Manual displacement of the uterus during Caesarean section

Abstract

SummaryNinety ASA 1 and 2 pregnant women with term singleton pregnancies and no maternal and fetal complications, scheduled for elective or emergency Caesarean section, were randomly allocated to group LT (15°left lateral table tilt, n = 45) and group MD (leftward manual displacement, n = 45). Subarachnoid block was established with a 25-gauge spinal needle at the L3-L4 interspace using 1.5 ml of 0.5% hyperbaric bupivacaine. A median sensory level of T6 was observed in both groups but the incidence of hypotension was markedly lower in group MD when compared to group LT (4.4% vs 40%; p < 0.001) with a significant reduction in mean (SD) ephedrine requirement (6 (0) vs 11.3 (4.9) mg; p < 0.001). The mean (SD) fall in systolic blood pressure was 28.8 (7.3) mmHg in group LT and 20 (12.7) mmHg in group MD. The time to maximum fall in systolic blood pressure was similar in both groups (4.5 min). We conclude that manual displacement of the uterus effectively reduces the incidence of hypotension and ephedrine requirements when compared to 15°left lateral table tilt in parturients undergoing Caesarean section. Supine hypotension that develops in pregnant women near term has been attributed to aortocaval compression by the enlarged gravid uterus, which decreases venous return to the heart. Use of subarachnoid block compounds the problem of hypotension in the supine parturient by causing vasodilation and venous pooling of blood in the lower limbs. The relative hypovolaemia caused by the combination of aortocaval compression and subarachnoid block may lead to placental insufficiency. The incidence of hypotension seems to be unexpectedly high despite preloading with crystalloids (47.4-83%) [1,2] or colloids (17-38%) [3,4] and the use of prophylactic vasoconstrictors (35-80%) [5].The universal practice of employing a 15°left lateral tilt using an obstetric wedge under the right hip [6] or tilting the table leftwards [7] might help to decrease the degree of aortocaval compression but does not guarantee its absence [8]. Maximum displacement of the uterus is best achieved by mechanical displacers. Hypotension was witnessed in only one out of the 300 patients by Colon-Morales [9] in his series. A similar magnitude of uterine displacement can be accomplished by the anaesthetist placing their right hand beneath the right costal margin to attain a maximum fundal push towards the left until the baby is delivered. Mechanical displacement of the gravid uterus seems to be a more logical and effective approach to managing hypotension as it helps in directly relieving the aortocaval compression by dislodging the gravid uterus. This study was therefore designed to evaluate the role of manual leftward uterine displacement in preventing hypotension for parturients undergoing lower segment Caesarean section (LSCS) under subarachnoid block. MethodsNinety pregnant women, ASA physical status 1 or 2, with full term singleton pregnancies and scheduled to undergo elective or emergency LSCS under subarachnoid block were included in the study followin...

Part 8: Advanced Life Support

“…Two nonarrest studies found that manual left uterine displacement (which is done with the patient supine) was as good as, or better than, left lateral tilt in relieving aortocaval compression, as assessed by the incidence of hypotension and ephedrine use. 452,453 Respiratory Considerations. One study documented that the upper airways in the third trimester of pregnancy are smaller (supine mean difference 0.20; 95% confidence interval [CI] 0.06 to 0.35) compared with their postpartum state and to nonpregnant controls (LOE 5).…”

Spatial Relationship of the Left Ventricle in the Supine Position and the Left Lateral Tilt Position (Implication for Cardiopulmonary Resuscitation in Pregnant Patients)

“…They also reported that the manikin tended to slide off the incline plane at angles above 30°. Several recent studies have indicated that manual left uterine displacement in the supine position is as effective as the left lateral tilt in relieving caval compression (14,15) . For these reasons, the present guidelines recommend performing manual left uterine displacement in the supine position before placing the patient in a left lateral tilt position (11) .…”

High Energy Trauma and Pregnancy

“…El yardımı ile uterus fundusu orta hattan yaklaşık 3,5 cm sola deviye edilebilir. Multiple travmalı hastada elle müdahelede sorun varsa, yattığı masa sola doğru eğilebilir veya hastanın sırtına yerleştirilen yastık veya yuvarlanmış bir battaniye de hastanın sola doğru yatmasını sağla-yacak ve böylece aortokaval kompresyon önlenerek, venöz dönüş minimal olarak etkilenecektir (23) .…”