II. Lateral tilt at Caesarean section: one angle fits all or made-to-measure?

Kinsella, S.M.

doi:10.1093/bja/aes402

Cited by 5 publications

(5 citation statements)

References 15 publications

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“…1 Indeed, the current study by Lee and colleagues that shows overall modest increases in cardiac output in term women who were rolled from supine to lateral tilt corroborates prior newer work using noninvasive cardiac output techniques. Older work suggests that nearly 10% of women who lay supine will fail to compensate hemodynamically and develop significant hypotension, theoretically placing their fetus in serious jeopardy for the consequences of uterine under perfusion.…”

Section: Commentsupporting

confidence: 84%

“…Older work suggests that nearly 10% of women who lay supine will fail to compensate hemodynamically and develop significant hypotension, theoretically placing their fetus in serious jeopardy for the consequences of uterine under perfusion. 1 Although using a cut-off of 20% reduction in cardiac output as the level at which tilt would be expected to have some salutatory effect is arbitrary, this reviewer agrees with their overall conclusion that a small minority of patients suffer from "concealed inferior vena caval compression" that would be best detected from measuring cardiac output noninvasively in 2 tilt positions; one less than and the other greater than the 15-degree pelvic tilt. 1 Indeed, the current study by Lee and colleagues that shows overall modest increases in cardiac output in term women who were rolled from supine to lateral tilt corroborates prior newer work using noninvasive cardiac output techniques.…”

Section: Commentsupporting

confidence: 67%

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II. Lateral Tilt at Cesarean Section

Kinsella¹

2014

Obstetric Anesthesia Digest

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A ortocaval compression (ACC) in parturients occurs when the uterus compresses the abdominal aorta and inferior vena cava (IVC). This compression can lead to maternal hypotension and uteroplacental hypoperfusion. However, potentially significant ACC is difficult to detect before a regional block because many patients have no signs or symptoms. Thus, predicting the patient in whom profound hypotension may occur after sympathectomy during regional anesthesia is difficult as well. A noninvasive technique for identifying patients with significant ACC would be helpful as invasive techniques, such as radiologic angiography, are not practical for routine clinical use. This prospective observational study was designed to measure changes in cardiac output (CO) and other maternal hemodynamic values at different degrees of lateral tilt. The authors hypothesized that this would allow them to identify the presence of IVC compression in term parturients.The authors recruited nonlaboring parturients at term who were to undergo elective cesarean section. Standard monitoring was applied, including noninvasive arterial pressure monitoring at 1-minute intervals on the left arm, ECG, pulse oximetry, and continuous cardiotocography. A second noninvasive arterial pressure monitor was placed on the patient's left calf for measuring lower limb arterial pressure (AP). Intermittent measurements of CO, stroke volume, and systemic vascular resistance were obtained using suprasternal Doppler ultrasound. Patient hemodynamic measurements were made before spinal anesthesia with the operating table placed at 4 levels of left lateral tilt sequentially applied: 0 degrees (lying completely supine), 7.5 degrees, 15 degrees, and 90 degrees (complete left lateral with the hips and knees slightly flexed). Patients were kept in each tilted position for at least 5 minutes to allow for stabilization of the parameters before hemodynamic measurements were taken. A Z20 mm Hg difference in CO was thought to be evidence of significant IVC compression and a Z20 mm Hg difference in AP between the upper and lower limb was thought to reflect aortic compression.Of 170 patients who provided consent, 157 patients had complete data sufficient for analysis. No patients had episodes of hypotension or fetal heart rate abnormalities during the study period. CO was on an average 5% higher when patients were positioned at 15-and 90-degree tilt compared with 0-and 7.5-degree tilt. CO values at the 0, 7.5, 15, and 90-degree positions were 5.9, 5.9, 6.2, and 6.3 L/min, respectively (P = 0.001 for comparisons between 15-and 90-degree tilt compared to 0-and 7.5-degree tilt). Stroke volume values were 74, 74, 76, and 78 mL, respectively (no difference detected) and systemic vascular resistances were 1006, 1024, 934, and 979, respectively (P = 0.003, for comparisons between 15-and 90-degree tilt compared with 0-and 7.5-degree tilt). Heart rates were 81, 80, 80, and 82 bpm, respectively (no difference). In 11 patients who had a Z20% difference in CO between tilted positions, the me...

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Section: Commentsupporting

confidence: 84%

Section: Commentsupporting

confidence: 67%

II. Lateral Tilt at Cesarean Section

Kinsella¹

2014

Obstetric Anesthesia Digest

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“…Left lateral tilt-an almost perpetual topic in obstetric anesthesia. 1 The study by Liu et al 2 had to be started twice, the initial plan was to maintain the assigned position (supine, 15 tilt, 30 degrees lateral tilt) during surgery. This was unacceptable for the obstetricians performing the surgery and the study was restarted with a modified protocol, where the allocated position was maintained until surgical preparation and changed to supine afterwards.…”

Section: Commentmentioning

confidence: 99%

“…Left lateral tilt—an almost perpetual topic in obstetric anesthesia 1. The study by Liu et al2 had to be started twice, the initial plan was to maintain the assigned position (supine, 15 tilt, 30 degrees lateral tilt) during surgery.…”

Section: Commentmentioning

confidence: 99%

Effect of Different Positions During Surgical Preparation With Combined Spinal-Epidural Anesthesia for Elective Cesarean Delivery: A Randomized Controlled Trial

Liu

Zou

Guo

et al. 2022

Obstetric Anesthesia Digest

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(Anesth Analg. 2021;133:1235–1243) A lateral tilt of the uterus is used to reduce pressure on the inferior vena cava in pregnant patients undergoing cesarean delivery. This may improve the fetal blood and oxygen supply. This position has been thought to improve the fetal acid-base status, though this has been recently called into question. This study aimed to evaluate whether moving the patient into a 30 degrees left lateral tilt position before elective cesarean delivery with combined spinal-epidural anesthesia could better improve the fetal acid-base status compared with a 15 degrees left lateral tilt or supine position.

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“…[192021] (3) In obstetric anaesthesia, the post-spinal hypotension (SHSP) is attributed to aortocaval compression, preload reduction and reduced CO. Lateral uterine displacement is traditionally advocated to reduce IVC compression. However, more recent findings[22] using femoral vein ultrasound demonstrate that significant vena caval compression occurs in only 30% of supine women. Although uterine displacement is widely used, it does not reliably prevent hypotension after spinal anaesthesia.…”

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confidence: 99%

'Advances in understanding and management in obstetric anaesthesia': The great myth of our times

Johnson

2017

Indian J Anaesth

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II. Lateral tilt at Caesarean section: one angle fits all or made-to-measure?

Cited by 5 publications

References 15 publications

II. Lateral Tilt at Cesarean Section

II. Lateral Tilt at Cesarean Section

Effect of Different Positions During Surgical Preparation With Combined Spinal-Epidural Anesthesia for Elective Cesarean Delivery: A Randomized Controlled Trial

'Advances in understanding and management in obstetric anaesthesia': The great myth of our times

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