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ORIGINAL ARTICLE

EVALUATION OF ANAESTHESIA METHODS IN CAESAREANSECTION FOR FOETAL DISTRESS

Sri Wahjoeningsih & Widowati Witjaksono*

Department of Anaesthesiology and Reanimation, School of Medicine, Airlangga University, Dr SoetomoHospital, Jl. Prof. Dr. Moestopo no.47, Surabaya 60128, Indonesia

*Department of Restorative Dentistry,School of Dental Sciences, Universiti Sains Malaysia, Health Campus,

16150 Kubang Kerian, Kelantan, Malaysia

The purpose of this study was to evaluate the anaesthetic technique for Caesareansection which was appropriate for the clinical situation. This retrospective studywas conducted on 240 patients undergoing Caesarean section with indications offoetal distress during a 3-year period (2002-2004). The data were reviewed fromthe patient’s medical record of the Department of Anesthesiology, Dr SoetomoHospital, Surabaya. The patients were divided into three groups, according to thecriteria of foetal heart rates. The success of the anaesthesia methods was determinedby assessing the Apgar scores of the newborn baby. The results were analyse usingKruskal-Wallis and Chi-Square test. P ≤0.05 was considered as statisticallysignificant. 1- and 5-minute Apgar score of the normal range group was significantlyhigher than that of the bradycardia group (p0.05). One-and five- minute Apgar scores of the sub-arachnoid block group were significantlyhigher than those of the general anesthesia group (p

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provision of adequate gas exchange during labour,because the presence of contractions decreases gasexchange. Foetal monitoring can effectively predictand diagnose foetal asphyxia during pregnancy andlabour (3, 4).

The Apgar score continued to be is widelyused to assess newborns, although its value has beenquestioned repeatedly. The Apgar score system at 1minute and 5 minute is in common use and givesinformation about the severity and prognosis ofasphyxia. The 1-minute score correlates withsurvival, while the 5 minute score is related toneurologic outcome (1). The success of obstetricanaesthesia can be seen gauged through the baby’sApgar score.

Caesarean delivery is indicated in thepresence of foetal distress for several reasons, asfollow; failure of labour which progressed tocephalopelvic disproportion; malpresentation;deteriorating foetal status; non reassuring foetal heartrate; and maternal decompensation, haemorrhage,worsening preeclampsia/eclampsia (2).

Classification of urgency Caesarian sectionis that proposed by Lucas (5). Category 1 Caesareansections, are those where there is an immediate threatto the life of the mother or foetus, due to prolapsedcord, bleeding placenta previa, abruptions placentawith a life foetus, dire fixed foetal bradycardia andfailed vaginal delivery. This may still allow time forthe performance of regional block. An expert maybe able to perform a spinal anaesthetic or top up anepidural anaesthesia within 15 minutes, but not toestablish a new epidural anaesthetic. For category 2Caesarian sections, where there is a threat to themother or baby, but it is not immediate, there isusually time for regional block except in the mostdifficult of women. For categories 3 and 4, there areno time pressures on the choice of anaesthesia.Before the balance between technique and urgencycan be successfully managed, it is important to havea good understanding of what regional anaesthesiamust achieve.

When choosing regional or generalanaesthesia for Caesarean delivery, one must

Sri Wahjoeningsih & Widowati Witjaksono

Table 1 : The demography of foetal distress, age, pregnancy and physical status

Table 2 : Foetal distress and its causes

GroupFetal distress

Bradycardia(N=84)

Normal range(N=135)

Tachycardia(N=21)

Total

66315292530

453063

≤20 yrs21-35 yrs>35 yrs

1st

2nd

>2nd

1234

Age

Pregnancy

Physicalstatus

Group of diagnosesFoetal distress

Bradycardia(N=84)

Normal range(N=35)

Tachycardia(N=21)

Total

207

57

ToxaemiaBleedingOthers

334

98

72

12

601 3167

10103

22642744

7647111

017

4786

810

30

16183

41100

6080

1298720

4

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consider outcome of both the mother and theneonate. Maternal outcome studies have primarilyfocused on maternal mortality, and neonatal outcomestudies have focused on umbilical cord pH, Apgarscore, the need for ventilatory assistance at birth andneurobehavioral score. Regional anaesthesia is thepreferred method for caesarean section in healthywomen, however general anaesthesia is stillnecessary in selected cases. The frequency of generalanaesthesia use is depend able on many factorswhich include the percentage of parturient whoreceive epidural analgesia, the percentage of high-risk parturient, and the skills of the managinganaesthesiologist. The choice of anaesthetictechnique and the method of delivery must beappropriate to the clinical situation. If time is thelimiting factor, sometimes general anaesthesia isnecessary because it offer rapid induction, reliability,controllability, reproducibility, and avoidance ofsympathectomy-induced hypotension. Themorbidity and mortality associated with generalanaesthesia, are in relation, pulmonary aspiration ofgastric contents and difficulties with trachealintubation. This has led to a perception thatanaesthetic risk is greater with general than regionalthe anaesthesia (1, 6). The baby can be affected

directly by transplacental drug transfer or indirectlyby alteration of foetal-placental perfusion, or both.The risks of direct effects from placenta transfer aregreatest with general anaesthesia, because maternaldrug exposure is greater, but it might also occur withepidural anaesthesia, particularly when a preexistinglabour epidural catheter is topped up for caesareandelivery (1). The purpose of this study is to evaluatethe choices of anaesthetic technique for CaesareanSection in accordance with patients clinicalconditions.

Materials and Methods

This survey was a retrospective studyperformed on 240 patients having Caesarean sectionfor foetal distress undertaken in Dr SoetomoHospital at Surabaya in the period of 2002-2004 (3years). The medical record’s were reexamine andthe patients’diagnoses, the choice of anaesthesia, theASA physical status of the patients, medicalinduction, and the babys, Apgar scores wererecorded. Anaesthesia was performed by a residentanaesthetist under supervision from the anaestheticconsultant of the anaesthesiology department.Patients were divided into three groups accordingly

ANAESTHESIA METHODS ON THE CAESAREAN SECTION FOR FOETAL DISTRESS

Table 3 : Foetal distress having Apgar Score of 1 and 5 minute

Table 4 : Foetal distress and its condition in childbirth

ApgarScore Median

1 minute

5 minute

≥ Median≤ Median> Median≤ Median

≥ Median≤ Median

Bradycardia(N=84)

> Median≤ Median

5679

Normal range(N=135)

8055

417

Tachycardia(N=21)

516

0.000

Significance(P)

0.000

7

8

Fetal distress

Baby delivered

1 minute

Severe asphyxiaModerate asphyxiaVigorous babyStill birthSevere asphyxiaModerate asphyxiaVigorous babyStill birth

27263019

17562

19249113

12119

1

858044

130

5455

1292

1633

1883

5 minute

Bradycardia(N=84)

Normal range(N=135)

Tachycardia(N=21)

Fetal distressTotal

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to the criteria of the number of the foetal heart beats:The first group was bradycardia group (n =

84) whereby the foetal heart beats were less or equalto 100/min, the second group normal group ( n =135 ) was one having normal threshold of foetalirregular heart beats, it was 101 – 160/min and/oraccompanied by a divergence in the NST picture,and the third group was tachycardia group ( n = 21 )having more than 161/min of foetal heart beats. Thestatistical analyses obtained was based on theKruskal-Wallis, Chi-Square and median tests. Thedifference was considered as significant if the p valuewas 0 05.

Results

The demographical characteristics of the 240patients who underwent having Caesar an sectionas a result a diagnosis foetal distress is shown inTable 1. In 76.25% g th patients of were between 21and 35 years of age, while 17.08% of the patientswere more the of 35 years old. Patients 53.7%,physical status of ASA 1, 36.25% patients had ASA2 physical status. While 41.67% of the patients wereprimigrarid while 25.00% of the patients were intheirsecond pregnancy.

A diagnosis of foetal distress due to toxaemiacousitited 25.00% of patients while those withbleeding conotituted only 7. 08% (Table 2).

The Apgar score of 1 - 5 minutes was of grouphaving heart beats significantly higher than normalthreshold (p0.05) to tachycardi group (Table. 3).

22.50% of babies having 1 minute ApgarScore and delivered through Caesarian section ofwith fetal distress diagnose would suffer fromserious or severe asphyxia and after resucitation wasundertaken, the percentage decreased to 6.67% andonly one (1) baby (0.42%) died (Table 4).

The analyses result as seen on Table 5 shownthat 1 and 5 minute Apgar score of the group of sub-arachnoid block was significantly higher compared(p0.05)towards the Apgar score (Table 7).

The average dose of 1.0 mg/kgBB was1.17 (±0.10) mg/kg BW.

Table 5: Anaesthesia Method and 1- and-5-minute Apgar score

Table 6 : The induction agent in general anaesthesia with 1- and 5-minute Apgar score

Sri Wahjoeningsih & Widowati Witjaksono

ApgarScore

1 minute

5 minute

7

8

Median

Anaesthesia Method

> Median≤ Median> Median≤ Median

0.000

0.001

Significance(p)

4313168

106

33

GeneralAnesthesia(N=174)

Subarachnoid Block(N=66)

334323

Apgar Score

1- minute

5- minute

6

8

MedianInduction agent

> Median≤ Median> Median≤ Median

0.049

0.6 5

Significance

65585073

18

Ketamine(N=123)

Thiopental(N=51)

331833

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Discussion

The management of foetal distress is one ofthe challenging tasks for both the obstetrician andanaesthesiologist. The consequences ofunrecognized or poorly managed perinatalemergencies can be devastating, ranging fromneurologic impairment to intrauterine foetal death.Perinatal asphyxia at term remains a significantcause of infant death and development impairment.The choice of anaesthesia in these critical situationsconsist of general anaesthesia with rapid-sequenceinduction. The latest recommendation of the GermanSociety for Gynacology and Obstetrics demands 20minute time frame for decision-to-delivery time (1).

Sub arachnoid block was done on 27.5% oftotal patients having Caesarean section with thediagnosis of foetal distress, 96.96% patients of PS1 and 2 out of sub arachnoid block done. The Apgarscore at 1 minute was 50.00% above the median,while at 5 minutes was 65.15% above the median.The Apgar score at 1 minute and 5 minutes weresignificantly higher compared to those of generalanaesthesia (p Median≤ Median

The ketamine dose for induction

17482936

13

1.0 mg/kg BW(N=58)

452137

0.786

0.445

Significance(P)

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decrease incidence of maternal awareness whencompared with administration of thiopental as singleagent or combination of smaller doses of thiopentaland ketamine. Ketamine rapidly croses the placenta,and reached its peak on fetus about 1.5 to 2.0 minutesafter the induction (7, 8). In this research, it wasfound that the induction time of birth in ketamineinduction was 6.35 (±2.89) minute while that of thethiopental was 7.39 (±2,91) minute. Chestnut (5)performed an observation at the umbilical cord, theblood gases and the pH of the same Apgar scoreafter ketamine and thiopental inductions on theCaesarean section compared general anesthesia. Hefound that 1 mg/kg BW of ketamine induction forthe Caesarean section would a higher neurobehaviour scoreof the baby compared to thiopentalinduction. The results obtained in this researchsupports the view that the ketamine is the mostpowerful induction medicine in obstetric anesthesia(5).

It can be concluded from the research resultthat: 1) Subarachnoid block to the first choice ofanaesthesia for patients undergoning Caesareansection due to fetal distress, it should be done onpatients with plugsical status 1 and 2 because itproduces better Apgar score of 1 and 5 minutescompared to general anesthesia; and 2) Generalanesthesia with ketamine induction in Caesareansections due to foetal distress gives better Apgarscore of 1 minute compared to that of the thiopentalinduction.

Based on the explanation above, thesesuggestions should be recommended: 1) Manyfactors that causing foetal distress should beconsidered to determine the right way and the bestchoice of anaesthesia during Caesarian section 2)Preparation on the patients undergone Caesariansection should not be done only for the mothers butalso for the foetus covering foetal resuscitation,adequate infusign, oxygenation and setting positionto reduce pressure on vena cava inferior 3) Theproblems that can arise during general anaesthesiafor Caesarian section should be anticipated beforeintervention prevent immediately if somethinghappened 4) It needs the full cooperation ofinterdepartmental team work to manage criticalcondition in order to gain maximum result.

Corresponding Author :

Dr. Sri Wahjoeningsih MD (Uni. Surabaya, IND),MMed Anaesthesiologist (Uni. Surabaya, IND),CCU (Uni. Surabaya, IND).

Department of Anaesthesiology and Reanimation,School of Medicine, Airlangga University, DrSoetomo Hospital, Jl. Prof. Dr. Moestopo no.47,Surabaya 60128, IndonesiaTel: +62-315944487 Fax: +62-315991156Email: sri_wahjoe@fk.unair.ac.id

References

1. Birnbach DJ, Gatt SP, Datta S. Anesthesia forPresumed Fetal Jeopardy; Textbooks of ObstetricAnesthesia. Philadelphia; Churchill Livingstone. 2000.

2. James, FM, Wheeler, AS. Obstetric Anesthesia.Philadelphia; The Complicated Patient.Philadelphia;FA Davis Co. 1982.

3. Norris MC. Anesthesia for The Stressed Fetus;Obstetric Anesthesia. Philadelphia; J.B. LippincottCompany. 1993.

4. Lucas N, Yentis S, Kinsella SM, Holdcroft A, MayAE, and Wee M. New grading system for urgency ofcaesarean section. J Royal soc med 2000; 93: 346-50

5. Chesnut, DH. Obstetric Anesthesia Principles andPractice. 3rded. Philadelphia; Mosby Inc. 2004

6. Levy D. Emergency Caesarean section; best practice.[online] [Cited 2006 July 27] Available from: URL:http://www.mrashad.stores.yahoo.net/l68.html.

7. James. D. Caesarean section for fetal distress. Br MedJ 2001; 322: 1316-7.

8. Kuczkowski. KM. Anesthesia for the repeat Cesareansection in the parturient [online] [Cited 2006 July 27]Available from: URL: http:// 10.1517/” www.expertopin.com/doi/pdf/ 10.1517/14740338.5.2.251.

Sri Wahjoeningsih & Widowati Witjaksono