Influence of volume preloading on uteroplacental and fetal circulation during spinal anaesthesia for caesarean section in uncomplicated singleton pregnancies. General versus spinal anaesthesia for elective caesarean sections: effects on neonatal short-term outcome. A prospective randomised study. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Partogram action line study: a randomised trial. Uterine exteriorisation at caesarean section: influence on maternal morbidity. General anaesthesia versus epidural anaesthesia for primary caesarean section--a comparative study. A randomised, controlled study of uterine exteriorisation and repair at caesarean section. Effect of crystalloid and colloid preloading on uteroplacental and maternal haemodynamic state during spinal anaesthesia for caesarean section. Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour.
Effects of volume preloading during spinal anaesthesia for elective caesarean section on maternal blood pressure, feto-maternal circulation and fetal outcome.
                In a pilot study a randomised trial was performed in 22 healthy women with uncomplicated, singleton pregnancies at 36-40 weeks of gestation undergoing elective caesarean section under spinal anaesthesia. In the low volume group (group A) patients received 150 ml of crystalloid solution for preloading, in the high volume group (group B) they were given 15 ml/kg of crystalloid solution for preloading before the initiation of spinal anaesthesia. Maternal blood pressure was monitored intermittently. Hypotension was defined as a decrease in systolic pressure to less than 80% of the baseline value. The Doppler flow evaluation consisted of measurements from the uterine artery at the placental site, fetal umbilical artery and fetal middle cerebral artery. Pulsatility indices were derived before and after fluid preloading, and when spinal anaesthesia was established. The neonatal outcome was assessed by Apgar scores, arterial acid base status and neurologic and adaptive capacity scores (NACS).
                The incidence of maternal hypotension in both groups was 45.5% (n = 10); 3 cases occurred in group A compared to 7 cases in group B (n.s.). There was no evidence that the high dose volume is useful in preventing maternal hypotension. The pulsatility indices of uterine arteries, umbilical arteries and middle cerebral arteries were not altered. Statistical analysis showed no changes in neonatal outcome concerning umbilical arterial pH, Apgar score and NACS (n.s.) between groups A and B.
                Our preliminary results suggest that high dose crystalloid volume preloading has no preventive function in the avoidance of maternal hypotension in healthy parturients undergoing elective caesarean section under spinal anaesthesia, and shows no harmful effects on neonatal outcome as long as maternal hypotension is corrected immediately. However, the statistical significance may reflect the small sample size, and larger series are needed before changing the current management.
                Copyright 2002 S. Karger AG, Basel To compare neonatal short-term outcome in patients who underwent spinal, general anaesthesia and conversion from spinal to general anaesthesia.
                One hundred seventy-nine pregnant women undergoing elective caesarean section were allocated randomly to general (n=89) or spinal anaesthesia (n=90) and compared with 63 patients who required conversion to general anaesthesia. Umbilical cord artery pH, Apgar score as well as its individual parameter and need for assisted ventilation were evaluated.
                No differences were found in pH values (p=0.35), while the need for assisted ventilation differed significantly (p=0.001). The rate of depressed newborns was 1.1% in the spinal group, 25.9% in the general group and 12.7% in the conversion group with a significant difference for all comparisons. At 5-min, all newborns were vigorous. At 1 min, a higher score for each parameter was found in spinal group with respect to general group, while 'activity', 'grimace' and 'respiration' showed a higher score in conversion group than in general group. At 5 min, a difference was found only for 'activity'.
                All kinds of anaesthesia seem to be safe, but loco-regional blockade shows more advantages on the neonatal outcome also when a conversion is necessary. To compare the effectiveness of carbetocin and oxytocin when they are administered after caesarean section for prevention of postpartum haemorrhage (PPH).
                Double-blind randomised single centre study (1:1 ratio).
                Teaching hospital in Bristol, UK with 6000 deliveries per annum.
                Women at term undergoing elective or emergency caesarean section under regional anaesthesia, excluding women with placenta praevia, multiple gestation and placental abruption.
                Women were randomised to receive either carbetocin 100 microg or oxytocin 5 IU intravenously after the delivery of the baby. Perioperative care was otherwise normal and use of additional oxytocics was at the discretion of the operating obstetrician. Analysis was by intention to treat.
                The proportion of women in each arm of the trial that needed additional pharmacological oxytocic interventions.
                Significantly more women needed additional oxytocics in the oxytocin group (45.5% versus 33.5%, Relative risk 0.74, 95% CI 0.57-0.95). The majority of women had oxytocin infusions. There were no significant differences in the secondary outcomes, including major PPH, blood transfusions and fall in haemoglobin.
                Carbetocin is associated with a reduced use of additional oxytocics. It is unclear whether this may reduce rates of PPH and blood transfusions. To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section.
                Randomised trial, conducted from May 2004 to August 2006.
                Four maternity units in south west England, and Scotland.
                742 pregnant women with one previous lower segment caesarean section and delivery expected at >or=37 weeks. Non-English speakers were excluded.
                Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher.
                Total score on decisional conflict scale, and mode of delivery.
                Women in the information programme (adjusted difference -6.2, 95% confidence interval -8.7 to -3.7) and the decision analysis (-4.0, -6.5 to -1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups.
                Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722. For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.
                At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.
                Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).
                Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups. To assess the effect of three different partograms on caesarean section and maternal satisfaction.
                Prospective randomised clinical trial.
                Regional teaching hospital in North West of England.
                Nine hundred and twenty-eight primigravid women with uncomplicated pregnancies who presented in spontaneous labour at term.
                The women were randomised to have their progress of labour recorded on a partogram with an action line 2, 3 or 4 hours to the right of the alert line. If the progress reached the action line, a diagnosis of prolonged labour was made. Prolonged labour was managed according to the standard ward protocol.
                Primary: Caesarean section rate and maternal satisfaction; secondary: need for augmentation, duration of labour, analgesia, cord blood gas analysis, postpartum haemorrhage, number of vaginal examinations, Apgar score and admission to special care baby unit.
                Caesarean section rate was lowest when labour was managed using a partogram with a 4-hour action line. The difference between the 3- and 4-hour partograms was statistically significant (OR 1 8, 95% CI 1.1-3.2), but the difference between 2 and 4 hours was not (OR 1.4, 95% CI 0.8-2.4). The women in the 2-hour arm were more satisfied with their labour when compared to the women in the 3-hour (P < 00001) and 4-hour (P <00001) arm.
                Our data suggest that women prefer active management of labour. It is possible that partograms which favour earlier intervention are associated with higher caesarean section rate. As the evidence on which to base the choice of partograms remains inconclusive further research is required. To compare the influence on caesarean section morbidity of uterine exteriorisation or in situ repair.
                Randomised controlled trial.
                Princess Anne Maternity Unit of the Royal Bolton Hospital, UK.
                One hundred and ninety-four women undergoing delivery by caesarean section.
                Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra- and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery.
                Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturation; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra- and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation.
                No clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra- and post-operative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups.
                We have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients. Exteriorising the uterus at caesarean section is a valid option. Forty-seven healthy parturients undergoing elective Caesarean section were randomly allocated to either general anaesthesia (n = 24) or epidural anaesthesia (n = 23) under standardized anaesthetic and surgical conditions. Seven women of the epidural group required additional systemic analgesia or sedation following delivery of the neonate. Nine of 24 newborns obtained 1-min Apgar scores below 7 after general anaesthesia compared to only 3/23 after epidural anaesthesia. The time period to establish normal colour in the babies was 2.2 min after epidural and 4.9 min after general anaesthesia. Three of the 24 general-anaesthesia newborns demonstrated a tendency to hypotonia compared to only one in the epidural group. Twenty-four hours and 7 days after delivery all infants of both groups were completely normal. At the time of delivery maternal PO2 was higher in the general anaesthesia compared to the epidural group, due to higher inspired oxygen concentrations. Comparable results were obtained in umbilical PO2 venous values; lower pH values, however, were observed in the umbilical artery after general anaesthesia. There were no significant differences in the glucose levels between the groups. A significant correlation was established between uterine incision-delivery interval and 1-min neonatal Apgar scores in the general-anaesthesia group, but not in the epidural group. Our investigation did not show either the incision-delivery interval or the start of operation-delivery interval to play a role in neonatal outcome. Epidural anaesthesia is superior to general anaesthesia in Caesarean section under normal conditions with regard to neonatal outcome. Whether this is also true for critical conditions cannot be concluded from this study. To determine the surgical and anaesthetic benefits and problems associated with the practice of routine exteriorisation of the uterus to facilitate repair at caesarean section.
                A randomised controlled study of women undergoing caesarean section. After establishment of anaesthesia, women were randomised to either exteriorisation and uterine repair or suture of the uterus in the abdomen.
                A maternity hospital in the United Kingdom.
                Peri-operative haemoglobin change, duration of operation, maternal morbidity and length of hospital stay. Intra-operative pain, nausea, vomiting, pulling or tugging sensations were secondary outcome measures.
                Three hundred and sixteen women were randomised, of whom 288 were subsequently analysed (139 women in whom the uterus was exteriorised and 149 where the uterus was not exteriorised). Exteriorisation of the uterus, an elective caesarean section and a spinal or general anaesthesia each had a statistically significant association with reduced blood loss (P < 0.05). There were no statistically significant differences between the two groups with regard to intra-operative complications or pain, nor were there any statistically significant difference in post-operative wound sepsis, pyrexia, deep vein thrombosis, blood transfusion or length of hospital stay.
                With effective anaesthesia, exteriorisation of the uterus for repair following caesarean delivery is not associated with significant problems and is associated with less blood loss. We have studied the effects of crystalloid 1 litre (lactated Ringer's) or colloid 0.5 litre (hydroxyethyl starch) preloading in 26 healthy parturients undergoing elective Caesarean section under spinal anaesthesia. Maternal placental uterine artery circulation was measured using a pulsed colour Doppler technique with simultaneous measurement of maternal haemodynamics. A high incidence of maternal hypotension was observed during spinal anaesthesia in the crystalloid group (62%) but the incidence was lower in the colloid group (38%). Central venous pressure was increased significantly in both groups after preload but decreased shortly after induction of spinal anaesthesia to baseline values. The mean pulsatility index (PI) in the uterine arteries did not change during preload or spinal block. A surprising finding was the widespread variation and some high values for the uterine artery PI after spinal anaesthesia. These individual increases in PI were transient and always returned to baseline values within 2 min. These results suggest that preloading with either solution is ineffective in preventing maternal hypotension and that changes in maternal heart rate, systolic arterial pressure and central venous pressure during spinal anaesthesia were not associated with rapid individual increases in uteroplacental vascular resistance. These changes seemed not to have any major effect, however, on the clinical condition of the newborn, as assessed by Apgar scores and umbilical artery pH values. Walking after regional blockade for labour using low-dose combinations of bupivacaine and fentanyl is possible due to the maintenance of lower limb motor power. In order to investigate concerns that dorsal column function, important in maintaining balance, is impaired after such techniques, clinical assessment of lower limb proprioception and vibration sense was evaluated in parturients after either low-dose epidural (n = 30) or spinal blockade (n = 30) for labour analgesia and compared with spinal anaesthesia (n = 30) for elective Caesarean section using a larger total dose of local anaesthetic. Of the patients receiving low-dose regional labour analgesia 7% (n = 4) had abnormal dorsal column function compared with 97% (n = 29) receiving spinal anaesthesia for Caesarean section (p < 0.001). All patients in the Caesarean section group developed lower limb motor weakness, compared with only 10% (n = 6) in the low-dose groups (p < 0.001). There were no significant differences between the low-dose groups with respect to sensory block, motor block or dorsal column function. Overall, 90% of patients receiving low-dose bupivacaine/fentanyl regional labour analgesia had both normal lower limb motor power and dorsal column function. Assessment of these parameters is recommended before allowing patients to walk after low-dose regional techniques for labour.
The findings indicate that music during planned caesarean section under regional anaesthesia may improve pulse rate and birth satisfaction score. However, the magnitude of these benefits is small and the methodological quality of the one included trial is questionable. Therefore, the clinical significance of music is unclear. More research is needed to investigate the effects of music during caesarean section under regional anaesthesia on both maternal and infant outcomes, in various ethnic pregnant women, and with adequate sample sizes.