common indications include fetal distress, severe preeclampsia/eclampsia, and prolonged obstructed labor.
[Table 3] shows some sociodemographic characteristics of the patients. The characteristics of the women in the two groups were fairly matched, and there was no significant difference in the maternal demographics characteristics: maternal age, parity, and gestational age (P > 0.05). There was also no significant difference in the mean neonatal birth weight and the duration of the surgery; however, patients who had spinal anesthesia had less intraoperative blood loss compared with those who had general anesthesia (814 ± 124 vs. 842 ± 324; P = 0.0007).
[Table 4] shows the outcome measures. There was a significant difference in the intraoperative blood loss; women who had spinal anesthesia were less likely to have blood loss >1000 ml compared with women who had general anesthesia (odd ratio [OR]: 0.6832, 95% confidence interval [CI]: 0.3390–0.9779; P = 0.0005). Those who had emergency CS under spinal anesthesia were less likely to have a 1st-min Apgar score <7 (OR: 0.6096, 95% CI: 0.4066–0.9140; P = 0.016). There was no statistically significant difference in the 5th-min Apgar score in both groups (OR: 0.6546, 95% CI: 0.4145–1.0338; P = 0.0678). There was also no significant difference in the number of neonates admitted into the Intensive Care Units (OR: 0.5424, 95% CI: 0.24760–1.0659; P = 0.071).
| Discussion|| |
In this study, patients who had emergency CS under general anesthesia had a higher mean blood loss compared with patients who had their surgery under spinal anesthesia. More so, patients who had spinal anesthesia were noted to have a reduced risk of excessive bleeding at CS. This reduced risk of blood loss had been noted in similar studies.,, The reason for the increased blood loss associated with general anesthesia might be due to the uterine atony produced by medications used in maintaining general anesthesia. Besides, general anesthesia had been noted to increase blood pressure, thereby increasing perfusion at the surgical site which may further worsen the blood loss., This difference in blood loss may not be unrelated to the indication for the surgery. The most common indication for surgery in the general anesthesia group was antepartum hemorrhage/placenta previa which may be associated with increased risk of bleeding. This may contribute to the differential blood loss at the surgery. The hypovolemia noted in spinal anesthesia may contribute to the reduced blood loss in the patient.
Neonates who were delivered under spinal anesthesia were less likely to have Apgar score of <7 at the 1st min of life. This finding had been reported in others studies.,, Conversely, Imtiaz et al. and Prakash et al. did not demonstrate any difference in the Apgar score in either group., Factors that may affect the neonatal 1st-min Apgar score were more likely to the related to the indication for the surgery rather than the type of anesthesia. Notwithstanding, a prolonged induction to delivery time for general anesthesia may result in lower Apgar scores for the neonates. More so, a uterine incision to delivery time over 3 min had been reported to be associated with a low Apgar score regardless of anesthesia technique used.,
There was no significant difference in the 5th-min Apgar score between the two groups. Similar finding was reported by mekonen and Imtiaz., However, Martin et al. noted a significant difference in the 5th-min Apgar score between the two groups. This difference may be related to the facility where the study was conducted. The 5th-min Apgar score is related to the appropriateness of neonatal resuscitation and may not be related to the anesthesia administered.
There was no difference in the need for neonatal intensive care admission in this study. This is at variance with other similar studies that noted an increased risk for neonatal admission in babies delivered under general anesthesia. The maternal and perinatal mortality was not different in both arms of the study. This finding had been reported in other similar studies.,,, This would suggest the safety of these forms of obstetric anesthesia since they are not associated with increased risk of maternal and/or perinatal mortality.
| Conclusion|| |
Both general anesthesia and spinal anesthesia are safely applied in emergent cesarean operations in our facility. Choice between these two should be guided by clinical indications, expertise, and availability. This study did not evaluate maternal satisfaction with the form of anesthesia administered. It will be subject of another study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Curtin SC, Gregory KD, Korst LM, Uddin SF. Maternal morbidity for vaginal and cesarean deliveries, according to previous cesarean history: New data from the birth certificate, 2013. Natl Vital Stat Rep 2015;64:1-13.
Incerpi MH. Operative delivery. In: Decherney AH, Nathan L, Laufer N, Roman A, editors. Diagnosis and Treatment, Obstetrics and Gynecology. 11th
ed. New York, USA: McGraw-Hill, Company Incorporated; 2013. p. 334-48.
Ugwu EO, Obioha KC, Okezie OA, Ugwu AO. A five-year survey of caesarean delivery at a Nigerian tertiary hospital. Ann Med Health Sci Res 2011;1:77-83.
] [Full text]
Arulkumaram S. Malpresentation, malposition, cephalopelvic disproportion and obstetric procedures. In: Edmond DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology. 8th
ed. West Sussex, UK: John Wiley and Sons, Ltd.; 2012. p. 311-25.
Geidam AD, Audu BM, Kawuwa BM, Obed JY. Rising trend and indications of caesarean section at the university of Maiduguri teaching hospital, Nigeria. Ann Afr Med 2009;8:127-32.
] [Full text]
Yeoh SB, Leong SB, Heng AS. Anaesthesia for lower-segment caesarean section: Changing perspectives. Indian J Anaesth 2010;54:409-14.
] [Full text]
Ogboli-Nwasor E, Yunus AA. Anesthesia for cesarean delivery in a low-resource setting, an initial review. Open J Anesthesiol 2014;4:217-22.
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. Anesthesiology 2016;124:270-300.
Cyna AM, Dodd J. Clinical update: Obstetric anaesthesia. Lancet 2007;370:640-2.
Martin TC, Bell P, Ogunbiyi O. Comparison of general anaesthesia and spinal anaesthesia for caesarean section in Antigua and Barbuda. West Indian Med J 2007;56:330-3.
Mekonen S, Eshete A, Desta K, Molla Y. Maternal and neonatal outcomes in mothers who undergo caesarean section under general and spinal anesthesia in Gandhi memorial hospital, Addis Ababa. Adv Tech Biol Med 2015;3:119-21.
Lertakyamanee J, Chinachoti T, Tritrakarn T, Muangkasem J, Somboonnanonda A, Kolatat T, et al.
Comparison of general and regional anesthesia for cesarean section: Success rate, blood loss and satisfaction from a randomized trial. J Med Assoc Thai 1999;82:672-80.
Páez LJ, Navarro VJ. Anestesia regional versus general para parto por cesárea. Rev Colomb Anestesiol 2012;40:203-6.
Imtiaz A, Mustafa S, Haq N, Ali SH, Imtiaz K. Effect of Spinal and general anaesthesia over APGAR score in neonates born after elective cesarean section. JLUMHS 2010;9:151-4.
Prakash S, Singh K, Loha S, Meena R, Ranjan P, Meena K. Comparative study for maternal and fetal outcome in spinal anaesthesia and general anaesthesia for LSCS. Int J Recent Sci Res 2015;6:7443-6.
Algert CS, Bowen JR, Giles WB, Knoblanche GE, Lain SJ, Roberts CL, et al.
Regional block versus general anaesthesia for caesarean section and neonatal outcomes: A population-based study. BMC Med 2009;7:20.
Rollins M, Lucero J. Overview of anesthetic considerations for cesarean delivery. Br Med Bull 2012;101:105-25.
[Table 1], [Table 2], [Table 3], [Table 4]