DOI: 10.7860/JCDR/2018/27753.

11184
Original Article

Effect of Position during Induction of Spinal

Anaesthesia Section

Anaesthesia for Caesarean Section on

Maternal Haemodynamic: Randomised
Clinical Trial
Atashkhoei Simin1, Bahman Naghipour2, Haleh farzin3, Maddahi Saeede4,
Hatami Marandi Pouya5, Pourfathi Hojjat6

ABSTRACT anaesthesia was induced in lateral decubitus position (study

Introduction: Hypotension is common after spinal anaesthesia group; n=38) or sitting position (control group; n=38). Maternal
during caesarean section (c/s). Methods for prevention of haemodynamic, block characteristic, side effects, and neonate
hypotension are mechanical approaches such as leg rise, Apgar scores were recorded. Data were analysed using SPSS
compression stocks and positioning. On the other hand, mother version 16.0 software and student's t-test, Chi-square test, and
position may have an effect on haemodynamic variables due to Mann Whitney U test were used for statistical analysis.
speed of onset of sensory block. Position during induction has Results: Incidence of hypotension (50% vs 76.3%; p=0.016),
maternal and foetal importance. bradycardia (0% vs 21.1%; p=0.014) and vasopressors
Aim: To compare the maternal haemodynamic variables after consumption (36.2% vs 76.3%; p=0.012) were statistically lower
spinal anaesthesia in sitting or lateral decubitus position in patients in lateral position. There was no significant differences in sensory
undergoing c/s. height (p=0.89) and duration of sensory and motor block between
two groups (p=0.42, p=0.29; respectively).
Materials and Methods: In this prospective, randomised and
double-blinded clinical trial, 76 healthy parturient, undergoing Conclusion: The changes in maternal haemodynamic were
c/s, were allocated in two groups. The study was conducted from significantly lower in lateral position than sitting position in patients
September 2014 to August 2015 at Al-Zahra Hospital. Spinal undergoing spinal anaesthesia for c/s.

Keywords: Block, Complication, Lateral position, Sitting position

Introduction Anaesthesiologists (ASA) І- П (it means, participants in this study

Hypotension is a common complication of neuraxial anaesthesia in were healthy or with mildly systemic disease) [9], aged 18-40 years
obstetric patients [1]. Prophylactic routes have been suggested to and term pregnancy undergoing elective c/s with spinal anaesthesia.
reduce the incidence and severity of hypotension which includes Exclusion criteria was pre-eclampsia, cardiovascular, respiratory,
fluid loading, left lateral uterine displacement, leg elevation, use of hepatic or renal problems, known allergy to local anaesthetics,
low dose local anaesthetics and the use of vasopressors. However, contraindication for spinal anaesthesia and psychological disorder.
incidence of hypotension under spinal anaesthesia for c/s is The sample size was selected based on data driven from previous
common [1-4]. study [10]. We determined that an effective sample size (n=76),
would be required for the current study to provide statistical power
Spinal technique can be induced with patient in either the sitting of 80% to detect a 15% difference of incidence of hypotension
or lateral decubitus position. Spread of local anaesthetic solution between two groups.
in Cerebrospinal Fluid (CSF) depends on patient posture [5]. This
In operation theatre, routine standard monitoring with Non-Invasive
may have an impact on the incidence and severity of hypotension
Arterial Pressure (NIBP), Electrocardiography (ECG), and pulse-
after intrathecal injection of the local anaesthetic [1]. Studies have
oximetry was established. Base line values were recorded. Each
shown that the patient’s position in the incidence of hypotension
patient was preloaded with 8-10 mL/kg of Ringer solution over
after spinal anaesthesia for c/s maybe effective [6-8]. Whether the
15 minutes before induction of spinal anaesthesia. Parturient was
use of the lateral or the sitting position is best for routine initiation of
allocated by box randomisation by sealed envelope, to one of the
neuraxial anaesthesia for c/s is controversial [1].
two groups, for positioning during induction of spinal puncture
The current study aimed to compare the maternal haemodynamic [Table/Fig-1]. Spinal puncture was performed with the parturient
effects associated with sitting or lateral decubitus positions during either in sitting (control group, n=38) or in left lateral decubitus
induction of spinal anaesthesia for elective c/s. position (study group, n=38).
A 25-gauge Quinke needle (B-BRAUN Melsungen AG 34209
MATERIALS AND METHODS
After the Medical Ethics Committee approval (With ethical no: Germany) was used, through which 2 mL 0.5% hyperbaric
92137N8 with IRCT no: 201402017013 N8) and written consent Bupivacaine and 15 µg Fentanyl was administered for over 10
obtained from participants, 76 healthy pregnant women undergoing second. at the L3-4 or L4-5 level in the subarachnoid space.
c/s were enrolled in this prospective, randomised, and double- Following spinal injection, without delay, the parturient was smoothly
blind clinical trial from September 2014 to August 2015 in Al-Zahra and gradually laid supine with a wedge under right hip.
Hospital. Patients were selected by simple randomisation method. After spinal-anaesthetic injection, oxygen 4 to 6 L/minutes was
The inclusion criteria were physical status, American Society of delivered by nasal cannula, until delivery of baby. Level of sensory
Journal of Clinical and Diagnostic Research. 2018 Feb, Vol-12(2): UC05-UC08 5
 Atashkhoei Simin et al., Position Effect on Spinal Anesthesia www.jcdr.net

Lateral group Sitting group

Variables p-value
(n=38) (n=38)
Upper sensory block
T5 (T3-T6) T5 (T3-T6) 0.89
(dermatome)
Sensory block level>T4 18 (47.36) 16 (42.10) 0.91
Sustained hypotension 1 (2.6) 8 (21.1) 0.014
Nausea-Vomiting (%) 0 (0) 3 (7.9) 0.12
Unconsciousness (%) 0 (0.0) 0 (0.0) 1.00
Respiratory depression
1 (2.6) 4 (10.5) 0.18
(%)
SPO2<90% (%) 1 (2.6) 2 (5.3) 0.50
Total IV fluid (mL) 2590.79±265.55 2602.63±323.19 0.25

[Table/Fig-1]: Flow chart of patients enrolled to the study. Duration of sensory

65.71±5.02 72.74±5.8 0.42
block (min)
block by the anaesthesiologist performing the block using pin-prick Duration of motor block
74.76±6.60 81.29±5.40 0.29
sensation every two minute after the spinal injection was assessed. (minute)
An upper level of T4 was considered adequate for surgery. [Table/Fig-3]: Obstetric and anaesthesia variables in two study groups.
Data were presented as mean (SD), median (range) and number (%).
Every two minute after the spinal injection until neonate delivery,
assessments were made for haemodynamic parameters {Heart
Lateral group Sitting group
Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure Variables p-value
(n=38) (n=38)
(DBP), and Mean Arterial Pressures (MAP)}. Decrease in SBP>
Baseline haemodynamic data
25% of the baseline levels, was treated by incremental doses IV
ephedrine 5 mg or phenylephrine 50 µg. Vasopressor requirements SBP (mmHg) 126.50±7.21 123.97±12.03 0.09

and timing of injection, total amount of fluids administered, incidence DBP (mmHg) 79.89±8.69 77.66±11.53 0.22
of peri-operative nausea and vomiting, and neonatal Apgar MAP (mmHg) 94.18±9.11 91.87±11.79 0.34
scores at 1 and 5 minute were recorded. We had no access to HR (bmp/min) 95.66±13.81 99.18±17.93 0.10
bedside echocardiography and cardiologist, so, we cannot assess
SPO2(%) 97.16±0.89 97.13±0.93 0.96
haemodynamic variables by this modality.
Prevalence of hypotension (%) 19(50.0) 29(76.3) 0.016
Two anaesthesiologists; first for preparing the study solutions and
management of anaesthesia, and the later with medical students Time of first hypotension (minute) 5.05±2.147 5.24±2.23 0.14

who were unaware of study group, were responsible for recording Duration of hypotension (minute) 8.63±2.73 12.21±7.18 0.002
the patient’s data. Maximum hypotension value
73.83±10.71 80.53±7.72 0.11
(mmHg)
Statistical analysis Vasopressor need (%) 14(36.20) 29(76.31) 0.012
Statistical analysis was performed using SPSS version 16.0. Data Ephedrine dose (mg) 10.52±31.10 36.84±58.9 <0.001
were analysed using student’s t-test, Chi-square test, and Mann-
Bradycardia (%) 0(0) 8(21.1) 0.014
Whitney U-test. A p-value ≤0.05 was considered to be significant.
Atropine dose (mg) 0.01±0.08 0.09±0.28 0.001

RESULTS Metoclopramide dose (mg) 0.00±0.00 0.13±0.81 0.04

There were no significant difference between two groups with Midazolam dose (mg) 0.05±0.22 0.10±0.31 0.09
respect to maternal demographic data including age, weight, height, Neonatal Apgar scores at:
gravidity, duration of surgery, and causes of c/s [Table/Fig-2]. 1 minute 9.26±0.44 8.92±0.81 0.91

Lateral group Sitting group 5 minute 10.00±0.45 9.87±0.52 0.87

Variables p-value
(n=38) (n=38) [Table/Fig-4]: Perioperative maternal variables and neonatal Apgar scores in two
Age (year) 28.68±5.85 30.84±5.52 0.70 study groups.
Data were presented as mean (SD) and number (%).
Weight (kg) 77.89±9.56 78.87±10.15 0.67
Height (cm) 159.47±3.65 159.74±3.58 0.94 There were significant changes from base value in HR after spinal
Gravidity (range) 1-5 1-6 0.85 anaesthesia at the study period in each group. Bradycardia occurred
Cause of C/S (%) 0.31
in 8 (21.1%). Patients of sitting position which required treatment
with atropine, while none of the patients in the lateral group had
CPD 8 (21.1) 5 (13.2)
bradycardia. Blood pressure was affected by the position used for
Repeat 22 (57.1) 26 (68.4) induction of spinal block. Hypotension (fall in SBP>25% of base
Elective 8 (21.1) 5 (13.2) value) occurred in 29 (76.3%) patients in group S, and 19 (50.0%)
Others 0 (0) 2 (5.3) patients in group L (p=0.016). As well as, duration of hypotension
0.53
Duration of surgery (min) 54.50±13.00 56.03±12.38 was significantly greater in group S (p=0.002). In group S, 29
[Table/Fig-2]: Demographic data in two study groups.
(76.31%) patients and in group L 14 (36.20%) patients required
Duration of surgery (minute) vasopressor ephedrine or phenylephrine or both (p=0.01).
Data was presented as mean (SD) or median (range).
CPD- Cephalopelvic Disproportion Intraoperative side effects and neonatal Apgar score was shown
in [Table/Fig-4]. There was significant differences in frequency
Sensory block variables were shown in [Table/Fig-3]. In the sitting of sustained hypotension between two groups (21.1% vs. 2.6%;
group 16 (42.10%) and lateral group 18 (47.36%) patients had p=0.014). There were no differences in other side effects among
highest sensory block >T4 level (p=0.91). The median sensory block two groups.
level were not significant in two groups (p=0.89). There were no differences in neonatal Apgar scores at one min of
Maternal haemodynamic was presented in [Table/Fig-4]. Base line delivery, but mean neonatal Apgar scores in five min was higher in
HR, SBP, DBP and MAP values were matched in both groups. lateral with p-value=0.87 that was not significant.
6 Journal of Clinical and Diagnostic Research. 2018 Feb, Vol-12(2): UC05-UC08
www.jcdr.net Atashkhoei Simin et al., Position Effect on Spinal Anesthesia

DISCUSSION system compensatory mechanisms during low spinal anaesthesia

Neuraxial anaesthesia is a safest and preferred method for c/s but than with general anaesthesia [21]. Frölich MA and Caton D revealed
it has some complications and effects on maternal haemodynamic that higher baseline HR, it means higher sympathetic tone may be
[11]. Maternal haemodynamic instability is a common event in spinal a useful parameter to predict after spinal anaesthesia hypotension
anaesthesia that can affect mother and infant status. Traditionally, [22]. In other study were showed that maternal haemodynamic
it was said that other positions has implications on resolving of this were significantly improved in the lateral positions as compared to
problem. Few studies investigated possible correlation between the sitting position with respect to maternal cardiac index stroke,
position effect and haemodynamic stability. Prophylactic routes volume index, heart rate and systolic blood pressure. They showed
such as pre-anaesthesia hydration, vasopressors or leg rise are that position has no effect on blood flow to the healthy foetus.
performed before spinal anaesthesia but had not dramatic role in Currently, these results were confirmed [23]. Mavridou I et al.,
prevention of hypotension [12]. suggested that although, maternal positioning is a routine practice,
but has not been shown to be sufficient to prevent or relieve spinal
Present study showed that the lateral position is associated with
hypotension [24].
greater haemodynamic stability, less vasoconstrictor use, lower side
effects, and better neonatal status, when compared with the sitting There was no significant difference in the incidence of maternal side
position [5]. In this study, hypotension was recorded in 63.15% of effects (nausea, vomiting, respiratory depression, and decrease in
all patients. This indicates that despite the methods of prevention, SPO2) between two groups. But consumption of metoclopramide
the complete prevention of hypotension during c/s is not possible. was greater in sitting position.
Generally, the sympathetic blockade usually results in hypotension All neonates had good Apgar scores at 1 and 5 minute after delivery.
whether the patient in the sitting or the lateral position [6,7]. Previous This may be explained by the fact that only healthy women were
studies have shown that the prevalence and severity of hypotension scheduled in this study. Mean Apgar score at 5 min was better in the
is associated with the height of block, such as Carpenter RL et al., study group. This may be due to placental flow and gas exchange
and Morgan P et al., study [13,14]. maintain more effectively in lateral position compared to the sitting
In this study, we didn't demonstrate any difference in height of position. We did not obtain umbilical cord PH, because it is practice
sensory block after spinal anaesthesia between two groups. This at our hospital to obtain these only when the Apgar score is ≤ 7 at
finding was contrary to study of Coppejans et al., which reported a 1 or 5 min.
greater number of patients in lateral decubitus had a higher sensory
block level than patients in sitting position. He also concluded that LIMITATION
performing a CSE technique for caesarean delivery in the sitting Mother’s body mass index has possible effects on haemodynamic
position was technically easier and induced less severe hypotension, as higher chances of induced hypotension and other comorbid
females in the sitting postion required less ephedrine (p=0.012) but disease that affected studied variables [22], were not considered
in the lateral group, blocks extended more cephalad than with the in our study. We had no access to Doppler ultrasonography or
sitting position (p=0.014) [7]. bedside echocardiography.
Haemodynamic instability could be due to the vasovagal episode that
might occur with a great frequency or severity in the sitting position CONCLUSION
and additional gravity dependent peripheral pooling may result in Results of present study revealed that changes in maternal
decrease in cardiac output, orthostatic hypotension and uterine haemodynamic, side effects, and use of vasopressors were lower
blood flow in sitting position [8]. Also, it could be related to slower when spinal anaesthesia induced in lateral position. In addition,
recovery from sympathectomy induced venous pooling in the lower neonatal Apgar scores were improved in this position. These
results were parallel with previous studies which confirmed effect
extremities on assuming supine position vs. the sitting position [15].
of supine versus position on speed of onset of block sensory and
Thus, the use of vasoconstrictors was more in sitting position, its implications on maternal haemodynamic. However, it is clear
because the duration of hypotension was longer in the sitting that sever hypotension has important effects on maternal and fetus
position. outcomes and by prevention of hypotension, we can reduce them.
Episodes of bradycardia requiring treatment were more in sitting
position. Jackson N and Peterson Brown S, stated that vasovagal Acknowledgements
reflexes are not rare in regional anaesthesia and their rate is up to We would like to thank Research Vice Chancellor of Tabriz University
90% [16]. These findings were almost similar to what has been of Medical Sciences for financial support and department of
reported previously. In Yun EM et al., study, maternal HR rate and Anaesthesiology Research Council for their co-operation.
SPO2 at the start of the study were 102±15 bpm and 100%±0.5%,
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PARTICULARS OF CONTRIBUTORS:
1. Professor, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran.
2. Assistant Professor, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran.
3. Resident, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran.
4. Medical Student, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran.
5. Medical Student, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran.
6. Assistant Professor, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Pourfathi Hojjat,
Assistant Professor, Department of Anaesthesiology, Tabriz University of Medical Sciences, Iran. Date of Submission: Feb 20, 2017
E-mail: hojjatpourfathi@yahoo.com Date of Peer Review: Mar 27, 2017
Date of Acceptance: Oct 07, 2017
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Feb 01, 2018

8 Journal of Clinical and Diagnostic Research. 2018 Feb, Vol-12(2): UC05-UC08