Socio-demographic characteristics of parturients
A total of 117 women met the eligibility criteria and were included into the study. The mean age was 30.5 ± 4.8 years (range: 18 to 42 years). Among the women included in the study, 18 (15.4%) were referred from other health facilities to DGH for CS delivery. The main reasons for referral included: stationary labour, post-term delivery, acute foetal distress (AFD), pre-eclampsia and preterm labour. The gestational age of pregnancy ranged from 30 to 42 weeks, with a median gestational age of 40 weeks (IQR: 39 – 40 weeks). The gravidity of participants ranged from 1 to 8 with a median gravidity of 2 (IQR = 1 to 4). Few women, 16 (13.68%) had undergone a previous CS.
Neonatal characteristics
Most of the babies born to the participants were males (61.11%). All the neonates were born alive. The APGAR score at birth ranged from 2 to 10, with a median of 8 (IQR 6 to 8). Table 1 summarizes the APGAR scores of newborns at birth and after the 3rd and 5th minutes of life. ( Table 1 here)
Table 1: Characteristics of the APGAR score of neonates at birth, 3 and 5 minutes of life
APGAR
|
Range
|
Median
|
IQR
|
At birth
|
2 to 10
|
8
|
6 to 8
|
At 3 minutes
|
3 to 10
|
9
|
7 to 10
|
At 5 minutes
|
5 to 10
|
10
|
8 to 10
|
Amongst the newborns, 42 were diagnosed of neonatal asphyxia giving a cumulative incidence of 35.9%. About two thirds (64.3%) of the new-borns with neonatal asphyxia were classified as Sarnat class 1, meanwhile 21.4% and 14.3% were Sarnat class 2 and 3 respectively. The duration of hospitalization of the newborns in the neonatal unit ranged from 2 to 43 days with a median of 4 days (IQR: 2 to 21days). A total of 29 neonates (24.8%) were resuscitated at birth. Table 2 summarizes the characteristics of the new-borns.
(Table 2 here)
Table 2: Summary of new-born characteristics
Variable
|
Category
|
Number (%)
|
Percentage (%)
|
Neonatal asphyxia
|
Yes
|
42
|
35.9
|
No
|
75
|
64.1
|
Sarnat classification
|
Sarnat 1
|
27
|
64.3
|
Sarnat 2
|
9
|
21.4
|
Sarnat 3
|
6
|
14.3
|
Birth Weight
|
Low
|
16
|
15.4
|
Normal
|
88
|
84.6
|
Immediate cry
|
Yes
|
27
|
23.1
|
No
|
90
|
76.9
|
Resuscitation
|
No
|
88
|
75.2
|
Yes
|
29
|
24.8
|
Apgar at birth
|
Low
|
36
|
30.8
|
Normal
|
81
|
69.2
|
Apgar at 3 minutes
|
Low
|
22
|
18.8
|
Normal
|
95
|
81.2
|
Apgar at 5 minutes
|
Low
|
8
|
6.8
|
Normal
|
109
|
93.2
|
Sex
|
Male
|
66
|
61.1
|
Female
|
42
|
38.9
|
Clinical Parameters of paturients
Upon hospital presentation, most of the parturients had a good general state 112 (95.7%). The ASA score was II in 75 (64.10%), III in 38 (32.48%) and IV in 4 (3.42%) of the parturients. Fever was present in 18 (15.4%) of participants.
Type of anaesthetic technique used for emergency caesarean section indicated for AFD
More than two thirds 83 (70.9%) of the participants underwent CS for AFD under spinal anaesthesia (SA); 29 (24.8%) under general anaesthesia; and five (4.3%) under epidural anaesthesia (EA). Paturients who underwent emergency CS for AFD under epidural anaesthesia had the epidural catheter placed before delivery for obstetrical analgesia. This was converted to obstetrical anaesthesia immediately within the operating room when CS was indicated for AFD. Among patients administered GA, the most used hypnotic for induction was propofol 24 (82.8%). Thiopental and ketamine were used in 3 and 2 paturients respectively. Bupivacaine (Bupi) with fentanyl as adjuvant was used in 79 (95.2%) of patients operated under SA. Bupivacaine only and combinations of Bupi+morphine or Bupi+morphine+Fentanyl were used in two, one and one cases respectively. Bupivacaine was used for epidural anaesthesia. Hypotension during regional anaesthesia was managed with the use of ephedrine in 32 (27.3%) of parturients.
Maternal outcome after surgery
Immediate postoperative complications were few. In the GA group, we had one case of Post-partum haemorrhage (PPH). In the SA group, there were 2 cases of PPH, one of the cases being complicated by maternal death. Furthermore, one case of severe hypotension was noted. No maternal complications were noted in the epidural anaesthesia group. Duration of hospitalisation of mothers ranged from 3 to 13 days with a mean of 5 days. Mean duration of hospitalization for women who underwent CS under SA was 4.5 days and 4.7 days for GA (p = 0.5154). Late complications observed during hospitalization were seen mostly in postpartum women who underwent SA. These included four cases of post-dural puncture headaches, two cases of endometritis, one case of malaria and one case surgical site infection.
Univariable analysis
Association of predictor variables with APGAR at the first minute
In univariable analysis, babies born of women who received GA had two-fold increase risk of having a low APGAR score at the first minute compared to babies of women who received SA (RR = 2.00, p = 0.011). Furthermore, neonates born of women with fever almost had a double likelihood of having a low APGAR score at the first minute compared to babies born of women without fever (RR = 1.83, p = 0.035). On the other hand, gravidity, the type of FHR pattern, use of epinephrine, gestational age, birth weight and previous CS were not associated with low APGAR in univariable analysis. Table 3 shows the association between the exposure variables and APGAR at the first minute in univariable analysis.. (Table 3 here)
Table 3: Association between exposure variables with APGAR at first minute
Exposure
|
Categories
|
APGAR at birth
|
≥ 7 (%)
|
< 7 (%)
|
RR
|
p value
|
95% CI
|
Type of Anaesthesia administered
|
Spinal
|
63 (80.7)
|
20 (58.8)
|
1
|
-
|
-
|
General
|
15 (19.2)
|
14 (41.2)
|
2.00
|
0.011
|
1.17 - 3.42
|
Gravidity
|
Multi-Gravida
|
60 (74.1)
|
26 (72.2)
|
1
|
-
|
-
|
Primi-gravida
|
21 (25.9)
|
10 (27.8)
|
1.06
|
0.833
|
0.58 - 1.95
|
Type of FHR
|
Abnormal
|
70 (86.4)
|
29 (80.6)
|
1
|
-
|
-
|
Non-Reassuring
|
11 (13.6)
|
7 (19.4)
|
1.32
|
0.396
|
0.69 - 2.55
|
Referral
|
Not referred
|
69 (85.2)
|
30 (83.3)
|
1
|
-
|
-
|
Referred
|
12 (14.8)
|
6 (16.7)
|
1.10
|
0.795
|
0.53 - 2.26
|
Use of Ephedrine
|
No
|
57 (70.4)
|
28 (77.8)
|
1
|
-
|
-
|
Yes
|
24 (29.6)
|
8 (22.2)
|
0.76
|
0.421
|
0.39 - 1.49
|
Gestational age
|
Term
|
81 (63.0)
|
21 (58.3)
|
1
|
-
|
-
|
Premature
|
6 (7.4)
|
7 (19.5)
|
1.85
|
0.052
|
0.99 - 3.43
|
Post term
|
24 (29.6)
|
8 (22.2)
|
0.86
|
0.666
|
0.42 - 1.72
|
Birth Weight
|
Normal or high
|
65 (86.7)
|
23 (79.3)
|
1
|
-
|
-
|
Low
|
10 (13.3)
|
6 (20.7)
|
1.43
|
0.328
|
0.69 - 2.96
|
Previous CS
|
No
|
66 (81.5)
|
35 (97.2)
|
1
|
-
|
-
|
Yes
|
15 (18.5)
|
1 (2.8)
|
0.18
|
0.080
|
0.03 - 1.22
|
Fever
|
No
|
72 (88.9)
|
27 (75.0)
|
1
|
-
|
-
|
Yes
|
9 (11.1)
|
9 (25.0)
|
1.83
|
0.035
|
1.04 - 3.22
|
Association of exposure variables with APGAR at the third minute
Babies born of women who underwent GA had almost three times the risk of having a low APGAR score at the third minute compared to babies of women who underwent SA (RR = 2.86, p = 0.007). Furthermore, neonates delivered by women with fever had three times the risk of having a low APGAR score at the third minute compared to babies born of women without fever (RR = 3.14, p = 0.002). On the other hand, gravidity, the type of FHR, use of epinephrine, gestational age, birth weight and previous CS were not associated with a low APGAR score at the third minute. Table 4 shows the association between the exposure variables and APGAR score at the third minute.(Table 4 here)
Table 4: Association between exposure variables and APGAR at third minute
Exposure
|
Category
|
APGAR 3rd minute
|
≥ 7 (%)
|
< 7 (%)
|
RR
|
p value
|
95% CI
|
Type of Anaesthesia administered
|
Spinal
|
73 (79.3)
|
10 (50.0)
|
1
|
-
|
-
|
General
|
19 (20.6)
|
10 (50.0)
|
2.86
|
0.007
|
1.33 - 6.17
|
Gravidity
|
Multi-Gravida
|
70 (73.7)
|
16 (72.7)
|
1
|
-
|
-
|
Primi-gravida
|
25 (26.3)
|
6 (27.3)
|
1.04
|
0.927
|
0.45 - 2.42
|
Type of FHR
|
Abnormal
|
80 (84.2)
|
19 (86.4)
|
1
|
-
|
-
|
Non-Reassuring
|
15 (15.8)
|
3 (13.6)
|
0.87
|
0.803
|
0.29 - 2.63
|
Referral
|
Not referred
|
80 (84.2)
|
19 (86.4)
|
1
|
-
|
-
|
Referred
|
15 (15.8)
|
3 (13.6)
|
0.87
|
0.803
|
0.28 - 2.63
|
Use of Ephedrine
|
No
|
65 (68.4)
|
20 (90.9)
|
1
|
-
|
-
|
Yes
|
30 (31.6)
|
2 (9.1)
|
0.27
|
0.063
|
0.06 - 1.07
|
Gestational age
|
Term
|
59 (62.1)
|
13 (59.1)
|
1
|
-
|
-
|
Premature
|
10 (10.5)
|
3 (13.6)
|
1.28
|
0.664
|
0.42 - 3.87
|
Post term
|
26 (27.4)
|
6 (27.3)
|
1.03
|
0.932
|
0.43 - 2.49
|
Birth Weight
|
Normal or high
|
74 (87.1)
|
14 (73.7)
|
1
|
-
|
-
|
Low
|
11 (12.9)
|
5 (26.3)
|
1.96
|
0.129
|
0.82 - 4.69
|
Previous CS
|
No
|
80 (84.2)
|
21 (95.6)
|
1
|
-
|
-
|
Yes
|
15 (15.8)
|
1 (4.6)
|
0.30
|
0.224
|
0.04 - 2.08
|
Fever
|
No
|
85 (89.5)
|
14 (63.6)
|
1
|
-
|
-
|
Yes
|
10 (10.5)
|
8 (36.4)
|
3.14
|
0.002
|
1.54 - 6.38
|
Association of exposure variables with APGAR at the fifth minute
The type of anaesthesia administered, maternal fever, gravidity, the type of FHR, use of epinephrine, gestational age, birth weight and previous CS were not significantly associated with low APGAR at the fifth minute. Table 5 shows the association between the exposure variables and APGAR at the fifth minute. (Table 5 here)
Table 5: Association between exposure variables with APGAR at fifth minute
Exposure
|
Category
|
APGAR at 5th minute
|
≥ 7(%)
|
< 7(%)
|
RR
|
p value
|
95% CI
|
Type of Anaesthesia administered
|
Spinal
|
79 (76.0)
|
4 (50.0)
|
1
|
-
|
-
|
General
|
25 (24.0)
|
4 (50.0)
|
2.86
|
0.118
|
0.76 - 10.71
|
Gravidity
|
Multi-Gravida
|
82 (75.2)
|
4 (50.0)
|
1
|
-
|
-
|
Primi-gravida
|
27 (24.8)
|
4 (50.0)
|
2.77
|
0.131
|
0.74 - 10.42
|
Type of FHR
|
Abnormal
|
92 (84.4)
|
7 (87.5)
|
1
|
-
|
-
|
Non-Reassuring
|
17 (15.6)
|
1 (12.5)
|
0.79
|
0.816
|
0.10 - 6.01
|
Referral
|
Not referred
|
93 (85.3)
|
6 (75.0)
|
1
|
-
|
-
|
Referred
|
16 (14.7)
|
2 (25.0)
|
1.83
|
0.434
|
0.40 - 8.38
|
Use of Ephedrine
|
No
|
79 (72.5)
|
6 (75.0)
|
1
|
-
|
-
|
Yes
|
30 (27.5)
|
2 (25.0)
|
0.88
|
0.878
|
0.19 - 4.16
|
Gestational age
|
Term
|
66 (60.6)
|
6 (75.0)
|
1
|
-
|
-
|
Premature
|
13 (11.9)
|
0 (0.00)
|
-
|
-
|
-
|
Post term
|
30 (27.5)
|
2 (25.0)
|
0.75
|
0.715
|
0.16 - 3.52
|
Birth Weight
|
Normal or high
|
83 (84.7)
|
5 (83.3)
|
1
|
-
|
-
|
Low
|
15 (15.3)
|
1 (16.7)
|
1.1
|
0.928
|
0.14 - 8.80
|
Previous CS
|
No
|
93 (85.3)
|
8 (100.0)
|
1
|
-
|
-
|
Yes
|
16 (14.7)
|
0 (0.0)
|
-
|
-
|
-
|
Fever
|
No
|
93 (85.3)
|
6 (75.0)
|
1
|
-
|
-
|
Yes
|
16 (14.7)
|
2 (25.0)
|
1.83
|
0.434
|
0.40 - 8.38
|
Association of exposure variables and neonatal resuscitation
Newborns of women who underwent GA were twice at risk of being resuscitated compared to those born of women who received spinal anaesthesia (P=0.015). Table 6 shows the association between the exposure variables and neonatal resuscitation. (Table 6 here )
Table 6: Association between exposure variables and neonatal resuscitation
Exposure
|
Category
|
Resuscitation
|
Yes (%)
|
No (%)
|
RR
|
p value
|
95% CI
|
Type of Anaesthesia administered
|
Spinal
|
16 (57.1)
|
67 (79.8)
|
1
|
-
|
-
|
General
|
12 (42.9)
|
17 (20.2)
|
2.15
|
0.015
|
1.16 - 3.98
|
Gravidity
|
Multi-Gravida
|
21 (72.4)
|
65 (73.9)
|
1
|
-
|
|
Primi-gravida
|
8 (27.6)
|
23 (26.1)
|
1.06
|
0.878
|
0.52 - 2.13
|
Type of FHR
|
Abnormal
|
25 (86.2)
|
74 (84.1)
|
1
|
-
|
-
|
Non-Reassuring
|
4 (13.8)
|
14 (15.9)
|
0.88
|
0.787
|
0.35 - 2.23
|
Referral
|
Not referred
|
28 (96.6)
|
71 (80.7)
|
1
|
-
|
-
|
Referred
|
1 (3.4)
|
17 (19.3)
|
0.19
|
0.98
|
0.03 - 1.35
|
Use of Ephedrine
|
No
|
23 (79.3)
|
62 (70.5)
|
1
|
-
|
-
|
Yes
|
6 (20.)
|
26 (29.5)
|
0.69
|
0.370
|
0.31 - 1.54
|
Gestational age
|
Term
|
20 (69.0)
|
52 (59.1)
|
1
|
-
|
-
|
Premature
|
2 (6.9)
|
11 (12.5)
|
0.55
|
0.383
|
0.15 - 2.09
|
Post term
|
7 (24.1)
|
25 (28.4)
|
0.79
|
0.534
|
0.37 - 1.67
|
Birth Weight
|
Normal or high
|
20 (83.3)
|
68 (85.0)
|
1
|
-
|
-
|
Low
|
4 (16.7)
|
12 (15)
|
1.1
|
0.841
|
0.43 - 2.79
|
Previous CS
|
No
|
26 (89.7)
|
75 (85.2)
|
1
|
-
|
-
|
Yes
|
3 (10.3)
|
13 (14.8)
|
0.73
|
0.562
|
0.25 - 2.13
|
Fever
|
No
|
23 (79.3)
|
76 (86.4)
|
1
|
-
|
-
|
Yes
|
6 (20.7)
|
12 (13.6)
|
1.43
|
0.342
|
0.68 - 3.02
|
Association of exposure variables with neonatal asphyxia (NNA)
In univariable analysis, the type of anaesthesia administered was not significantly associated with the clinical diagnosis of NNA. Furthermore, gravidity, the type of FHR pattern, gestational age, birth weight, previous CS, the use of epinephrine and the presence of postoperative fever were not associated with NNA in univariable analysis. Table 7 shows the association between the exposure variables and NNA. (Table 7 here)
Table 7: Association between exposure variables with NNA
Exposure
|
Category
|
Neonatal Asphyxia
|
No (%)
|
Yes (%)
|
RR
|
P value
|
95% CI
|
Type of Anaesthesia administered
|
Spinal
|
54 (75.0)
|
29 (72.5)
|
1
|
-
|
-
|
General
|
17 (22.7)
|
11 (22.5)
|
1.08
|
0.770
|
0.63 - 1.88
|
Gravidity
|
Multi-Gravida
|
58 (77.3)
|
28 (66.7)
|
1
|
-
|
-
|
Primi-gravida
|
17 (22.7)
|
14 (33.3)
|
1.39
|
0.193
|
0.85 - 2.27
|
Type of FHR pattern
|
Abnormal
|
65 (86.7)
|
34 (80.9)
|
1
|
-
|
-
|
Non-Reassuring
|
10 (13.3)
|
8 (19.1)
|
1.29
|
0.387
|
0.72 - 2.32
|
Referral
|
Not referred
|
65 (86.7)
|
34 (80.9)
|
1
|
-
|
-
|
Referred
|
10 13.3)
|
8 (19.1)
|
1.29
|
0.387
|
0.72 - 2.32
|
Use of Ephedrine
|
No
|
53 (70.7)
|
32 (76.2)
|
1
|
-
|
-
|
Yes
|
22 (29.3)
|
10 (23.8)
|
0.83
|
0.531
|
0.46 - 1.48
|
Gestational age
|
Term
|
42 (56.0)
|
30 (71.4)
|
1
|
-
|
-
|
Premature
|
10 (13.3)
|
3 (7.2)
|
0.55
|
0.261
|
0.20 - 1.55
|
Post term
|
23 (30.7)
|
9 (21.4)
|
0.67
|
0.212
|
0.36 - 1.25
|
Birth Weight
|
Normal or high
|
57 (81.4)
|
31 (91.2)
|
1
|
-
|
|
Low
|
13 (18.6)
|
3 (8.8)
|
0.53
|
0.243
|
0.18 - 1.53
|
Previous CS
|
No
|
63 (84.0)
|
38 (90.5)
|
1
|
-
|
-
|
Yes
|
12 (16.0)
|
4 (9.5)
|
0.66
|
0.365
|
0.27 - 1.61
|
Fever
|
No
|
65 (86.7)
|
34 (80.9)
|
1
|
-
|
-
|
Yes
|
10 (13.3)
|
8 (19.1)
|
1.29
|
0.387
|
0.72 - 2.32
|
Association of exposure variables and new-born hospitalization in the neonatal unit
There was no significant difference in the chances of neonates being hospitalised in the neonatal unit for both SA and GA. However, post term newborns were about 50% less likely to be hospitalized in the neonatal unit compared to neonates born at term(P=0.035).Also, babies with low birth weights were about twice as likely to be hospitalised (P=0.001). Table 8 shows the association of exposure variables with hospitalization of newborns in the neonatal unit.(Table 8)
Table 8: Association between exposure variables and neonatal unit admission
Exposure
|
Category
|
Hospitalization in the neonatal unit
|
Yes (%)
|
No (%)
|
RR
|
p value
|
95% CI
|
Type of Anaesthesia administered
|
Spinal
|
43 (70.5)
|
40 (78.4)
|
1
|
-
|
-
|
General
|
18 (29.5)
|
11 (21.6)
|
1.20
|
0.314
|
0.84 - 1.70
|
Gravidity
|
Multi-Gravida
|
44 (68.8)
|
42 (79.3)
|
1
|
-
|
|
Primi-gravida
|
20 (31.2)
|
11 (20.7)
|
1.26
|
0.172
|
0.90 - 1.76
|
Type of FHR
|
Abnormal
|
53 (82.8)
|
46 (86.8)
|
1
|
-
|
-
|
Non-Reassuring
|
11 (17.2)
|
7 (13.2)
|
1.14
|
0.529
|
0.76 - 1.72
|
Referral
|
Not referred
|
52 (81.2)
|
47 (88.7)
|
1
|
-
|
-
|
Referred
|
12 (18.8)
|
6 (11.3)
|
1.27
|
0.215
|
0.87 - 1.85
|
Use of Epinephrine
|
No
|
49 (76.6)
|
36 (67.9)
|
1
|
-
|
-
|
Yes
|
15 (23.4)
|
17 (32.1)
|
0.81
|
0.324
|
0.54 - 1.23
|
Gestational age
|
Term
|
43 (67.2)
|
29 (54.7)
|
1
|
-
|
-
|
Premature
|
10 (15.6)
|
3 (5.7)
|
1.29
|
0.160
|
0.90 - 1.83
|
Post term
|
11 (17.2)
|
21 (39.6)
|
0.57
|
0.035
|
0.34 - 0.96
|
Birth Weight
|
Normal or high
|
40 (74.1)
|
48 (96.0)
|
1
|
-
|
-
|
Low
|
14 (25.9)
|
2 (4.0)
|
1.92
|
< 0.001
|
1.43 - 2.58
|
Previous CS
|
No
|
57 (89.1)
|
44 (83.0)
|
1
|
-
|
-
|
Yes
|
7 (10.9)
|
9 (17.0)
|
0.77
|
0.391
|
0.43 - 1.39
|
Fever
|
No
|
53 (82.8)
|
46 (86.9)
|
1
|
-
|
-
|
Yes
|
11 (17.2)
|
7 (13.2)
|
1.14
|
0.529
|
0.76 - 1.72
|
Association of exposure variables and duration of neonatal unit hospitalization
Neonates born following GA were likely to have a longer mean duration of hospitalisation in the neonatal unit compared to those born under SA 4.7 days versus 4.5 days. However, the difference in mean was not statistically significant (p = 0.515).
Multivariable Analysis
After accounting for foetal heart rate patterns on CTG, past caeserian scar and whether or not paturients were refered from another hospital, SA remainded significantly associated with better APGAR scores in the first and 3rd minute following Caeserean section, and with lesser risks of rescusiation of newborns (P<0.05). Table 9 shows the association between anaesthesia technic and main outcome variables in multivariable analysis. (Table 9 here).
Table 9: Association between Anesthesia technic and outcome Variables in Multivariate Analysis
Exposure
|
ARR
|
CI
|
P-Value
|
APGAR at birth
|
Type of anaesthesia*
|
Regional
|
1
|
-
|
0.016
|
General
|
1.86
|
1.12 – 3.08
|
Yes
|
0.212
|
0.03 – 1.44
|
APGAR 3rd minute
|
Type of anaesthesia*
|
Regional
|
1
|
-
|
0.025
|
General
|
2.33
|
1.11 – 4.86
|
APGAR at 5th minute
|
Type of anaesthesia*
|
Regional
|
1
|
-
|
0.124
|
General
|
2.81
|
0.75 – 10.53
|
Resuscitation
|
Type of anaesthesia*
|
Regional
|
1
|
-
|
0.041
|
General
|
1.90
|
1.02 – 3.51
|
Neonatal Asphyxia
|
Type of anaesthesia*
|
Regional
|
1
|
-
|
0.765
|
General
|
1.08
|
0.63 – 1.88
|