Techniques for preventing hypotension during spinal anaesthesia for caesarean section

Background Maternal hypotension, the most frequent complication of spinal anaesthesia for caesarean section, can be associated with severe nausea or vomiting which can pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis and neurological injury). Objectives To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2005). We updated this search on 30 June 2010 and added the results to the awaiting classification section of the review. Selection criteria Randomised controlled trials comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. Data collection and analysis Three review authors independently assessed eligibility and methodological quality of studies, and extracted data. Main results We included 75 trials (a total of 4624 women). Crystalloids were more effective than no fluids (relative risk (RR) 0.78, 95% confidence interval (CI) 0.60 to 1.00; one trial, 140 women, sequential analysis) and colloids were more effective than crystalloids (RR 0.68, 95% CI 0.52 to 0.89; 11 trials, 698 women) in preventing hypotension following spinal anaesthesia at caesarean section. No differences were detected for different doses, rates or methods of administering colloids or crystalloids. Ephedrine was significantly more effective than control (RR 0.51, 95% CI 0.33 to 0.78; seven trials, 470 women) or crystalloid (RR 0.70, 95% CI 0.50 to 0.96; four trials, 293 women) in preventing hypotension. No significant differences in hypotension were seen between ephedrine and phenylephrine (RR 0.95, 95% CI 0.37 to 2.44; three trials, 97 women) and phenylephrine was more effective than controls (RR 0.27, 95% CI 0.16 to 0.45; two trials, 110 women). High rates or doses of ephedrine may increase hypertension and tachycardia incidence. Lower limb compression was more effective than control (no leg compression) (RR 0.69, 95% CI 0.53 to 0.90; seven trials, 399 women) in preventing hypotension, although different methods of compression appeared to vary in their effectiveness. No other comparisons between different physical methods such as position were shown to be effective, but these trials were often small and thus underpowered to detect true effects should they exist. Authors' conclusions While interventions such as colloids, ephedrine, phenylephrine or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension during spinal anaesthesia for caesarean section. No conclusions can be drawn regarding rare adverse effects due to the relatively small numbers of women studied. [Note: The 89 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]