Br. J. Anaath.

(1984), 56,1009

FETAL-NEONATAL STATUS FOLLOWING CAESAREAN SECTION FOR

FETAL DISTRESS
G. F. MARX, W. M. LUYKX AND S. COHEN

SUMMARY
Fetal biochemical and neonatal Hiniml data were compiled in 126 emergency Caesarean sections performed
for fetal distress. The choice of anaesthetic technique was determined by the wishes of the mother. General
anaesthesia was administered to 71 parturients and regional armlgnria to 55 (subarachnoid block 33, extension
of extradural block 22). The aetiologies of fetal distress and the skin incision-delivery and uterine
incision—delivery intervals were not significantly different between the two anaesthesia groups. Umbilical
artery blood pH values were higher than the last scalp capillary blood pH values in 63% of the general
anaesthesia and in 80% of the regional analgesia cases. Umbilical vein and artery blood-gas and pH data were
m'milar in the two anaesthesia groups, but 1-min Apgar scores were significantly better following regional
analgesia. Despite the presence of fetal distress, subarachnoid blockade was a most suitable method of
anaesthesia in experienced

Comparisons of the condition of neonates delivered
by elective Caesarean section under regional or gen-
eral anaesthesia have demonstrated better clinical
outcomes with regional techniques (Downing,
Houlton and Barclay, 1979; Fox et al., 1979; Datta
et al., 1981; Crawford and Davies, 1982). In a series
of 105 elective Caesarean sections in gravidae with-
out placental dysfunction, Apgar-minus-colour
scores were lower and times-to-sustained respiration
longer in the 42 infants born under general anaes-
thesia than in the 57 babies born under extradural
block (Crawford and Davies, 1982).
To our knowledge, a similar comparison has not
been undertaken in association with emergency
Caesarean section and we report our findings in 126
cases of abdominal delivery for fetal distress.
PATIENTS AND METHODS
Acute fetal distress was the reason for emergency
Caesarean section in 168 patients during 1982. The
diagnosis of fetal distress was based on persistent
severe heart rate abnormalities and a capillary blood
pH which was less than 7.20, or was decreasing
steadily. Internal fetal heart rate monitoring was
performed in all patients, scalp capillary blood pH
values were obtained in most, but both scalp capil-
lary blood pH values and umbilical vein and artery
blood biochemical data were available in only 126.
G. F. MARX, M.D.; W. M. LUYKX, M.D.; S. COHEN, M.D.;
Department of Anesthesiology, Albert Rinntrin College of
Medicine, 1300 Morris Park Avenue-J-1226, Bronx, New York
10461, U.S.A.
The results from these 126 patients form the basis of
this report. All Caesarean sections commenced
within 20 min of the last scalp capillary blood deter-
mination. The scalp samplings were performed in
the left semi-lateral position. The umbilical vein and
artery blood samples were obtained from a segment
of cord doubly clamped before the baby's first
breath. The PO2, PCO2, and pH values were deter-
mined using a Corning Model 175 Blood Gas Anal-
yzer. Apgar scores were assigned by the paediatri-
cian in attendance.
It is our practice to leave the choice of anaesthesia
for Caesarean section to the mother unless medical
or obstetric abnormalities (such as coagulopathy or
prolapsed cord) dictate otherwise. In this series,
general anaesthesia was administered to 71 women
and regional analgesia to 55. Regardless of the
method, an oral antacid was given as soon as the
decision for operation was made, and appropriate
left uterine displacement was maintained rigorous-
ly. General anaesthesia consisted of: premedication
with glycopyrrolate 0.2 mg i.v. and tubocurarine
3 mg, preoxygenation, induction of anaesthesia with
thiopentone 3.5-4.0mgkg~1 or a ketamine-
thiopentone sequence (ketamine 0.75 mgkg" 1 -
thiopentone 1.0-1.5 mgkg"1)) endotracheal
intubation with the aid of suxamethonium
100 mg and maintenance with nitrous oxide 4
litre in oxygen 6 litre until the delivery of the infant.
Thiopentone induction was used in 17 women
and a ketamine-thiopentone sequence in 54,
according to the preference of the anaesthetist in
charge. Special attention was paid to verify correct
© The Macmillan Press Ltd 1984
1010 BRITISH JOURNAL OF ANAESTHESIA

placement of the endotracheal tube before permis-
sion for skin incision was given. Awareness was
prevented by rapid deepening of the plane of anaes-
thesia including the administration of diazepam and
pethidine i.v., after cord clamping. In the regional
analgesia group, the rate of the i.v. infusion was
increased, if necessary with the help of a pressor
infusor, to achieve an acute preload of at least 800 ml
of electrolyte-containing solution. Oxygen
6 litre min"1 was administered via a transparent face
mask. Subarachnoid blockade was administered to
33 parturients in the sitting position, with a 22-
gauge needle and injection of amethocaine in dex-
trose 7 - 9 mg. Three per cent 2-chloroprocaine was
used in 22 women for extension of extradural
blockade.
Student's t test and Chi-square test were used for
the statistical analyses. The data are presented as the
mean± 1 standard deviation (SD).
RESULTS
The course of anaesthesia was uneventful in both
groups. Decreases in systolic arterial pressure in the
women under regional analgesia did not exceed
lSmmHg and did not decrease to less than
100 mm Hg, so that vasopressor treatment was not
needed.
The aetiologies of the fetal distress were similar in
the two groups (table I). Likewise, skin
incision-delivery and uterine incision-delivery in-
tervals (UDI) were not significantly different, and in
no patient did the UDI exceed 150 s (table II). The
duration from induction to skin incision ranged
from 55 to 90 (mean 67 ± 12) s in the general anaes-
thesia group, as the abdomen was cleaned and
draped before induction. In contrast, in the regional
analgesia group, the abdominal preparation was
undertaken following institution of the subarach-
noid, or extension of the extradural, blockade, and
TABLE II. Skin incision-delw*ry and uxtrxnt incmon-diUvtry
inttrvals in two anatsthtsia groups (mtan i SD)
Intervals
Skin incision Uterine incision
to delivery to delivery
Anaesthesia (ruin) (s)
7.0±2.8 68.3 ±42.7
General (n-71)
Regional (« - 55) 7.8±2.9 74.0 ±40.3
the time from injection to skin incision ranged from
4.5 to 6.0 (mean 5.3±0.52)min. There was no
correlation between any of these intervals and the
biochemical or clinical conditions of the infants at
birth.
Fetal scalp capillary blood pH ranged from 7.12
to 7.26 in the general anaesthesia group and from
7.13 to 7.26 in the regional analgesia group, with
similar mean values (table III). Umbilical artery
blood pH values were higher than the last scalp
capillary blood pH in 63% of the babies delivered
under general anaesthesia (thiopentone 65%;
ketamine-thiopentone 63%) and in 80% of those
born under regional analgesia (subarachnoid 84%;
extradural 75%). The increases or decreases in pH
values ranged from 0.01 to 0.05 units except in five
patients (three bradycardia, two late deceleration) in
which decreases ranged from 0.06 to 0.09 units.
There was no difference between the mean umbili-
cal artery blood pH values of the two anaesthesia
groups (table III). Umbilical vein and artery blood
carbon dioxide and oxygen tensions also were simi-
lar (table III). In contrast, 1-min Apgar scores were
TABLE III. Fttal biochtmical dam (mtan±SD) in two anatsthtsia
groups. SC-Scalp capillary blood; UV-umbilical vtin blood;
UA — umbilical arury blood

TABLE I. Attiology offttal distrtss in two anatsthtsia groups General Regional

General anaesth. Regional analg. Parameter (n-71) (»-55)

(n = 71)
Aetiology "(%) SCpH 7.204 ±0.053 7.198±0.043
UVpH 7 ?R#>+o nsn 7 2fi? + 0 0V1
Late decelerations 26 29 UApH 7.221 ±0.057 7.220 ±0.053
Variable decelerations 9 12
Persistent bradycardia 34 31 UVfCO2(kPa) 5.75 ±0.97 5.64±0.80
Persistent tachycardia 7 8 VAPcO2(kPa) 6.61 ±1.37 6.73 ±1.10
Acidosis 14 8
Thick meconium during UVPOi(kPa) 3.86±1.14 3.52 ±0.93
first stage of labour 10 12 UAPo 2 (kPa) 2.39±0.94 2.18±0.69
FETAL-NEONATAL STATUS AFTER CAESAREAN SECTION 1011

a significant inverse correlation has been demon-

TABLE IV. Neonatal clinical condition in two anaathtna groups
(mean ±SD).*P< 0.01 strated between maternal noradrenaline concentra-
tions and uterine blood flow (Shnider et al., 1979).
Apgar score
However, adrenaline concentrations decreased 56%
lmin 5min (P<0.01) and noradrenaline concentrations de-
clined 19% (n.s.) in 15 women in labour following
8-10 5-7 1-4 8-10 5-7 1-4 institution of lumbar extradural analgesia.
Anaesthesia (%) (%) (%) (%) (%) (%)
It was postulated that this decrease resulted either
General (n-71) 51* 29 20 85 14 l from the elimination of psychological and
Thiopentone physiological stresses associated with painful
(n-17) 42 29 29 71 29 0 uterine contractions or from denervation of the
Ketamine- adrenal medulla. "Whatever the mechanism, reduc-
thiopentone
(i.-54) 54 29 17 89 9 2 ing pain and activity of the sympathetic nervous
system should increase uterine blood flow" (Shnider
Regional (n - 55) 78* 15 7 98 2 0 et al., 1983). Moreover, in a study of 40 healthy
Subarachnoid gravidae undergoing elective Caesarean section and
(I.-33) 79 15 6 97 3 0
Eitradural(it-22) 77 9 100 0 0
10 parturients being delivered vaginally without
14
signs of intrapartum fetal distress, venous
catecholamine concentrations measured at the time
of delivery were highest in the vaginal delivery
sirniifimntiv (P<C0.01 ier in the infants deli- group and lowest in the extradural Caesarean group.
vered under regional blockade than in those born Since the 20 mothers choosing extradural analgesia
under general anaesthesia; at 5 min, the difference were clinically comparable to the 20 gravidae select-
was no longer statistically significant (table IV). ing general anaesthesia, it was concluded that the
difference in adrenaline and noradrenaline concent-
DISCUSSION rations between the two groups was a result of the
The results of our analysis have revealed two clini- "anaesthetic blockade of a great part of the sym-
cally important findings First, acid-base status pathetic nervous trunk". In the 50 infants, Apgar
improved in the majority of fetuses during the scores and umbilical arterial blood-gas data were
period of preparation, anaesthesia and surgery and, similar, but catecholamine concentrations differed
with the exception of five instances, any deteriora- markedly. They were higher after vaginal than after
tion was slight. Second, as with infants born by abdominal delivery. However, in the Caesarean
elective Caesarean section, the clinical condition of group, the type of maternal anaesthesia influenced
the neonates was significantly better following reg- sympathoadrenal activation inasmuch as the neo-
ional analgesia than following general anaesthesia. natal concentrations of both adrenaline and nor-
Although the anaesthetic method was not random- adrenaline were significantly higher in the extradur-
ized, it was chosen by the mother, not by the degree al analgesia group (Irestedt et al., 1982). This differ-
of fetal impairment, thus avoiding bias. Both the ence may result either from blunting of the adrenal
above two findings may be related to the same cause, medullary activity by general anaesthesia or from
that of plasma catecholamine concentrations in the stress associated with surgical stimulation in the
mother and newborn. Maternal circulating ad- non-anaesthetized fetus during regional analgesia.
renaline and noradrenaline concentrations are sig- Animal experiments appear to indicate that in-
nificantly higher during labour than during the last creased sympathoadrenal activity promotes neo-
trimester of pregnancy (Lederman et al., 1977), and natal adaption to extrauterine life (Lagercrantz,
the more anxious the mother, the greater is the Bistoletti and Nylund, 1981), resembling a fight-
adrenaline concentration (Lederman et al., 1978). and-flight reaction. Thus, infants born by abdominal
When parturients are fearful or in pain, uterine delivery under general anaesthesia may be at a two-
activity decreases, the occurrence of fetal heart rate fold disadvantage: they are subjected to the effects
abnormalities increases and Apgar scores tend to be of central nervous system depressant drugs and
lower (Lederman et al., 1981), most likely as a result probably also to less efficient preparation for
of the increased catecholamine concentrations pro- extrauterine life.
ducing uterine vasoconstriction. In pregnant sheep, Acidosis alters the distribution of local anaesthe-
1012
tics in the fetus because the ionized drug may remain
trapped on the fetal side of the placenta (Morishima
and Covino, 1981; Pickering, Biehl and Meatherall,
1981). We avoided this complication by using only
ester-type drugs which have no or minimal placenta!
transfer.
In contrast to the findings of Crawford and Davies
(1982), we could not establish any correlation be-
tween uterine incision-delivery interval and the
neonatal condition. All our fetal presentations were
by the vertex and none of the uterine
incision-delivery intervals exceeded 150s. Datta
and colleagues (1981) reported increased fetal
acidosis when this interval was longer than 180 s.
Frequently, fetal distress is considered a contra-
indication to subarachnoid blockade. The results of
our review appear to contradict this belief. Although
establishment of an extradural block de novo may be
too time-consuming in the presence of fetal distress,
subarachnoid blockade can be administered in
2-3 min. The occurrence of post-regional blockade
hypotension is known to be decreased in women in
labour (Clark, Thompson and Thompson, 1976). In
our patients, a preload of approximately 1 litre was
sufficient to forestall hypotension, and this amount,
in a parturient without cardiac disease, can be in-
fused safely between decision for surgery and arrival
in the operating theatre.
In conclusion, regional analgesia provides mater-
nal and fetal advantages, even in the presence of fetal
distress. Fetal blood-gas and pH data were in the
same ranges following regional analgesia and general
anaesthesia, while 1-min Apgar scores were signific-
antly better following the former. This factor is of
importance in institutions in which special person-
nel for infant resuscitation are lacking as the 1-min
score, in contrast to the 5-min score, has little prog-
nostic value, but is indicative of the resuscitative
help the baby requires. In addition, the mothers
under regional analgesia could experience and enjoy
the birth of their baby. Considering the speed with
which surgical conditions must be achieved in the
presence of fetal distress, subarachnoid blockade
emerges as a most suitable and safe method of
anaesthesia.
REFERENCES
Clark, R. B., Thompson, D. S., and Thompson, C. H. (1976).
Prevention of spinal hypotension associated with cesarean
section. Anesthesiology, 45, 670.
Crawford, J. S., and Davies, P. (1982). Status of neonatei
BRITISH JOURNAL OF ANAESTHESIA
delivered by elecive Caesarean section. Br. J. Anaetth., 54,
1015.
Datta, S., Ostheimer, G. W., Weiss, J. B., Brown, W. U., and
Alper, M. H. (1981). Neonatal effect of prolonged anesthetic
induction for cesarean section. Obsttt. Gynecol., 58, 331.
Downing, J. W., Houlton, P. C , and Barclay, A. (1979). Ex-
tradural analgesia for Caesarean section: a comparison with
general anaesthesia. Br. J. Anaesth., 51, 367.
Fox, G. S., Smith, J. B., Namba, Y., and Johnson, R. C. (1979).
Anesthesia for cesarean section: further studies. Am. J. Obtut.
Gynecol, 133, 15.
Irestedt, L., Lagercrantz, H., Hjemdahl.P., Hagnevik, K.,and
Belfrage, P. (1982). Fetal and maternal plasma catecholamine
levels at elective cesarean section m«W general and epidural
anesthesia versus vaginal delivery. Am. J. Obstet. Gynecol.,
142,1004.
Lagercrantz, H., Bistoletti, P., and Nylund, L. (1981). Sym-
pathoadrenal activity in the foetus during delivery and at birth;
in Intensive Can in the Ntwborn (eds L. Stern, B. Salle, and B.
Friis-Hansen). New York: Masson Inc.
Lederman, E., Lcderman, R.P., Work, B.A. jr, and McCann,
D.S. (1981). Maternal psychological and physiologic correlates
of fetal-newborn health. Am. J. Obstet. Gynecol., 139, 956.
Lederman, R. P., Lederman, E., Work, B. A. jr, and McCann,
D. S. (1978). The relationship of maternal anxiety, plasma
catecholamines, and plasma cortisol to progress in labor. Am.
J. Obstet. Gynecol, 132,495.
McCann, D. S., Work, B. jr, and Huber, M. J. (1977).
Endogenous plasma epinephrine and norepinephrine in last-
trimester pregnancy and labor. Am.]. Obstet. Gynecol., 129,5.
Morishima, H. O., and Covino, B. G. (1981). Tcoricity and
distribution of lidocaine in nonasphyxiated and asphyxiated
baboon fetuses. Anesthesiology, 54,182.
Pickering, B., Biehl, D., and Meatherall, R. (1981). The effect of
foetal acidosis on bupivacainc levels in utero. Can. Anaesth. Soc.
/.,28,544.
Shnider, S. M., Abboud, T. K., Anal, R., Henriksen, E. H.,
Stefani, S. J., and Levinson, G. (1983). Maternal
catecholamines decrease during labor after lumbar epidural
anesthesia. Am. J. Obstet. Gynecol., 147,13.
Wright, R. G., Levinson, G., Roizen, M. F., Wallis, K. L.,
Rotbin, S. H., and Craft, J. B. (1979). Uterine blood flow and
plasma norepinephrine changes during maternal stress. Anes-
thesiology, 50, 524.
ETAT DU FOETUS ET DU NOUVEAU-NE APRES
CESARIENNE POUR SOUFFRANCE FOETALE
RESUME
Nous avons exploitc les donnees biochimiques chez le foetus et
cliniques chez le nouveau-ne recueillies au cours de 136 cesarien-
nes pratiquees en urgence pour souffrance foetale. Le choix de la
technique anesthesique etait conditionne par le desir de la mere.
Soixante et onze parturientes ont recu une ancsthesie generale et
55 une ancsthesie locorcgionale (dont 33 rachianesthesies et 22
complements de peridurale). 1 ** etiologies des souffrances
foetales et les delais entre I'incision cutanee et 1'extraction et
l'incision uterine et 1'extraction n'etaient pas significativement
differents entre les deux groupes d'anesthesies. Le pH mngiiin
dans l'artere ombilicale etait plus eleve que le dernier pH capil-
FETAL--NEONATAE. STATUS AFTER X^ESAREAN SECTTON
laiie du scalp chez 63% des enfants dont lc mere etait anesthesice
totalement et chcz 80% des enfants dont le mere avait recu unc
anesthesie locoreginale. Les pH et les gaz du sang dans la veine et
l'artere ombilicalr etnient semblables dans les deux groupes mats
l'Apgar a 1 min etah significarivemCTit mrilleur apres anes-
thesie locoregtonale. Malgre l'ezistence d'une souffrance foetale,
la rachianesthesie apparait comme nn^ technique tout a fait
adaptee dans des main* entrainees.
FETALER UND NEONATALER STATUS NACH
KAISERSCHNTTT WEGEN FETALEM DISTRESS
ZUSAMMENFASSUNG
Die fetalen biochemischen und neonatalen Hinittctwri Daten von
126 Notfall-Raiserscnnitten wegen fetalem Distress wurden
zusammengetragen. Die Wahl der Narkosetechnik wurde durch
die Wunsche der Mutter bestimmt. Ein und siebzig Patientinnen
erhkften Vollnarkose, 55 Regionalanasthesie (33 Spinalanas-
thesien, 22 PeriduralanSsthesien). Bei beiden Gruppen waren die
Ursachcn fur den fetalen Distress ""H die Intervalle zwischen
Hautschnitt und Entbindung und Uterusirizision und Entbin-
dung nkfat tignifikant voneniander verschieden. Bei 63% der
Falle mit Vollnarkose und 80% der Faille mit Regkmalanisthesie
waren die pH-Werte im Nabelarterienbtut holier als die zuletzt
bestimmten pH-Werte im Kopfhaut-Kaptllarbhit. Bei beiden
Gruppen ahnelten sich die Blutgas- und pH-Werte im Nabdve-
nen- und Nabelarterienblut, doch waren die Apgar-Werte nach
1013
besser. Trotz Vorhandesein von
fetatem Distress erwies die Spinalanasthesie in erfahrenen
Hinden als sear gunstige Methode.
ESTADO FETO-NEONATAL DESPUES
DE UNA OPERAOON CESAREA DEBIDA
A TRASTORNO DEL FETO
SUMAKIO
Se compilaron en 126 operaciones cesarea* de emergencia debidas
a trastomos del feto los datos clinicos p<-^"°"l^« y bioquimicas
fetales. LaffHf^Tiy>nde la t£cnica anestctica fue ^^^ minoHn en
base a los deseos de la madre. SeadministnSunasnestrsia general
a 71 parturientas y una analgesia regional a 55 de ellas (bloqueo
sub-aracnoideo: 33, extensi6n del bloqueo extradural: 22). Las
etiologias dd trastomo fetal y la incision—parto e irvrt^1!
uterina—parto en cuanto a intervaios no difirieron mayormente
entre los dos grupos de anrwrsii Los vdores del pH de la sangre
arterial del omtriligo eran mayores de los del pH de la sangre
rapier del cuero cabelludo en un 63% ^^ gmpo de anestesia
general y en un 80% en los casos de anrstnria regional. Los datos
relacionados con el pH y d gas-sangre de la arteria y de la vena del
ombfligo eran similares en ambos grupos de anestesiadas, peros
las marcas Agpar al 1 min eran mucho mejores despues de la
annlg^a regional. A pesar del trastomo del feto, el bloqueo
subaracnoidfo fue d metodo mis tdeciifk) de anestesia con
personal czperimentado.