Comparison of Maternal and Neonatal Effects of Combined Spinal Epidural Anaesthesia in Either the Sitting or Lateral Position During Elective Cesarean Section

Effects of neuraxial anesthesia in sitting and lateral positions on maternal hemodynamics in cesarean section: A systematic review and meta-analysis

STUDY OBJECTIVE

During cesarean section, hypotension is a frequent side effect of spinal anesthesia. As a sitting or lateral position is required for spinal anesthesia performance, which of these two positions is more likely to cause intraoperative nausea, vomiting, and hypotension is still unknown. This meta-analysis compared the effects of these two positions on maternal hemodynamics and intraoperative nausea and vomiting.

DESIGN

Systematic review and meta-analysis.

SETTING

Operating room.

PATIENTS

This study included 803 patients from 12 randomized controlled trials (RCTs).

INTERVENTIONS

Neuraxial anesthesia in sitting position vs. lateral position.

MEASUREMENTS

We chose RCTs comparing the effects of spinal anesthesia in the sitting and lateral positions on maternal hemodynamics by thoroughly searching PubMed, Embase, the Cochrane Library, and the Web of Science for articles published from database inception until October 31, 2022. The Cochrane Handbook was used to assess the methodological quality of each RCT; the results were analyzed using RevMan 5.4 software; and the Egger test was used to assess publication bias.

MAIN RESULTS

12 randomised controlled trials with 803 participants were ultimately included in the final analysis. No significant differences were observed between the two positions in terms of the incidence of hypotension(RR, 0.82; 95% CI, 0.58-1.16; P = 0.26; I2 = 66%), lowest systolic blood pressure(MD, -0.81; 95% CI, -7.38-5.75; P = 0.81; I2 = 86%), the dose of ephedrine(MD, -1.19; 95% CI, -4.91-2.52; P = 0.53; I2 = 83%), and number of parturients requiring ephedrine(RR, 0.97; 95% CI, 0.64-1.46; P = 0.88; I2 = 74%). For the incidence of intraoperative nausea and vomiting, there was no statistical difference between the two positions.

CONCLUSION

Parturients undergoing elective cesarean section under spinal anesthesia in the sitting or lateral position experienced similar incidence of hypotension, and there were no significant differences between these two positions in terms of the amount of ephedrine administered or the number of patients needing ephedrine. In both positions, the frequency of nausea and vomiting was comparable. The ideal position for anesthesia can be chosen based on the preferences and individual circumstances of the parturient and anesthesiologist.

Comparison of induction of spinal anesthesia in sitting position with legs parallel and crossed for cesarean section: A randomized controlled trial

Background and Aims

The position of the patient during subarachnoid block has a role in its success. Landmarks of the spine can be easily identified in sitting position. Sitting position with legs parallel (LPSP) produces a reversal of lumbar lordosis. The crossed-leg sitting position (CLSP) is an alternative position. In this study, we compared the ease of performing subarachnoid blocks in these two positions. The objectives were to compare the attempts at subarachnoid placement, patient comfort, ease of landmark palpation, level of block, hypotension, and neonatal outcomes.

Material and Methods

This randomized trial was performed in 80 parturients posted for elective cesarean section. Parturients were assigned randomly to two groups. In group LPSP, the subarachnoid block was performed in sitting position with legs parallel and in group CLSP in the CLSP with knees and hips flexed.

Results

The percentage of parturients with a successful subarachnoid block in the first attempt was higher in the CLSP than in LPSP group (87.5% versus 55%). The remaining 12.5% parturients in the CLSP group had successful block in the second attempt. In the LPSP group, 32.5% required two attempts and 12.5% required more than two attempts. This difference was statistically significant (P-value of 0.003). The landmark was easily palpable in 92.5 versus 67.5% of parturients in CLSP and LPSP, respectively, with a P-value of 0.014.

Conclusion

CLSP is better than a sitting position with legs parallel for reducing the number of attempts and improving the ease of performing the subarachnoid block.

Influence of maternal position during combined spinal-epidural anesthesia for labor analgesia on technical difficulties and complications

PURPOSE

Generally, combined spinal-epidural anesthesia (CSEA) for labor analgesia is performed in the lateral or sitting position; however, only few studies have investigated the effect of maternal position on labor analgesia induction. We aimed to retrospectively assess the influence of maternal position on induction time and complications.

METHODS

We retrospectively analyzed anesthetic and medical records regarding labor analgesia in 201 parturients treated between January 2019 and November 2019. Patients were classified into 2 groups based on their position (sitting or lateral) during induction. The primary outcome was the time required for CSEA induction. We compared 2 groups on the primary outcome and the occurrences of other complications during CSEA induction using hyperbaric bupivacaine. Moreover, we performed multiple linear regression analysis to identify independent factors associated with induction time.

RESULTS

There was no significant between-group difference in the time required for induction. Multiple linear regression analysis revealed an independent association of the distance from the skin to the epidural space with the time required for induction. The lateral group had a significantly higher incidence of paresthesia than the sitting group (P = 0.028). The lateral group had a significantly higher ephedrine requirement (P < 0.001) than the sitting group.

CONCLUSION

Maternal position was not associated with the time required for CSEA induction. However, the sitting group had a lower paresthesia occurrence and ephedrine requirement than the lateral group. Other technical complications were not associated with maternal position during CSEA induction.

Combined spinal epidural anesthesia in obese parturients undergoing cesarean surgery : A single-blinded randomized comparison of lateral decubitus and sitting positions

BACKGROUND

There is a significant increase in number of obese pregnant women worldwide. Obese parturients undergoing cesarean section have a higher risk for hypotension and require higher doses of vasopressors following spinal anesthesia compared to nonobese parturients.

OBJECTIVE

This study aimed to compare the maternal hemodynamic changes when combined spinal-epidural anesthesia (CSEA) is induced in the left lateral decubitus and sitting positions in obese pregnant women undergoing elective cesarean section.

MATERIAL AND METHODS

In this study, pregnant women with full-term gestation diagnosed as obese undergoing elective cesarean section were included. Two groups were formed: the CSEA was performed in left lateral position in group I (n = 50) and in sitting position in group II (n = 50). At the end of the CSEA procedure, patients were placed in the supine position. When the sensory block reached at the upper level of T6 dermatome, surgery was initiated. Hemodynamic, anesthetic and neonatal parameters were recorded.

RESULTS

In all patients, CSEA was successful and sufficient anesthesia was provided for surgery. Time to reach T6 dermatome sensory level in group II was found to be longer than group I (P = 0.011). At 20 min after spinal injection, the maximum sensory block level was similar in both groups. There were no significant differences between groups in terms of sensory block time and the time to requiring postoperative supplemental analgesics. There were no significant differences in terms of the volume of intravenous fluid administered, ephedrine and atropine requirements between groups. Both groups had similar systolic blood pressure, heart rate and oxygen saturation values during surgery and postoperatively. While both groups had similar diastolic blood pressure (DBP) values during surgery and at the 1st postoperative hour, group II had lower DBP values at the 2nd postoperative hour compared with group I (P = 0.04).

CONCLUSION

Left lateral decubitus and sitting positions during performance of CSEA lead to similar maternal hemodynamic changes in obese pregnant women undergoing cesarean section.

Comparison of cross-legged sitting position with the traditional sitting position for the ease of insertion of an epidural catheter in parturient for providing labour analgesia: A randomised control trial

Background and Aims:

The patient's position during the insertion of the epidural catheter plays a major role in the success of labour analgesia. In our study, we compared the ease of insertion of the epidural catheter in either traditional sitting position (TSP) or crossed-legged sitting position (CLSP). The primary objective was to compare the number of successful first attempts at epidural placement between the groups. Secondary objective included patient comfort, ease of landmark palpation and the number of needle-bone contacts.

Methods:

The prospective non-blinded randomised control study was conducted on 50 parturient with uncomplicated pregnancy during active labour. Patients were randomly assigned into two groups using a computer-generated random sequence of numbers by closed envelope technique. Group TSP received epidural in a traditional sitting position and group CLSP received an epidural in a crossed-legged sitting position with knee and hip flexed.

Results:

The parturient in both groups were comparable with respect to the distribution of age, height, weight and parity. The baseline visual analogue score (VAS) and VAS scores at 15 min were comparable between groups. Percentage of a parturient with successful epidural placement in the first attempt was higher in CLSP group than in TSP group (88% versus 44%, P = 0.004). The landmark, needle-bone contact and comfort during positioning were comparable between the two groups.

Conclusion:

Cross-legged sitting position is a better position than the traditional sitting position for the ease of insertion of labour epidural catheter.