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Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study.

Algert CS, Bowen JR, Giles WB, Knoblanche GE, Lain SJ, Roberts CL - BMC Med (2009)

Bottom Line: Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4).The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.

View Article: PubMed Central - HTML - PubMed

Affiliation: Kolling Institute of Medical Research, Clinical and Perinatal Population Health Research, University of Sydney, Australia. calgert@med.usyd.edu.au

ABSTRACT

Background: Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections.

Methods: Cohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (N = 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.

Results: The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.

Conclusion: The infants most affected by general anaesthesia were those already compromised in utero, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.

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Related in: MedlinePlus

Risk differences for neonatal outcomes, for caesarean section under general anaesthesia compared with regional block, by caesarean section indication and hospital level.
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Figure 1: Risk differences for neonatal outcomes, for caesarean section under general anaesthesia compared with regional block, by caesarean section indication and hospital level.

Mentions: Figure 1 shows the risk differences for resuscitation with intubation and for an Apgar5 <7 for each CS indication group, by hospital category. For all of the CS indications and across all of the hospital levels, the results favoured regional block over GA. The planned repeat CS group showed no variation by hospital level in difference in intubation rates (heterogeneity I2 = 0%), but there was strong heterogeneity for the Apgar5 score (I2 = 75%). This was influenced by private hospitals, which had both the lowest rate of Apgar5 <7 scores after GA (1.4%) and the highest rate after regional block (0.2%), resulting in the smallest risk difference (1.2 extra Apgar5 <7 scores per 100 deliveries under GA). For the failure to progress group, there was strong heterogeneity in the risk differences for intubation (I2 = 82%) and the Apgar5 outcome (I2 = 52%). The heterogeneity was driven by the relatively high rate of intubation (5.4%) and Apgar5 <7 (5.4%) in large public hospitals after GA, whereas other public and private hospitals had intubation rates of <2.5% after GA. For the foetal distress indication group, there was strong heterogeneity in the risk differences for intubation (I2 = 72%) and weak heterogeneity for the Apgar5 outcome (I2 = 7%). This was mainly due to the relatively low rates of intubation (3.9%) and Apgar5 <7 (5.7%) in private hospitals after GA for this group.


Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study.

Algert CS, Bowen JR, Giles WB, Knoblanche GE, Lain SJ, Roberts CL - BMC Med (2009)

Risk differences for neonatal outcomes, for caesarean section under general anaesthesia compared with regional block, by caesarean section indication and hospital level.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2683867&req=5

Figure 1: Risk differences for neonatal outcomes, for caesarean section under general anaesthesia compared with regional block, by caesarean section indication and hospital level.
Mentions: Figure 1 shows the risk differences for resuscitation with intubation and for an Apgar5 <7 for each CS indication group, by hospital category. For all of the CS indications and across all of the hospital levels, the results favoured regional block over GA. The planned repeat CS group showed no variation by hospital level in difference in intubation rates (heterogeneity I2 = 0%), but there was strong heterogeneity for the Apgar5 score (I2 = 75%). This was influenced by private hospitals, which had both the lowest rate of Apgar5 <7 scores after GA (1.4%) and the highest rate after regional block (0.2%), resulting in the smallest risk difference (1.2 extra Apgar5 <7 scores per 100 deliveries under GA). For the failure to progress group, there was strong heterogeneity in the risk differences for intubation (I2 = 82%) and the Apgar5 outcome (I2 = 52%). The heterogeneity was driven by the relatively high rate of intubation (5.4%) and Apgar5 <7 (5.4%) in large public hospitals after GA, whereas other public and private hospitals had intubation rates of <2.5% after GA. For the foetal distress indication group, there was strong heterogeneity in the risk differences for intubation (I2 = 72%) and weak heterogeneity for the Apgar5 outcome (I2 = 7%). This was mainly due to the relatively low rates of intubation (3.9%) and Apgar5 <7 (5.7%) in private hospitals after GA for this group.

Bottom Line: Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4).The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.

View Article: PubMed Central - HTML - PubMed

Affiliation: Kolling Institute of Medical Research, Clinical and Perinatal Population Health Research, University of Sydney, Australia. calgert@med.usyd.edu.au

ABSTRACT

Background: Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections.

Methods: Cohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (N = 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.

Results: The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.

Conclusion: The infants most affected by general anaesthesia were those already compromised in utero, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.

Show MeSH
Related in: MedlinePlus