Cesarean section (CS) accounts for 20-25% of all births in

Israel and more than 30% of all births in the United States
Many CSs are elective because of a previous CS, multiple
pregnancy, breech presentation of the fetus, estimation of
high fetal weight, maternal medical conditions, maternal
request, and others.
Anesthetic used in elective CS is mostly regional (epidural or
spinal)
1 well-documented and common effect of regional
anesthesia is maternal hypotension
Hypotension causing lower maternal mean arterial
blood pressure (MABP) and reduced uteroplacental
perfusion
no studies have been performed to evaluate the clinical
outcome of newborn infants born by elective CS under
regional anesthesia that caused maternal hypotension
This study was designed to evaluate the risk
factors, rate, and extent of maternal
hypotension after regional anesthesia for
elective CS, and to document the short-term
clinical outcome of term newborn infants born
to mothers who underwent elective CS and had
severe vs milder degrees of hypotension
develop.
We retrospectively reviewed the retrieved data on
newborn infants and their mothers who gave birth at
the Sheba Medical Center in Israel during a 15-month
period
All mothers who gave birth at term (gestational age
[GA], 37-42 completed weeks) by an elective CS with
regional Anesthetic were included
Excluded were mothers who had multiple pregnancy
and infants with major congenital malformations
The data recorded on the computerized system of
the obstetrics operation room included:
maternal age
number of parity and gravida
indications for CS
type of anesthetic (spinal or epidural)
blood pressure parameters on admission and
thereafter
medications and volume of IV fluid needed
The data collected from the infants medical files included:
Gestational age (GA)
Birthweight (BW)
Sex
Apgar score
the need for a pediatrician to be present
postnatal complications
the need for oxygen or antibiotic treatment
the rate of phototherapy
feeding intolerance
919 mother-infant pairs comprised the study
group and their characteristics are listed in
Table 1
The rate of maternal diabetes was relatively
high (13.9%) compared with the rate of
diabetes among all mothers in labor in our
institution (5.4%)
A total of 427 (46.5%) of the mothers
experienced a drop in their MABP of 30%
compared with their pre-CS BP
The 2 groups were similar for other
maternal diseases or medications (data not
shown) as well as the numbers of deliveries
Infants born to mothers who had a drop
in their MABP of 30% had a higher
mean BW
There were no significant differences in
GA, sex, Apgar scores, and/or any of the
other perinatal parameters
There were also no differences in other
selected clinical complications
Seventy mothers (7.6%) experienced a
drop in their MABP during CS of 50%
compared with their preoperative MABP
Maternal hypertension, a preoperatively
higher MABP, a higher fluid volume, and
a need for antihypotensive medications
during the CS were more common among
the mothers in the subgroup with a higher
drop of BP
The ones that predicted hypotension were maternal
preoperative hypertension, higher maternal age,
spinal anesthetic, and higher infant BW
the only parameter that predicted a low Apgar 1-
minute score was maternal preoperative
hypertension
The only 2 parameters that predicted respiratory
distress were GA and male sex
The occurrence of maternal hypotension
during CS (a MABP decrease by 30%, 50%, or
more) and the duration of the drop in BP (ie,
longer than 3, 5, and 10 minutes) were not
found to predict any postnatal complications
Our investigation of this subject revealed that nearly one-
half of the mothers experienced a drop in their MABP of 30%
compared with their initial preoperative measurement
Hypotension was more severe among the older mothers, in
those with preoperative hypertension, and those who
underwent spinal as opposed to epidural anesthesia
Our current findings support previous reports that
demonstrated the occurrence of hypotension after regional
anesthesia during CS and confirmed the high prevalence of
this phenomenon
most of previous studiesf ound that a spinal anesthetic
increases the risk for hypotension compared with an epidural
anesthetic, or causes a similar but more rapid decrease in BP
Other studies showed that general anesthesia resulted in
neonatal acidemia and low Apgar scores compared with
epidural anesthesia
A comparison between epidural and spinal anesthesia
revealed that the spinal anesthesia was associated with
increased rates of acidemia
The other risk factors for hypotension were
high maternal preoperative BPs, higher infant
BW, and higher maternal age

Higher maternal age was also previously
described as a risk factor for hypotension
during spinal anesthesia
The risk for respiratory distress among infants
born by elective CS was reportedly increased
by 3- to 4-fold that of infants born by vaginal
delivery
Our study results showed similar rates (6%)
of postnatal respiratory distress to those of
previous reports among infants born by
elective CS
the risk of perinatal
complications to
the newborn infant
is low in elective
CSs
the attendance of a
pediatrician is not
required
A low
Apgar score
was rare
(1%) among
our study
infants
short duration of hypotension
that was dealt with by the
anesthesiologist
BP drops lasted less than 3
minutes
the placenta has its own
autoregulation in maintaining
adequate perfusion
low prevalence
of adverse
shortterm clinical
events of term
infants born by
elective CS to
mothers who
underwent
significant MABP
drops during the
CS procedure
EXPLANATION
Despite a very high prevalence of maternal
hypotension during cesarean sections, term
infants tend to tolerate this placental blood
perfusion challenge without any major
sequel