Elective Lower Segment Caesarean Section Research Articles

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Comparative study of isobaric levobupivacaine and hyperbaric bupivacaine for subarachnoid block in elective cesarean sections

Background & Objective: Hyperbaric bupivacaine 0.5% with fentanyl is often used for spinal anesthesia in lower segment cesarean section (LSCS). Its cardiotoxicity, extended sensory block and high sympathetic blocks in parturients can be disadvantageous. Levobupivacaine, an s-enantiomer of racemic bupivacaine is truly isobaric with CSF. It should be able to produce adequate sensory block with less hemodynamic changes and less cardiovascular toxicity. We aimed to evaluate the clinical efficacy of intrathecal 0.5% isobaric levobupivacaine compared to 0.5% hyperbaric bupivacaine with fentanyl 25 µg for elective LSCS.

Frequency of spinal hypotension in patients undergoing elective lower segment caesarean section using preoperative preload and intramuscular ephedrine.

Objectives: To observe the frequency of spinal hypotension in patients undergoing Elective Lower Segment Caesarean Section receiving pre-operative preload compared with intramuscular ephedrine. Study Design: Cross Sectional study. Setting: Department of Anesthesia, Independent Medical College, Faisalabad. Period: July 1st 2018 to December 31st 2018. Material & Methods: This study included fifty-two female patients, aged 20-35 years, undergoing elective C/section under spinal anesthesia with ASA physical status I & II, pre-operatively preloaded and given prophylactic intramuscular ephedrine. Hemodynamic changes were recorded in both groups after receiving spinal anesthesia. Results: Compared with the prophylactic ephedrine group, frequency of Post spinal hypotension was higher significantly in pre-load group (p=0.019). Conclusion: It has been concluded that there is the use of prophylactic intra muscular ephedrine is associated with low incidence of post spinal hypotension.

Effectiveness of intravenous boluses of phenylephrine, ephedrine and mephentermine as vasopressors for management of perioperative hypotension in elective lower segment caesarean section under spinal anaesthesia – A prospective comparative study

Hypotension after subarachnoid block for caesarean section is the commonest but serious complication encountered by anaesthesiologists. Various vasopressors are used to prevent/treat this complication. This study was done to compare the efficacy of three commonly used vasopressors – phenylephrine, ephedrine, mephentermine for treatment of perioperative hypotension. Sixty American Society of Anaesthesiologists (ASA) physical status class II parturients undergoing elective caesarean section under subarachnoid block were randomly allotted three groups (P, E, M) (n = 20) to receive intravenous boluses of phenylephrine 100 mcg, ephedrine 6mg & mephentermine 6mg respectively, following hypotension. Maternal Haemodynamic parameters, complications & neonatal APGAR scores were recorded. P-value < 0.05 was considered significant and P-value < 0.001 considered highly significant. Demographic values, baseline vital parameters and mean number of vasopressor boluses required were similar in the three groups (P > 0.05). The mean trends of systolic blood pressure (P = 0.06), diastolic blood pressure (P = 0.7) and mean arterial pressure (P = 0.6) were similar in the three groups. Heart rate was raised during periods of hypotension; the mean heart rate was lower in the phenylephrine group after vasopressor administration. The overall trend was similar (P = 0.1) among the three groups. There was (P = 0.003) higher incidence of bradycardia in the phenylephrine group. The neonatal APGAR scores were > 7 in the three groups at the 1st and 5th minute (P = 0.5). All three vasopressors effectively maintained arterial blood pressure during the subarachnoid block for caesarean section. Phenylephrine caused a significant reduction in heart rate compared to ephedrine or mephentermine.

Ehlers-Danlos syndrome with huge bladder diverticulum in pregnancy – A rare and interesting case report

Ehlers-Danlos syndrome (EDS) is one of the commonest inheritable connective tissue disorders (CTD) affecting one in 5000 people globally. The incidence of bladder diverticula (BD) is reported to be 1.7% seen more commonly in children without any bladder outlet obstruction. BD are associated with congenital syndromes, namely, EDS. We report a case of huge BD in pregnancy that became symptomatic as the pregnancy progressed to term with urinary retention, recurrent urinary infections and fetal malpresentation. The patient was taken for elective Lower segment cesarean section (LSCS) wherein intra-operative findings of soft abdominal wall, velvety and jelly-like rectus muscle made us suspect connective tissue disorder. A thorough retrospective evaluation of medical history, physical examination along with orthopedic evaluation led to the diagnosis of EDS. To the best of our knowledge, this is the first case report of EDS with huge BD in pregnancy.

Comparison of successful spinal puncture between pendant position and traditional sitting position for cesarean deliveries

Background & objectives: Several positions are used for performing subarachnoid block with varying difficulty of spinal access. Pendant position is known to reduce lumbar lordosis in patients’ especially pregnant patients making spinal access easier. The most ideal position for the easy spinal access is yet to be determined. This study was planned to compare ease of spinal access in pendant position vs. traditional sitting position (TSP) in pregnant females, and to establish the superiority of the former.
 Methodology: This randomized controlled trial was conducted in our hospital on 232 subjects over 6 month period. Parturients undergoing elective lower segment cesarean section (LSCS) were randomly divided into two groups: Group A (pendant group) and Group B (TSP group). Spinal puncture was performed at L3-L4 interspace, randomly making one of the two positions. Time for successful spinal, number of needle-to-bone contacts and total number of attempts were recorded.
 Results: The median age of the patients was 29 yrs with the interquartile range (IQR) 7. The number of needle-to-bone contacts in Group A was significantly higher compared to Group B (59.48% vs. 33.62%, p = 0.000). Mean time for successful spinal puncture was less in Group A than Group B (17.69 sec vs. 25.54 sec, p = 0.001). The difference in number of attempts for spinal in both positions was not significant.
 Conclusion: Pendant position is better than traditional sitting position in achieving successful spinal puncture in terms of needle-to-bone contacts and the time to puncture. However there is no difference in number of attempts for both positions.
 Key words: Traditional sitting position; Pendant position; Spinal anesthesia; Cesarean section
 Citation: Arshad QUA, Jadoon H, Raza A, Furqan Z, Shahani YA. Comparison of successful spinal puncture between pendant position and traditional sitting position for cesarean deliveries. Anaesth. pain intensive care 2020;24(6):---
 Received: 13 July 2020, Reviewed: 28 September 2020, Accepted: 29 September 2020

Higher baseline perfusion index can predict hypotension in parturient undergoing elective lower segment caesarean section under spinal anaesthesia

Higher baseline perfusion index can predict hypotension in parturient undergoing elective lower segment caesarean section under spinal anaesthesia

Ultrasound-assisted subarachnoid block in obese parturient: Need of the hour

Subarachnoid block is commonly used for caesarean deliveries, by virtue of its simplicity in terms of performance and safety for the parturients when compared with general anesthesia. The landmark technique involves palpating the interspinous space at the level of Tuffier's line to ensure the interspace level and direct the spinal needle through optimally selected puncture site for performing the subarachnoid block. However, spinal block is sometimes not easy to perform in obese parturients primarily because of poorly palpable surface landmarks and challenges related to positioning for the block. Recently, ultrasound (USG) is being used for facilitating central neuraxial block, using low-frequency curvilinear probe with encouraging results. We report a case of a 28-year-old, 95-kg parturient, with body mass index of 39.1 kg/m2 scheduled for elective lower segment caesarean section under subarachnoid block, the indication being previous caesarean section. As the landmarks were not appreciable on palpation, we performed USG-assisted preprocedural landmark-based subarachnoid block successfully.

Spinal anaesthesia for cesarean section in a case of congenital complete heart block

We report a case of congenital complete heart block on a temporary pacemaker who underwent an elective lower segment cesarean section under spinal anesthesia uneventfully. These patients could be completely asymptomatic but are at risk of sudden cardiovascular collapse. Spinal anesthesia is a safe option. Maintenance of hemodynamic stability including heart rate control with a temporary pacemaker is important

Successful pregnancy and its outcome in a woman with 46XX gonadal dysgenesis

A 25-year-old lady with 3 years of primary infertility was diagnosed with an infantile uterus, premature ovarian failure due to streak gonads, and 46XX gonadal dysgenesis. She has received hormone therapy irregularly since menarche and gets withdrawal bleeding only after taking estrogen and progesterone combination. She also received three cycles of ovulation induction elsewhere. Her transvaginal ultrasonogram (USG) showed uterus that measured 4.1 × 2.3 cms, right ovary measured 1.4 × 0.9 × 1.08 cm and left ovary could not be visualized. She was given hormone replacement therapy to achieve optimal uterine size for a period of 1 year and achieved pregnancy with the second cycle of the donor oocyte program. She developed early onset-gestational hypertension and underwent elective lower segment caesarean section (LSCS) at 37 weeks. At cesarean section, fallopian tubes were normal and ovaries were small in size and streak like. An alive female baby was delivered who weighed 3.5 kg.

Incidence and outcome of vaginal birth after cesarean among women receiving counseling at El Manial University Hospital

Background Repeated cesarean section (CS) is the most significant factor contributing to overall increased CS rates. The primary indicator of repeated CS is a prior CS. Vaginal birth after cesarean (VBAC) is a trial to reduce CS rates. Aim The aim of study was to examine the effect of counseling on the incidence, maternal, and neonatal outcomes of VBAC. Design A quasi-experimental one-group posttest-only design was adopted for this study. Setting The study was conducted at the Outpatient Clinic and Casualty Department at Manial University Hospital affiliated to Cairo University. Sample A purposive sample of pregnant women was recruited through a period of 6 months from July to December 2019 based on certain criteria; the most important one is to have a previous CS. Tool A structured interviewing tool, labor progress record (Partograph), and neonatal Apgar score were used to collect the data. Results A total of 90 participants were enrolled into study. A total of 79 (87.8%) women agreed to have VBAC after counseling compared with only 11 (12.2%), who refused to have VBAC and chose CS. The trial of labor after cesarean (TOLAC) rate was 40.5%. The rate of VBAC was 31.6%. Success rate of TOLAC was 78.1%, whereas failed TOLAC was 21.9% owing to lack of labor progress and fetal distress. Overall, 68.4% had CSs lower segment cesarean section (LSCS). Among them, 37% had elective LSCS and 63% had emergency LSCS. Physician decision without any medical indication for CS was the most common indications of elective repeat CS, with a rate of 85%. Oligohydramnios was the most common cause for emergency CS delivery, with a rate of 44.5%. All women who delivered VBAC had normal progress of labor and their babies had normal Apgar score (8–10). No cases that underwent VBAC had any morbidity or mortality. Conclusion Counseling is needed for the selection of VBAC as a mode of delivery. Successful VBAC is associated with better fetomaternal and neonatal outcomes, so most women with one previous cesarean delivery with a low-transverse incision should be counseled and encouraged to undergo a trial of labor in her recurrent pregnancy. Recommendations A qualitative research study should be conducted to assess the satisfaction of women from VBAC and compare it with CS.

A Comparative Study of Intrathecal Isobaric 0.5% Bupivacaine and Intrathecal Isobaric 0.75% Ropivacaine in Elective Lower Segment Cesarean Section

Objective: To compare the anesthetic efficacy of isobaric 0.75% ropivacaine with isobaric 0.5% bupivacaine in patients undergoing elective lower segment cesarean section (LSCS) under spinal anesthesia (SA) with respect to the nature of sensory block, motor block, and duration of analgesia. Materials and Methods: In this prospective, randomized, double-blinded study, sixty full-term parturients of American Society of Anesthesiologists Grade I–II, aged 20–35 years, scheduled for elective LSCS, were randomized into two groups namely B and R (n = 30). Preoperative medication regimen and anesthesia protocol followed, were uniform for all patients. Patients received 2.5 ml of either local anesthetic agent intrathecally. Hemodynamic parameters, onset and duration of sensory and motor blockade, level achieved, and side effects were compared between the two groups. Postoperative analgesia was assessed using the Visual Analog Scale scoring and also by noting the time of requirement of the first dose of rescue analgesic. Qualitative data were analyzed by Chi-square test and quantitative data were analyzed by independent sample t-test. Results: All the thirty patients in each arm completed the study without any dropouts. Baseline demographic variables, hemodynamic parameters, characteristics of sensory block (onset, time to reach peak sensory level, and duration), postoperative analgesia, and neonatal outcome were similar in both groups. However, intrathecal isobaric 0.75% ropivacaine demonstrated delayed onset (P = 0.005), and a significantly shorter duration (P = 0.001) of motor block. Conclusion: In view of the shorter duration of motor blockade, with similar duration of sensory blockade, hemodynamics, and postoperative analgesia, 0.75% isobaric ropivacaine (18.75 mg) is an efficient and safe alternative to bupivacaine for SA in elective LSCS.

Comparison of 2-chloroprocaine 1% versus hyperbaric bupivacaine 0.5% for subarachnoid block in pregnant females posted for elective caesarean section

Introduction and Objectives: Caesarean sections generally done under subarachnoid block using 0.5% hyperbaric bupivacaine as the local anaesthetic of choice. As most caesarean sections are of short duration, we decided to study whether 1% 2-chloroprocaine would be suitable alternative to bupivacaine with primary outcome being duration of sensory blockade in elective lower segment caesarean sections. Materials and Methods: In this prospective study, 60 pregnant females belonging to ASA status 1 and 2, posted for elective lower segment caesarean section were equally randomized into two groups. The first group received 1% chloroprocaine 25 mg (2.5 ml, Group CP) and second group received 0.5% hyperbaric bupivacaine 10 mg (2.0 ml, Group B), intrathecally. We measured the level of sensory and motor blockade, duration of sensory blockade and side effects. Results: Mean duration of sensory blockade was 61.83 23.54 minutes for group CP, which is significantly shorter than group B which had 174.67 41.17 minutes (p Value clinically significant incidences of hypotension (53.33% Vs 30%) compared to group CP. Conclusion: Intrathecal low dose 1 % chloroprocaine is a safe and suitable alternative to low dose 0.5% hyperbaric bupivacaine for an uncomplicated elective lower segment caesarean section. Keywords: 1% 2-Chloroprocaine 0.5% Hyperbaric bupivacaine, Subarachnoid block, Lower segment caesarean section.

Early versus Late Oral Feeding on the Recovery of Normal Bowel Functions After Caesarean Section: A Randomized Controlled Study

Background. To compare early oral feeding (EF) versus late oral feeding (LF) on the return of normal bowel functions in spinally anesthetized women after having lower segment Caesarean section (LSCS). Secondary outcomes such as maternal satisfaction and gastrointestinal complications were also evaluated. Methods. Three-hundred and sixty-two singleton pregnant women undergoing elective LSCS with spinal anesthesia were assigned to receive either EF (n= 183) or LF (n= 179) after surgery. Participants began to take normal diet between immediately and 6 hours, or began sipping water after 12 hours and soft diet after 24 hours then normal diet after 48 hours of surgery. Results. The ages of participants ranged from 19 to 47, with a mean age of 35±12 years. There was no-loss follow up and no significant difference in patient characteristics. Participants given EF were more likely to experience bowel sound the next morning after surgery than patients given LF (EF 93% vs. LF 71%, P<0.05). However, there was no difference in time to passing flatus and time to passing stool. Maternal satisfaction, rated on a 5-point scale was significantly higher in the EF group. However, there was no significant difference in gastrointestinal complications between both groups. Conclusion. The findings of this trial support the recommendation of EF for women who undergo uncomplicated LSCS under spinal anesthesia.

Comparison of the effect of induction position in spinal anaesthesia on sensory block in pregnant women undergoing elective lower segment caesarean section with hyperbaric bupivacaine

Comparison of the effect of induction position in spinal anaesthesia on sensory block in pregnant women undergoing elective lower segment caesarean section with hyperbaric bupivacaine

EFFECTS OF PROPHYLACTIC MATERNAL DEXAMETHASONE ADMINISTRATION ON THE NEONATAL RESPIRATORY OUTCOMES AT TERM AFTER ELECTIVE CAESAREAN SECTION: RANDOMIZED CONTROLLED TRIAL

OBJECTIVE: To assess the effects of prophylactic antenatal dexamethasone administration in reducing the neonatal respiratory morbidity at term after elective lower segment caesarean section (LSCS).METHODS: This open label randomized-controlled trial was conducted in Department of Obstetrics and Gynaecology, Kahuta Research Laboratories (KRL) Hospital, Islamabad from September 2017 to February 2018. Patients with singleton pregnancy and non-anomalous fetus between gestational age of 37+0 and 38+6, planned to be delivered by elective LSCS were randomized through block-randomization method into interventional group (A): who received dexamethasone and control group (B): who did not receive prophylactic dexamethasone. Main outcomes of the study included Apgar-score at one & five minutes, admission to neonatal intensive care unit (NICU) due to transient tachypnea of newborn (TTN) and respiratory distress syndrome (RDS). Data was analyzed by SPSS version 23.RESULTS: A total of 304 women were randomized and equally assigned to interventional and control group. In group-A, 2 neonates developed RDS as compared to one neonate in group-B (p=0.391). Mean age of patients in group A and B was 30.48±4.18 years and 29.38±4.57years respectively. Five-minutes Apgar score was 8.91±0.290 in group A & 8.87±0.393 in group B (p=0.320). TTN developed in four neonates in group-A while one neonate in group-B (p=0.176). Eighteen (11.8%) cases in group A & 12(7.9%) cases in group B were admitted in NICU (p=0.249).CONCLUSION: Prophylactic dexamethasone administration in term LSCS after 37 weeks of gestational age has no significant effects on reducing the incidence of RDS, TTN and neonatal admission to NICU.

Takayasu's arteritis: Anesthetic implications and management of a patient for cesarean section using combined spinal-epidural technique

Takayasu's arteritis (TA) or pulseless disease is a rare, idiopathic, chronic granulomatous vasculitis that affects mainly aorta and its major branches. We report herewith the anesthetic management of a parturient who suffered from TA scheduled for elective cesarean section by using combined spinal-epidural technique, which offers the combined advantage of both spinal and epidural anesthesia and postoperative analgesia. Anesthesia for patients with TA is complicated by severe uncontrolled hypertension, end-organ dysfunction, stenosis of major branches of aorta, and difficulties in monitoring hemodynamic parameters. Our patient was a full-term, 29-year-old female weighing 60 kg, of height 154 cm, gravida 1, and para 0 scheduled for elective lower segment cesarean section. The intraoperative period was uneventful with minimal rise in blood pressure (BP) which was managed accordingly with antihypertensive medications. The patient was stable in the postoperative period with minor rise in BP from baseline and was shifted to ward after being monitored in the intensive care unit for 24 h.

Role of IVC collapsibility index to predict post spinal hypotension in pregnant women undergoing caesarean section. An observational trial.

Background:Postspinal anesthesia hypotension (PSH) in pregnant women is common and may lead to poor maternal and fetal outcome. Fluid loading in pregnant women before spinal anesthesia to prevent hypotension is of limited ability. We hypothesized that those women who are hypovolemic before spinal anesthesia may be at risk of PSH and inferior vena cava collapsibility index (IVCCI) will be able to identify hypovolemic parturients.Methods:In this prospective observational study, n = 45 women undergoing elective lower segment cesarean section with singleton pregnancy were recruited and IVCCI in left lateral tilt (with wedge) and supine position (without wedge) were noted by M-mode ultrasound (USG) before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted till 15 min after spinal anesthesia.Results:USG measurements were obtained in 40 patients and 23 of 40 patients (57.5%) had at least one episode of hypotension. Area under the ROC curve of IVCCI with wedge to predict PSH was 0.46 (95% CI 0.27, 0.64) and best cut-of value was 25.64 with a sensitivity and specificity of 60.9% and 35.5%, respectively. Area under the ROC curve of IVCCI without wedge to predict PSH was 0.38 (95% CI 0.19, 0.56) and best cut-of value was 20.4 with a sensitivity and specificity of 69.6% and 23.5%, respectively.Conclusion:We conclude that IVCCI is not a predictor of PSH in pregnant women undergoing elective cesarean section.

Late Presentation of Rheumatic Heart Disease during Pregnancy: A common occurrence in the NT

Rheumatic heart disease remains an undertreated and underdiagnosed entity in Australia. As 98% of acute rheumatic fever and rheumatic heart disease occurs in the Indigenous population and as females represent two thirds of rheumatic heart disease, our most vulnerable population suffers from this disease the most. This is a disease of the socially disadvantaged: social, cultural, physical barriers exist between this population and appropriate prevention, diagnoses and management. We present here 6 years of data, equating to 60 females, diagnosed with rheumatic heart disease during pregnancy. Approximately one third with moderate to severe valvular disease and 20% pulmonary hypertension. This is not uncommon in the Northern Territory. The majority of these cases were diagnosed before admission for birth, however a small number were only diagnosed perinatally. The majority of these cases were able to be managed through normal vaginal delivery or elective lower segment caesarean section without fatal complications. A small number of attempted vaginal deliveries resulted in emergency. We observe the changing physiology within pregnancy trimesters and stages of delivery and the impact this has on valvular gradients and pulmonary hypertension, including the incredible and unexpected physiological reserve many of these females display. We also discuss the various methodology of diagnosis, the medical and social management of such females, including the anaesthetic approach to vaginal delivery or lower segment caesarean section.

Effect of Tranexamic Acid on Blood Loss in Elective Cesarean Delivery

Background: tranexamic acid as an agent given before surgical procedures reduces the blood transfusion risk, mean volume lost, and the requirement for reintervention due to bleeding issues, without raising thrombotic risks. Aim: to evaluate Tranexamic acid agent infusion as regards its efficacy in blood volume loss reduction in practice of elective lower segment cesarean section delivery. Patients and Methods: A double blinded, randomized, controlled research clinical trial. All study subjects have been recruited from the cases scheduled for elective cesarean delivery in the labor ward of Mokattam Insurance Hospital. The study subjects were totally 200 cases allocated in by randomization into 2 research groups. The study research group have been composed of 100 cases that were administered a mixture of tranexamic acid 25mg/kg in 200 ml of normal saline by intravenous drip for 20 minutes before incision, while the control research group contained 100 cases administered a volume of normal saline in accordance to patient’s weight (25 mg/kg) by intravenous drip for 20 minutes before time of incision. Results: Blood loss volume was statistically significantly lower among Tranexamic research group than among placebo research group (p value <0.001). Postoperative hematocrit was statistically significantly higher among Tranexamic research group than among placebo research group (p value =0.020). Hematocrit reduction was statistically significantly lower among Tranexamic research group than among placebo research group (p value <0.001). PPH and blood transfusion were statistically significantly less frequent among Tranexamic research group (p values=0.010, 0.005 consecutively). Conclusions and Recommendation: The administration of tranexamic acid before starting a cesarean section is valuable as a prophylaxis against intra-operative and post-partum bleeding issues. Future research studies are required to consider various variables such as racial and ethnic differences and consider various clinical case scenarios e.g. previous cesarean delivery and categorization of more possible critical indications of cesarean such as second stage cesarean, emergency cesarean section and time interval of decision to incision as those variables could influence blood volume loss indices.