Regional versus general anaesthesia for caesarean section

Writer : Afolabi BB, Lesi FEA, Merah NA

Sumber :Afolabi BB, Lesi FEA, Merah NA. Regional versus general anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004350. DOI: 10.1002/14651858.CD004350.pub2.

Dipresentasikan oleh : Merie Octavia 11.2012.096 Theresia Puspita Sari 11.2012.146

Abstract
Background Regional and general anaesthesia (GA) are commonly used for caesarean section (CS) and both have advantages and disadvantages Objectives To compare the effects of regional anaesthesia (RA) with those of GA on the outcomes of CS.

Abstract
Search strategy We searched the Cochrane Pregnancy and Childbirth Groups Trials Register (30 December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 1), MEDLINE (1966 to December 2005), and EMBASE (1980 to December 2005)..

Abstract
Selection criteria Randomised and quasi-randomised controlled trials evaluating the use of RA and GA in women who had CS for any indication Data collection and analysis Two authors independently assessed trials for inclusion, data extraction and trial quality.

Abstract
Main results Although the operation has become very safe over the years, it is still associated with greater maternal mortality and morbidity (4X) Sixteen studies (1586 women) were included in this review.

PLAIN LANGUAGE SUMMARY

There were some differences which favoured general anaesthesia, for example, less nausea and vomiting There were also some differences which favoured regional anaesthesia, for example, less blood loss and less shivering.

Background
General anaesthesia refers to the loss of ability to perceive pain associated with loss of consciousness produced by intravenous or inhalation anaesthetic agents. The risks include the aspiration of stomach contents, failed intubations, and respiratory problems for both mother and baby

Background
general anaesthesia has also been associated with a greater risk of maternal blood loss compared with regional anaesthesia Spinal and epidural anaesthesia cause a substantial drop in maternal blood pressure, which may affect both mother and fetus

Background
Spinal anaesthesia has a faster onset of action and requires less of the drug, but causes more hypotensive episodes than epidural anaesthesia The advantages of regional anaesthesia include the reduction of the incidence of general anaesthetic complications and that of early bonding between the mother and the newborn, since the mother is awake during the procedure

Background
Most of the studies that report no difference are those done on women who had elective operations while those done on emergencies tend to report a positive difference in neonatal outcome with regional anaesthesia compared with general.

Criteria for considering s t u d i e s f o r t h i s r e v i ew Types of studies Randomised and quasi-randomised controlled trials. Types of participants Mothers having elective or emergency caesarean section for any indication, with the various definitions of elective and emergency taken into consideration.

Criteria for considering s t u d i e s f o r t h i s r e v i ew

Types of intervention Intervention: regional anaesthesia, whether spinal, epidural or any combination of both. Control: general anaesthesia using any combination of anaesthetic drugs and muscle relaxants.

Types of outcome measures

Maternal outcomes Neonatal outcomes

DESCRIPTIONOFSTUDIES
There are 16 trials (1586 women) in this review In 12 of the trials, the indication for caesarean section was nonurgent and the women were healthy and stable. In three of the remaining four trials, the indication for caesarean was severe preeclampsia in two, and pre-eclampsia with non-reassuring heart trace in one.

RESULTS
Maternal outcomes 1. Maternal deaths No trial reported on deaths. 2. Pre and postoperative haematocrit One study reported a significant difference which favoured epidural anaesthesia and spinal anaesthesia over general anaesthesia.

RESULTS
3. Maternal blood loss Two trials each reported on maternal blood loss and noted that significantly less blood was lost when using regional than general anesthesia 4. Wound and other infections No study reported on wound and other infections. 5. Pain. It reported that the perception of pain during the caesarean section was less when general anaesthesia was used when compared to spinal anaesthesia or epidural anaesthesia

RESULTS
However, postoperative pain is less in patients with neuraxial techniques, since the time for the first boost of analgesia is longer .

RESULTS
6. Satisfaction One study reported on satisfaction using a visual analogue score and noted that there was no difference in the level of satisfaction when general anaesthesia is compared with regional. However, when asked which form of analgesia they would prefer for subsequent procedures, one study reported that women preferred general over regional In contrast, 81% preferred neuraxial anesthesia

RESULTS
7. Adverse events Nausea and vomiting women were significantly more frequent in the regional group than general Shivering was significantly commoner in women who received general anaesthesia

RESULTS
8. Other outcomes The percentage of patients who walked during the first 24h was higher in neuraxial anesthesia patients.

RESULTS
Neonatal outcomes 1. Neonatal deaths No study reported on neonatal deaths

RESULTS
2. Umbilical artery pH when the indications for caesarean section were not urgent (seven out of the eight trials), there was no difference in the pH in babies whose mothers had received regional anaesthesia compared to general anaesthesia Two studies found the mean umbilical artery pH to be significantly lower in regional when compared to the general anaesthesia group

RESULTS
3. Umbilical vein pH The pH was significantly higher in babies whose mothers had received regional anaesthesia compared to general anaesthesia

RESULTS
4. Apgar score. They reported that scores were significantly lower among babies delivered by general anaesthesia the percentage of neonates with Apgar scores less than 7 at 1min was 25.9% for the general anesthesia group and 1.1% for the spinal anesthesia group, however, after 5min, all neonates had a score over 9.

RESULTS
5. Need for oxygen for resuscitation
no differences in the need for supplementary oxygen in neonates born with general or epidural anesthesia C-section. Another more recent trial did find differences: the percentage of neonates requiring oxygen or positive pressure ventilation during neonatal adaptation was 14 % for the general anesthesia group versus 0% for the spinal anesthesia group

RESULTS
6 Neurological adaptation scores No differences were found in the neurological adaptive capacity at 2 and 4h of newborn life from mother who underwent general or epidural anesthesia C-section.

Conclusion
From the results, regional anaesthesia (both spinal and epidural) appears to be associated with less blood loss and a higher postoperative haematocrit than general anaesthesia

Conclusion
None of the trials addressed important outcomes for women like effects on breastfeeding, effects on the mother-child relationship and length of time before mother feels well enough to care for her baby

Conclusion
Although the preferred anesthetic technique for cesarean section delivery is neuraxial anesthesia, when the indication for the procedure is under general anesthesia, there is no increased risk of maternal death or unfavorable neonatal clinical outcomes. Mortality may be more linked to the indication for cesarean section rather than with the anesthetic technique. The scale tips in favor of neuraxial anesthesia when considering variables such as post-operative pain, bleeding, and patient satisfaction

Conclusion
Nausea is more frequent in epidural anesthesia and in spinal anesthesia, while vomiting is more frequent only in the spinal anesthesia group of patients, when compared against general anesthesia. No significant difference was seen in terms of neonatal Apgar scores of six or less and of four or less at one and five minutes and need for neonatal resuscitation with oxygen

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