J Anaesth Clin Pharmacol 2011; 27(1): 31-34 31

Table Tilt Versus Pelvic Tilt Position for Intrauterine Resuscitation during Spinal
Anaesthesia for Caesarian Section
Shahla Haleem, Neeraj K.Singh, Shyam Bhandari, Dheeraj Sharma, S. Hussain Amir

ABSTRACT
Background: This study was undertaken to compare the effects on intrauterine resuscitation by table tilt versus pelvic tilt
position after spinal anaesthesia for Caesarian Section.
Patients & Methods: Fifty ASA I and II patients who fulfilled the eligibility criteria were enrolled in the study and were divided
into two groups: group W (Pelvic tilt with wedge under right hip and group L- (150 left lateral table tilt) and received spinal
anaesthesia. The following parameters were recorded. Heart rate (HR), mean arterial pressure (MAP) at baseline, 2mins,
5 min and then 5 min thereafter. Mean height of block, Total no. of segments blocked, Onset Time of sensory block (in
Minutes), ephedrine doses, incidence of hypotension & bradycardia, APGAR score at 1& 5 Minutes.
Results: The decrease in MAP was much more in wedged position as compared to table tilt position also the
incidence of hypotension was 40% in wedged position as compared to 12% in table tilt position. Mean height of
block, Total no. of segments blocked, and boluses of inj. ephedrine used were more in the wedged position than in table
tilt position.
Conclusion: Wedge placement caused increased incidence of hypotension and higher blockade after spinal anaesthesia
as compared to left lateral table tilt position, there was no adverse effects on foetus and patients tolerated wedge better
than left lateral table tilt position. Also surgery was easier to perform after wedge placement.

KEYWORDS: Intrauterine Resuscitation (IUR), Table Tilt & Pelvic Tilt Position, Spinal Anaesthesia, Caesarian Section

Recently the role of intrauterine resuscitation (IUR) to Decreased cardiac output secondary to vena-cava
improve O2 delivery to the placenta and umbilical blood obstruction by the gravid uterus can be prevented by lateral
flow, for reversal of foetal hypoxia and acidosis has been tilt position5. To alleviate this, conventionally, a small pillow
recognized.1 However, fewer studies have evaluated the or “wedge” is used to provide left uterine displacement of
role of IUR by maneuvers and drugs for improvement of 15 to 20 degrees. This angle can be increased as necessary
foetal wellbeing. by increasing the wedge or tilting the table. Cardiac output
Aortocaval compression is an important cause of did not significantly improved when the patient was placed
reduced foetal oxygenation. The syndrome of “Supine supine or with tilt < 15 degree.6,7 So the recommendation
hypotension” presents an enigmatic challenge to an obstetric of tilt is at least 150 or more. Crawford (1972)8, advocated
anesthesiologist. Mostly parturients don’t experience any the use of a wedge shaped cushion (10 cms of height),
symptoms, but in about 10 % of cases venous return of arbitrarily angled at 150.
heart may get seriously impaired assuming supine position1. The anaesthesiologists are actively involved in IUR
Hypotension, tachycardia, nausea, dizziness, syncope and especially during establishment of regional anaesthesia for
decreased uteroplacental perfusion2 may occur due to delivery of foetus. Therefore, we designed a randomized
aortocaval compression. prospective study to compare the role of two different
Anaesthetic drugs (vasodilating) and or techniques maternal positions (table tilt versus pelvic tilt position) on
(neuraxial) that cause sympathectomy may exacerbate the intrauterine resuscitation in pregnant patients following
impact of aortocaval compression3. These changes in blood caesarian section under spinal anaesthesia.
volume and cardiac output may become more critical for
parturients who have concomitant cardiac disease (complain PATIENTS & METHODS
of shortness of breath, palpitations, dizziness, oedema, and After obtaining approval from ethical committee we recruited
poor exercise tolerance4), may also have an impact on 50 ASA grade I / II patients who were scheduled to undergo
healthy parturients. non emergent lower segment caesarian section. Females
Drs. Shahla Haleem, Reader, Neeraj K.Singh, Ex PG student, Shyam Bhandari, PG student, Dheeraj Sharma, PG student,
S.Hussain Amir, Lecturer, J.N. Medical College, AMU, Aligarh, India
Correspondence: Dr. Shahla Haleem, E-mail: shahlahaleem@yahoo.co.in
HALEEM S, ET AL: TABLE TILST VERSUS PEVIC TILT FOR INTRAUTERINE RESUCITATION 32

of age between 20-35 yrs having a height of 145-165 cm heart rate, paired T test was used, p value < 0.05 was
and weight of 45-70 kg were included after written informed considered to be significant.
consent. Patients with diagnosed fetal distress, signs and
symptoms of labor, prematurity (<37 wks of gestation), RESULTS
multiple pregnancies, hypertension, preeclampsia, obesity, Demographic profile was comparable with respect to age,
intrauterine growth retardation (IUGR) or any other factors weight, and height in both the groups. The effect of two
contraindicating a standard spinal anesthetic technique were different positions on heart rate (HR) in the two groups
excluded from the study. All patients were randomly allocated (Group L: left sided table tilt and Group W: left sided pelvic
into two groups of 25 patients in each by computer generated tilt) were statistically similar (p>0.05) at varying time interval
numbers. (Table-2). However, significant difference in mean arterial
GROUP (W) - Pelvic tilt with wedge under right hip. blood pressure (MAP) was noted after 2 minutes of spinal
GROUP (L) - 15 0 left lateral table tilt. blockade between two groups {p= 0.035 (p<0.05)} (table-
All patients were preloaded with Ringer’s lactate 2). The decrease in MAP was much more in wedged
solution (10 ml kg -1 ) along with premedication of position as compared to table tilt position and the incidence
metoclopromide (10 mg) i.v., ranitidine (50) mg i.v., 15 mins of hypotension was 40% in wedged position as compared
prior to surgery. to 12 % in table tilt position. Hence, more doses of
Spinal anaesthesia was given at L3-4 interspace vasopressor were required to treat hypotension in group W
using 26 G Quincke’s needle. Bupivacaine heavy (12.5 mg) as compared to group L patients (table-3).
was injected over 15 sec. in subarachnoid space. Table 1
Patients were put in the position according to the group Patients’ demographic profile
assigned.
Characteristic Group W Group L P value
In group W, patients were made to lie supine with a (n=25) (n=25)
wedge beneath the right hip of the patients which was Age ( years) 25.6 ± 1.97 25.9 ± 2.08 p>0.05
made by rolling of three drape towel together, placed below Weight(Kg) 25.6 ± 1.97 25.9 ± 2.08 p>0.05
the hip, to tilt the pelvis to 150. By this way the pelvis lift at Height (cms) 155.6 ± 0.76 154.9 ± 1.2 p>0.05
right side was approximately 10 cms.
Table 2
In group L, the table was tilted to left side by 15 degrees.
Heart Rate (HR) & Mean Arterial Pressure (MAP) in 2 groups
Each complete turn of the lateral tilting screw tilted the
patient by 3.5-4 degrees. Four complete turns were required Time Variables Group W Group L P Value
to tilt the patient left laterally by 15 degrees. If the patient Baseline HR(per min) 96 102 p > 0.05
felt intimidated by the tilted position, an assistant was kept MAP(mmHg) 100.56 98.532 p > 0.05
to support the patient. At 2 minutes HR(per min) 94.4 95.6 p > 0.05
Sensory block was assessed at one minute interval by MAP(mmHg) 88.24 110.616 p=0.035
(p<0.05) At 5
using loss of sensation to touch using tooth pick. Motor
minutes HR (per min) 88.36 94.52 p > 0.05
block was assessed by modified Bromage scale (0-No MAP (mmHg) 78.36 89.476 p > 0.05
paralysis, 1-Inability to raise extended leg, 2-additional At 10 minutes HR (per min) 84.32 90.28 p > 0.05
inability to flex the knee, 3-additional inability to flex ankle). MAP (mmHg) 83.036 85.9 p > 0.05
Time of onset of sensory blockade at T10 and maximum At 15 minutes HR (per min) 84 89.32 p > 0.05
MAP (mmHg) 87.324 89.656 p > 0.05
height of dermatomal block at 15 min. or when there was
no change in three consecutive reading, were assessed. Table 3
Recordings of blood pressure were done by an automated Comparative Block characteristics & Haemodynamics

sphygmomanometer at baseline, 2 mins, 5min then every Characteristic Group W Group L P value
5 mins. At the similar time interval, pulse rate and SpO2 Mean height of block at 15min T3.72±1.27 T5.56±1.30 p<0.05
were also noted. For an intergroup difference of 10 mm Hg Total no. of segments blocked 8.16±1.34 6.44±1.29 p<0.05
with a standard deviation of 15–20 mm Hg, it was calculated (counted from T- 12)
that to obtain a power of 0.8 the 2 groups had to include Onset Time of sensory block 1.64±0.44 1.69±0.38 p>0.05
(in Minutes)
25 patients. Unpaired two-tailed Student-t-test and Chi
inj. ephedrine administered 0.48±0.65 0.12±0.33 p<0.05
Square test were used for evaluating inter group parametric (mean no. of bolus inj)
& nonparametric data respectively. For intragroup Hypotension 10 (40%) 3 (12%) P<0.05
comparison of blood pressure (SBP, DBP and MAP) and Bradycardia 1 1 p>0.05
J Anaesth Clin Pharmacol 2011; 27(1): 31-34
The final mean height of block achieved was higher in
group W (T3.72±1.27) as compared to group L (T5.56±1.30)
(p<0.05). Total numbers of segments blocked (counted from
T12) were significantly higher in group W as compared to
group L (8.16± 1.34 and 6.44±1.29 in group W and L
respectively) p value < 0.05 (Table-3). None of the patient
required any additional analgesics.
The effect of intrauterine resuscitation on neonatal well
being was assessed by APGAR Scoring at 1minutes and
5 minutes interval which was found statistically similar ( p=
0.327 and p= 0.691 at 1& 5minutes respectively (Table-4).
Table 4
Mean APGAR Score
Foetal Apgar Score Group W Group L P Value
APGAR Score at 1 Minute 7.48 + 0.58 7.32 + 0.55 p= 0.327
APGAR Score at 5 Minutes 8.88 + 0.33 8.84 + 0.37 p=0.691
DISCUSSION
The importance of supine hypotension syndrome was
understood since early days when various authors reported
cases of hypotension, syncope, palpitation and shock
occurring in the third trimester of pregnancy. In routine
obstetric practice for the sake of intrauterine resuscitation
(IUR) parturients are usually kept in the lateral position but
they have to be placed supine for caesarean section.
Therefore a need for uterine displacement device was felt.
Various devices were tried such as a 150 wedge8, inflatable
wedge9,10 and left lateral table tilt positions13,14,6 of various
angles. It was noted that initial position of the patient just
after placement of spinal block affect the maximum height
of block attained and thus degree of hypotension.11,12
In the present study the relative efficacy of two different
maneuvers were compared in a prospective randomised
manner following spinal anaesthesia. The left uterine
displacement was done by either table tilt or pelvic method
for prevention of aortocaval compression and intra uterine
resuscitation. The changes in haemodynamic parameters
and block characteristics in two different positions were
assessed and compared at varying time interval. The heart
rate was found to be similar at different time point in both
the groups. However, it was noted that in the group W,
hypotension occurred within 2 minutes of spinal anaesthesia
and 5 minutes in the lateral tilt group. Hence more number
of boluses of vasopressor were required in wedge group
(n=12) as compared to boluses in left lateral table tilt group
(n=3). The explanation for the higher block and subsequent
hypotension in the wedge group could be the increased
cephalad spread of hyperbaric bupivacaine in the wedged
group. When a wedge of nearly 10 cm height was placed
under the right hip of patients the pelvis became higher as
33
compared to shoulder, thus with gravitational drag hyperbaric
bupivacaine might have spread more cephalad in group W
as compared to group L, where pelvis was almost at the
same height as the shoulder. The increased cephalad spread
of bupivacaine was higher in the wedge group (more thoracic
dermatome was blocked) resulting in increased incidence
of hypotension requiring treatment with vasopressor. Many
investigators have also suggested an increased incidence
of hypotension in the wedge positioN.11,12
Other studies have also considered these similar end-
points for evaluating the incidence of hypotension that is,
the lowest systolic or mean arterial blood pressure recorded,
degree and/or duration of hypotension, ephedrine
supplementation, vasopressor doses, and incidence of
nausea during regional anaesthesia.11,12,13,15 However, the
definition of hypotension differed considerably among
different studies.
The incidence of bradycardia was similar in both the
groups, where 1 out of 25 patients recorded heart rate of
<50 bpm. In the present study it was noted that APGAR
scores at 1min and 5 mins after birth were similar in both
the groups (p>0.05). Despite increased incidence of
hypotension and increased inj. ephedrine usage in wedge
group, the APGAR scores were similar. Various authors
have also found no difference in APGAR scores even if
increased doses of vasopressor were used.15
It is suggested that APGAR score is not a sensitive
parameter to judge foetal effects of hypotension or
aortocaval compression as suggested by other studies where
APGAR scores failed to follow trends of foetal acidosis
following maternal hypotension intraoperatively.15 Cord blood
pH16,17 and foetal tochography would have been a better
indicator of foetal effects of aortocaval compression which
was not recorded in the present study.
In the present study it was noted that patients felt
uncomfortable in the table tilt position. Patients in table tilt
position had to be assured constantly that they will not fall
off the table. Many times an assistant was required to stand
by the patient. Other authors have also experienced similar
fear in their patients.19,6 It was noted that patient would slide
off the table when the tilt is > 28 degrees.19 In this study the
maximum table tilt was only 150, half that is needed for the
patient to slide off the table. With the use of wedge, patients
were more relaxed with no such fears of falling off.
In the group W, the surgeons were able to perform
caesarean section easily but were not comfortable and
requested shifting the table back to horizontal or at least
reducing the lateral tilt. The table tilt < 150 was found to be
inefficient in relieving the aortocaval compression.6
In conclusion we found that although wedge placement
caused increased incidence of hypotension and higher
HALEEM S, ET AL: TABLE TILST VERSUS PEVIC TILT FOR INTRAUTERINE RESUCITATION
blockade after spinal anaesthesia as compared to left lateral
table tilt position, there was no adverse effects on foetus
and patients tolerated wedge better than left lateral table tilt
position. Also surgery was easier to perform after wedge
placement than with left lateral table tilt. Still further studies
are required for evaluation of optimal dose of local
anaesthetic whenever wedge is used.
Authors Disclosure: There is no conflict of interest &
financial considerations.
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