Effects of maternal supplementary oxygen on the newborn for elective cesarean deliveries under spinal anesthesia. Comparison of neonatal effects of epidural and general anesthesia for cesarean section. Comparison of general and regional anesthesia for cesarean section: success rate, blood loss and satisfaction from a randomized trial. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Amnioinfusion for relief of recurrent severe and moderate variable decelerations in labor. Anaesthetic technique for elective caesarean section and neurobehavioural status of newborns. Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study. Randomized trial of amniotomy in labour versus the intention to leave membranes intact until the second stage. Randomized trial of prophylactic antibiotic therapy after preterm amnion rupture. Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. Biophysical profile with amniotic fluid volume assessments. Neonatal status in cesarean section under epidural anesthesia with supplementary oxygen. A comparison of intrapartum automated fetal electrocardiography and conventional cardiotocography--a randomised controlled study. Comparison of the modified biophysical profile to a "new" biophysical profile incorporating the middle cerebral artery to umbilical artery velocity flow systolic/diastolic ratio. Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions. [The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs].
The aim of this investigation was to determine whether supplementary oxygen provided by either nasal cannula or face mask versus room air might affect fetal oxygenation during elective cesarean section under spinal anesthesia by assessing maternal and neonatal regional cerebral oxygenation (rSO(2)) with a cerebral oximeter.
                Ninety parturients were randomly allocated into three groups: two groups received 5 L/min oxygen by either nasal cannula (Group NC, n = 30) or face mask (Group FM, n = 30), respectively, and the third group was allowed to breathe room air (Group RA, n = 30). After maternal mean arterial pressure, heart rate and peripheral oxygen saturation had been monitored, rSO(2) was determined by cerebral oximeter. Umbilical artery (UA) and venous (UV) blood samples were collected for blood gas analysis. Neonatal rSO(2) and Apgar scores were recorded.
                The mean maternal rSO(2) which was recorded 3 and 5 min after administration of the spinal block in Group FM was lower than that of Group NC (p = 0.033 and 0.042, respectively). Neonatal rSO(2), UA pH, UV pH and UA base excess (BE) were lower in Group FM than in the other groups (p < 0.05). The Apgar score (1 min) in Group FM was lower than that of Group RA (p = 0.046).
                The effect of maternal supplementary oxygen on the newborn has been demonstrated by a cerebral oximeter monitor and supported by umbilical cord blood gas analysis and Apgar scores. We assessed the influence of anesthetic technique for cesarean section on neonatal outcome. Thirty parturient women (ASA I/II) were randomly allocated into two groups. In Group GA general anesthesia was induced with 4 mg.kg(-1) thiopental and 1.5 mg.kg(-1) succinylcholine. In group EA epidural anesthesia was performed with 20 ml 0.375% bupivacaine through L(3-4) inter-space. 1-min Apgar scores were significantly higher in group EA (p < 0.001). Neurologic and Adaptive Capacity scores at 2 and 24 h were higher in group EA (p < 0.001). In terms of blood gas values, umbilical arterial pH and pO(2) values were higher in group EA (p < 0.05 and p < 0.001, respectively). The first breast-feeding intervals were found to be shorter in group EA (p < 0.001). We conclude that in terms of better Apgar and NAC scores, acid-base status and earlier initiation of breast-feeding, the epidural anesthesia may be preferred to general anesthesia in cesarean section.
                Copyright 2003 S. Karger AG, Basel A prospective randomized trial was organized to compare the effectiveness of general and regional anesthesia for cesarean section (C/S).
                Three hundred and forty-one patients were randomized into the general anesthesia group (GA), epidural anesthesia group (EA) and spinal anesthesia group (SA). The effectiveness of interest was success rate, blood loss and patient satisfaction.
                We found that the success rates of EA and SA were lower than GA. Success in EA should be improved by using an epidural catheter to add more local anesthetic drug instead of a single shot; and the surgeon should allow more time for the block to work adequately. Success in SA should be improved by using bupivacaine instead of lidocaine. GA resulted in significantly more blood loss, lower postoperative hematocrit, and higher proportion of patients who had postoperative hematocrit < 30 per cent than EA and SA. The patients' satisfaction scores were not different among the 3 techniques. This meant that, given adequate explanation and perioperative care, Thai women were satisfied with regional anesthesia.
                Regional anesthesia is a better choice of anesthesia for C/S than general anesthesia. However, the availability of different techniques and ability to change the technique when needed were very useful and important. If GA is chosen, all safety procedures must be followed. Oxygen supplement and endotracheal intubation facilities must be available in all techniques. Guidelines of anesthesia for C/S at a national level should be agreed upon, including the type of personnel, monitoring equipment and postoperative care. There are no randomized studies on neonatal outcome after spinal versus general anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. This study examined both markers of neonatal hypoxia and maternal hemodynamics.
                Seventy patients were randomized to general (n = 35) or spinal anesthesia (n = 35). The general anesthesia group received thiopentone, magnesium sulfate, and suxamethonium intravenously before intubation, followed by 50% nitrous oxide in oxygen, 0.75-1.5% isoflurane, and morphine after delivery. The target end-tidal partial pressure of carbon dioxide (Pco2) was 30-34 mmHg. The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine plus 10 microg fentanyl at the L3-L4 interspace. Heart rate and blood pressure were measured at specific time points. Hypotension was treated with ephedrine. Maternal arterial and neonatal umbilical arterial blood gas samples were taken at delivery. Resuscitation requirements were recorded.
                In both groups, hemodynamic measures remained within acceptable limits. Spinal anesthesia patients required more ephedrine (13.7 vs. 2.7 mg). Maternal Paco2 was lower in the spinal group (28.9 vs. 32.4 mmHg). One-minute Apgar scores were lower after general anesthesia. Base deficit was greater (7.13 vs. 4.68 mEq/l) and neonatal umbilical arterial pH was lower (7.20 vs. 7.23) after spinal anesthesia. Post hoc analysis showed that if maternal diastolic blood pressure on admission was greater than 110 mmHg, neonatal umbilical arterial base deficit was greater after spinal anesthesia. There was no difference in the number of patients with Apgar scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in the requirements for resuscitation.
                In preeclamptic patients with a nonreassuring fetal heart trace, spinal anesthesia for cesarean delivery was associated with a greater mean neonatal umbilical arterial base deficit and a lower median umbilical arterial pH. The clinical significance remains to be established. Maternal hemodynamics were similar and acceptable with either anesthetic technique. To determine whether intrapartum amnioinfusion (AI) relieves recurrent moderate and severe variable decelerations in laboring women with clear or grade I meconium-stained amniotic fluid and reduces cesarean section rate for fetal distress.
                A randomized controlled trial was conducted in labor unit of Christian Medical College Hospital, Vellore, India, between October 2003 and September 2004. Women were randomized to receive AI (group I) and not to receive it (group II).
                A total of 150 women (75 in each group) were included in the study. There was significant relief of variable decelerations in group I and no difference in overall cesarean section rate but significant reduction in cesarean section rate for fetal distress in group I, and significant reduction in cesarean section rate for fetal distress in nulliparous women of group I. Neonatal acidemia was also significantly reduced in the nulliparous women receiving AI. The duration of maternal postpartum hospital stay was significantly reduced in group I. There were no adverse maternal or neonatal outcomes.
                AI was a beneficial therapeutic intervention in women patients showing fetal distress in first stage of labor, and it reduced cesarean section for fetal distress and neonatal acidemia. 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. To compare general and spinal anesthesia with respect to the short-term outcome of newborns born by elective cesarean deliveries.
                Pregnant women admitted to our hospital from January 1999 to July 2000, for whom elective repeat cesareans were planned after 37 weeks gestation, were allocated randomly after their informed consent to spinal anesthesia or general anesthesia. Maternal age, gestational age, birth weight, Apgar's score, hospital stay duration, and duration of cesarean section time were all noted. The rate of the neonatal respiratory depression, perinatal asphyxia, and admittance to the neonatal intensive care unit of the infants were documented. We also studied arterial samples withdrawn from the cord for the pH, bicarbonate, PaO(2) (oxygen pressure, arterial), and PaCO(2) (carbon dioxide pressure, arterial). The serum levels of creatine kinase with myocardial-specific isoform, aspartate aminotransferase, alanine aminotransferase, and total cortisol levels of the newborns were measured and served in ruling out perinatal stress and in confirming the diagnosis of perinatal asphyxia (and of myocardial damage). Statistical analyses was performed with the use of an unpaired Student's t-test, Chi-square test, and a power calculation was done.
                From the randomly selected patients, we had 38 (45.2%) infants for general anesthesia and 46 (54.8%) for spinal anesthesia. None of our primary endpoints favored any of the study groups, and the clinical short-term outcome of the infants was similar in the neonates born both by spinal and general anesthesia (P>0.05). The biochemical assays did not rule out or confirm any differences in the occurrence of perinatal stress (P>0.05).
                Anesthesia type does not seem to influence the short-term outcome of the newborn infants for the elective cesarean deliveries. We believe that both spinal and general anesthesia could be performed in elective term cesarean deliveries without any risk to the newborn infants. To compare by randomized prospective clinical trial the outcome of labours which are managed with the intention to leave the membranes intact, compared with the practice of elective artificial rupture of the membranes (ARM) in early established labour.
                Prospective randomized controlled trial of low risk women admitted in spontaneous labour, with intact membranes.
                The labour ward of St. James's University Hospital, Leeds, UK.
                362 women in spontaneous labour with intact membranes and no evidence of fetal distress, between 37 and 42 weeks gestation. During the course of the trial it was found that some randomization cards could not be accounted for and a system of daily checks was instituted. The results were analysed for all recorded women (n = 362) and after institution of the more rigorous system (n = 120).
                The duration of each phase of labour, epidural rate, prevalence of an abnormal cardiotocograph (CTG) (assessed blind), method of delivery and neonatal outcome.
                178 of the 183 women (97%) in the ARM group had their membranes ruptured in early labour, and 83 (46%) of the 179 women allocated to non-intervention had ARM performed at some stage. A significant decrease in the duration of labour (mean 8.3, SD 4.1 h vs mean 9.7, SD 4.8 h, n = 156; P = 0.05) was found amongst primigravidae allocated to ARM when compared with non intervention. The duration of the second stage of labour was unaffected. In the ARM group the epidural rate was higher and labour was more often complicated by CTG abnormalities. There were no differences in the method of delivery, fetal condition at birth (cord blood lactate, Apgar score) or postpartum pyrexia between the ARM and non-intervention groups. The same trends were observed when analysis was confined to women entered into the trial after the system of rigour was instituted.
                Routine ARM results in labour that is slightly shorter than if the membranes are allowed to rupture spontaneously but more epidurals are used suggesting that labour is more painful. There are fewer fetal heart rate abnormalities if the membranes are left intact but amniotomy has no effect on fetal condition at birth. Our purpose was to determine whether maternal administration of prophylactic ampicillin or erythromycin after preterm amnion rupture is associated with maternal or neonatal benefits.
                Women with singleton pregnancies between 24 and 33 weeks 6 days of gestation were eligible if they had no immediate indication for delivery. After giving informed consent, patients were randomized either to receive ampicillin (erythromycin if penicillin allergic) until delivery or to enter a control group. Women whose cervical cultures were positive for either group B streptococci or Neisseria gonorrhoeae received treatment. Tocolytics and corticosteroids were not used.
                From January 1990 to February 1992 117 patients (antibiotics 59, control 58) were recruited and analyzed. Prophylactic antibiotics were associated with a longer latent phase (mean 12 vs 7.0 days, p = 0.004) and fewer maternal infectious complications (29% vs 60%, p = 0.001). A higher incidence of neonatal necrotizing enterocolitis was observed in the treatment group (14% vs 3.5%, p = 0.05). Other neonatal complications, including death, were lower in the treatment group, but none attained statistical significance (p = 0.09 to 0.33).
                The use of prophylactic antibiotics in selected patients after preterm amnion rupture appears to have a demonstrable maternal benefit. Large, multicenter trials may demonstrate a significant neonatal benefit or confirm any adverse outcomes. Umbilical cord infection (omphalitis) is a risk factor for neonatal sepsis and mortality in low-resource settings where home deliveries are common. We aimed to assess the effect of umbilical-cord cleansing with 4% chlorhexidine (CHX) solution, with or without handwashing with antiseptic soap, on the incidence of omphalitis and neonatal mortality.
                We did a two-by-two factorial, cluster-randomised trial in Dadu, a rural area of Sindh province, Pakistan. Clusters were defined as the population covered by a functional traditional birth attendant (TBA), and were randomly allocated to one of four groups (groups A to D) with a computer-generated random number sequence. Implementation and data collection teams were masked to allocation. Liveborn infants delivered by participating TBAs who received birth kits were eligible for enrolment in the study. One intervention comprised birth kits containing 4% CHX solution for application to the cord at birth by TBAs and once daily by family members for up to 14 days along with soap and educational messages promoting handwashing. One intervention was CHX solution only and another was handwashing only. Standard dry cord care was promoted in the control group. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. The trial is registered with ClinicalTrials.gov, number NCT00682006.
                187 clusters were randomly allocated to one of the four study groups. Of 9741 newborn babies delivered by participating TBAs, factorial analysis indicated a reduction in risk of omphalitis with CHX application (risk ratio [RR]=0·58, 95% CI 0·41-0·82; p=0·002) but no evidence of an effect of handwashing (RR=0·83, 0·61-1·13; p=0·24). We recorded strong evidence of a reduction in neonatal mortality in neonates who received CHX cleansing (RR=0·62, 95 % CI 0·45-0·85; p=0·003) but no evidence of an effect of handwashing promotion on neonatal mortality (RR=1·08, 0·79-1·48; p=0·62). We recorded no serious adverse events.
                Application of 4% CHX to the umbilical cord was effective in reducing the risk of omphalitis and neonatal mortality in rural Pakistan. Provision of CHX in birth kits might be a useful strategy for the prevention of neonatal mortality in high-mortality settings.
                The United States Agency for International Development.
                Copyright Â© 2012 Elsevier Ltd. All rights reserved. To compare the amniotic fluid index (AFI) with the single deepest pocket technique along with the other components of the biophysical profile (BPP) in predicting an adverse pregnancy outcome.
                Prospective, randomized trial of amniotic fluid assessment by AFI or single deepest pocket during a BPP. Cesarean delivery for fetal distress was the primary outcome evaluated.
                The AFI was used in 273 pregnancies and the single deepest pocket in 264. The AFI significantly increased the number of pregnancies labeled as oligohydramnios, 102 women (38%) compared with 46 women (17%; P <.001), odds ratio (OR) = 2.84, 95% confidence interval 1.90-4.25 in the single deepest pocket group. There was no difference in the number of women with oligohydramnios in the AFI group, 16 of 102 (16%), undergoing a cesarean delivery for fetal intolerance of labor compared with the single deepest pocket group, 6 of 46 (13%; P =.676). More women with normal fluid by the AFI method (AFI > 5), 20 of 170 (12%), underwent a cesarean delivery for fetal distress than the women with normal fluid by the single deepest pocket technique (2 cm x 1 cm pocket present) group, 12 of 218 (6%; P =.037, OR = 2.22, 95% confidence interval 1.05-4.70).
                The AFI offers no advantage in detecting adverse outcomes compared with the single deepest pocket when performed with the BPP. The AFI may cause more interventions by labeling twice as many at-risk pregnancies as having oligohydramnios than with the single deepest pocket technique. Simple O2 mask has been used in patient under regional anesthesia for increasing the FiO2, especially in the aged and the pregnant. The relationships between maternal FiO2 and umbilical arterial (UA) and venous (UV) PO2, PCO2, pH, and neonatal Apgar score were studied in 45 patients receiving Cesarean section under epidural anesthesia. 2% xylocaine 18-20 ml with adrenaline 1:200,000 was used to attain the sensory level of T-4. Patients were allocated randomly into three groups. Group I, acting as a control group, breath only room air during the course of anesthesia. Group II was breathing through a simple face mask with an oxygen inflow of 6L/min. Group III was breathing oxygen with a flow rate of 10L/min through a simple face mask. UA and UV blood samples were collected separately at the time of delivery for blood gas analysis. The 1-min, and 5-min Apgar scores were recorded also. Mean values of the UA blood samples for the 3 groups (Gp. I, Gp. II and Gp. III respectively) were: PO2--16.50 mmHg, 20.20 mmHg and 19.50 mmHg; PCO2--49.20 mmHg, 48.10 mmHg and 50.3 mmHg; pH--7.31, 7.30 and 7.30. Mean values of the UV blood samples for the 3 groups (Gp. I, Gp. II and Gp. III respectively) were: PO2--28.6 mmHg, 36.9 mmHg and 36.5 mmHg; PCO2--38.20 mmHg, 38.80 mmHg and 40.40 mmHg; pH--7.36, 7.36 and 7.34. There was a significant increase in UA and UV PO2 when using a simple O2 mask (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS) To examine whether intrapartum monitoring by means of automatic ST analysis (STAN) of fetal electrocardiography could reduce the rate of neonatal acidemia and the rate of operative intervention during labour, compared with monitoring by means of cardiotocography (CTG).
                Randomised controlled trial.
                Labour ward in tertiary-level university hospital.
                A total of 1483 women in active labour with singleton term fetus in cephalic presentation.
                Women were randomly assigned to be monitored either by STAN or by CTG. Fetal blood sampling (FBS) was optional in both groups.
                Neonatal acidemia (umbilical artery pH <7.10), neonatal metabolic acidosis (umbilical artery pH <7.05 and base excess <-12 mmol/l) and operative interventions: caesarean section rate, vacuum outlet (VO) rate and FBS rate.
                There were no statistically significant differences between the STAN group and CTG group in the incidence of neonatal acidemia (5.8 versus 4.7%) or metabolic acidosis (1.7 versus 0.7%). The caesarean section rate (6.4 versus 4.7%) and the VO rate (9.5 versus 10.7%) were also similar in the STAN and CTG groups. The incidence of FBS was lower (P < 0.001) in the STAN group (7.0%) than in the CTG group (15.6%).
                Intrapartum fetal monitoring by means of automatic STAN did not improve the neonatal outcome or decrease the caesarean section rate. However, the need for FBS during labour was lower in the STAN group. The objective of this study was to determine whether the addition of the middle cerebral to umbilical artery systolic/diastolic velocity waveform ratio to the modified biophysical profile would improve perinatal outcome in patients at high risk.
                A prospective, randomized outcome study of patients referred to the perinatal laboratory for antenatal surveillance was undertaken. Six hundred sixty-five patients were randomized to two antenatal surveillance protocols: group 1, modified biophysical profile; and group 2, modified biophysical profile plus evaluation of the middle cerebral artery to umbilical artery systolic/diastolic ratio. Patients were followed up serially and neonatal outcome data including gestational age at delivery, birth weight, incidence of cesarean section delivery for fetal distress, admission to the neonatal intensive care unit, days in the neonatal intensive care unit, and the presence of significant neonatal morbidity were tabulated.
                The total population showed no statistical difference in outcome parameters between groups 1 and 2. However, a subgroup of patients evaluated for suspected uteroplacental insufficiency did show a significant reduction in caesarean section for fetal distress in group 2 patients.
                In a subgroup of patients at risk for uteroplacental insufficiency, the addition of the middle cerebral/umbilical artery ratio to an antenatal surveillance protocol should be expected to improve perinatal outcome. Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).
                Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.
                Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs: Two interventions prevent preterm births--smoking cessation and progesterone. Eight interventions prevent stillbirths--balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery. Eleven interventions improve survival of preterm newborns--prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome
                The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions. Influence of anesthetic technique on mental status in elderly patients submitted to major orthopedic procedures of lower limbs. Mental impairment is a common occurrence in elderly patients after major orthopedic surgery. Few studies have been published so far on this topic in spite of its relevant clinical and economic implications.
                1) To verify whether anesthesia has a causative role in postoperative mental confusion in elderly patients; 2) to compare the effects of General Anesthesia (GA) and Spinal Anesthesia (SA) on mental status.
                Controlled, comparative study.
                Sixty patients aged > or = 70, ASA I-II, submitted to femoral neck repair.
                Anesthesia Dept. and Orthopedic Dept. of a District Hospital in Italy.
                The day before surgery the mental status of elected patients was evaluated employing a modified Organic Brain Syndrome (OBS) scale (Gustafsson). The better the mental status, the lesser the OBS score. It was possible therefore to distinguish "oriented" from "confuse" patients (38 vs 22) if they scored < or = 6 or > 6 respectively. Patients from each group were than randomly assigned to receive either GA or selective SA. Neither group was premedicated. GA was induced with propofol 1 mg/kg and maintained with O2/N2O 40/60% and isoflurane; atracurium was employed to facilitate mioresolution. Spinal anesthesia was performed with hyperbaric 1% bupivacaine. All patients were monitored in the Recovery Room (RR) for at least one hour. Occurrence of hypotension and/or hypoxia in the Operating Room (OR) or the RR was immediately treated. Mental status was reassessed on the 1st and 2nd postoperative day and results were compared with the corresponding preoperative OBS scores both in GA patients and in SA patients.
                No statistically significant differences were found between pre- and postoperative OBS scores in both GA and SA group, whether "oriented" or "confuse".
                Mental status of elderly patients submitted to femoral neck repair doesn't seem to be influenced by the anesthetic technique chosen, independent of preoperative psychic conditions.
There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.