|Year : 2020 | Volume
| Issue : 2 | Page : 100-107
Neonatal outcomes following caesarean section in Aminu Kano Teaching Hospital, Kano, North-west Nigeria
Alhassan Datti Mohammed1, Ayyuba Rabiu2, Bashir Yusuf3, Fatima Usman4, Mahmoud J Gambo4, Rukayya A Sidi5, Ibrahim Garba2, Mujahid Muhammad Hassan5
1 Department of Anaesthesiology & Intensive Care, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Obstetrics and Gynecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Anaesthesiology, Federal Medical Centre, Katsina, Nigeria
4 Department of Paediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
5 Department of Anaesthesiology & Intensive Care, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||25-Dec-2019|
|Date of Decision||31-Mar-2020|
|Date of Acceptance||04-Jun-2020|
|Date of Web Publication||11-Sep-2020|
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, P.M.B. 3011, Kano
Source of Support: None, Conflict of Interest: None
Background: Type of anaesthesia is believed to have a role in neonatal outcomes at birth. Regional anaesthesia is thought to have a better neonatal outcome. We assessed the APGAR scores of neonates, the effect of anesthetic technique and associations between maternal and neonatal variables. Methods: This was a cross-sectional study conducted from 1st August, 2018, to 31st January, 2019, at Aminu Kano Teaching Hospital. Ethics approval was obtained from College of Health Science Ethics Committee, Bayero University Kano. All consenting pregnant women scheduled for elective or emergency caesarean section within the study period were recruited. Information such as anesthesia delivery interval and neonatal outcomes were recorded on a questionnaire. Data collected were analyzed using SPSS version 22.0. Fisher’s Exact Test was used for categorical data, and the P < 0.05 was considered significant. Results: Sixty-six pregnant women were recruited. The mean age (±SD) of the pregnant women was 29.4±5.58 years. Up to 59 patients (89.4%) received subarachnoid block (SAB). Thirty six (54.5%) were delivered within 10 minutes following administration of anesthesia. Most of the newborns had normal heart rate 65 (98.5%) and Apgar scores at 1st and 5th minutes (51 (77.3%), 62 (93.9%) respectively. Only ASA PS class was found to be statistically associated with neonatal Apgar scores at 5th minutes (Fisher’s Exact Test = 0.039). Conclusion: Subarachnoid block was the main anesthesia type for caesarean section and more than half of the patients were delivered following administration of anesthesia within 10 minutes with excellent neonatal outcomes.
Keywords: Caesarean section, neonatal outcomes, Nigeria, subarachnoid block
|How to cite this article:|
Mohammed AD, Rabiu A, Yusuf B, Usman F, Gambo MJ, Sidi RA, Garba I, Hassan MM. Neonatal outcomes following caesarean section in Aminu Kano Teaching Hospital, Kano, North-west Nigeria. J Med Trop 2020;22:100-7
|How to cite this URL:|
Mohammed AD, Rabiu A, Yusuf B, Usman F, Gambo MJ, Sidi RA, Garba I, Hassan MM. Neonatal outcomes following caesarean section in Aminu Kano Teaching Hospital, Kano, North-west Nigeria. J Med Trop [serial online] 2020 [cited 2021 Apr 22];22:100-7. Available from: https://www.jmedtropics.org/text.asp?2020/22/2/100/294821
| Introduction|| |
Caesarean section is one of the essential obstetric care required to improve both maternal and neonatal outcome. Although, the World Health Organization (WHO) has recommended Cesarean section rates of 5–15% as the optimal targeted range, the trend of its use has increased globally over the past two decades., In developing countries such as Nigeria, a caesarean section rate of 10.2%–34.7% has been reported in tertiary health institutions.,, Most of these caesarean sections were done as an emergency procedure and were associated with high perinatal mortality rate. A retrospective study on a five-year survey of caesarean delivery in a Nigerian tertiary institution reported that majority of the babies 918 (91%) were delivered through emergency procedure and more than half of them 582 (57.7%) had birth asphyxia leading to perinatal mortality of 3.9%. Immediate assessment and prompt resuscitation of newly born neonates may improve neonatal outcome following caesarean section.
Various methods such as measurement of umbilical artery blood pH and Apgar scoring system have been used for neonatal assessment immediately after delivery. The Apgar scoring system was proposed by Virginia Apgar in 1954 and has remained relevant for the prediction of neonatal survival. It provides a standardized and rapid method of assessing the clinical status of the newborn infant at 1 minute of age and the need to initiate an immediate resuscitation effort.
The quest to improve neonatal outcome following caesarean section by determining the trend of Apgar score and need for immediate resuscitation informed the need for this study. We therefore aimed to assess the APGAR scores of neonates following Caesarean delivery, the effect of anesthetic technique on neonatal Apgar scores and associations between maternal and neonatal variables with Apgar scores.
| Materials and methods|| |
This was a cross sectional study conducted from 1st August, 2018, to 31st January, 2019. Ethical approval was obtained from College of Health Science Ethics Committee, Bayero University Kano (BUK/CHS/REC/VI/57). This study was performed in accordance with the declaration of Helsinki. All consenting pregnant women of childbearing age (15–49 Years) scheduled for elective or emergency caesarean section within the study period were recruited. Women who delivered neonates with gross anomalies were excluded from the study. Patients that had received intravenous opioid 3 hours prior to caesarean section and those with maternal history of drug abuse were also excluded. Interviewer administered questionnaire containing closed and open-ended questions were structured and pretested prior to administration. Information such as socio-demographic characteristics, procedure-related characteristics, maternal clinical parameters, anesthesia delivery interval, fetal and neonatal parameters, maternal and neonatal outcomes were recorded on the questionnaire.
History and thorough general and systemic examination of the mothers were carried out and indication for caesarean section (C/S) was noted. The results of investigation such as urea electrolyte and creatinine, full blood count, urinalysis and clotting profile and other investigations based on patient’s clinical conditions were reviewed. Fetal clinical status was assessed using cardiotocography in the ward and pinard stethoscope while on operating table prior to C/S.
Pre-anaesthetic evaluation of the mother was carried out and their physical status was assessed according to American Society of Anesthesiologists (ASA) physical status classification (PSC) system. Patients for elective C/S were fasted according to the 2011 ASA fasting guidelines. They all received 150 mg of oral ranitidine and 10 mg oral metoclopramide on the night preceding C/S and in the morning of surgery. Patients for emergency C/S were administered intravenous doses of 50 mg ranitidine and 10 mg metoclopramide prior to C/S.
The anaesthetic machine was checked to ensure its functionality. Resuscitation equipment and drugs were made readily available. On arrival of the mothers in the operating room, they were connected to a multi-parameter patient monitor (DASH 4000 GE Medical System Information Technologies, Wisconsin, USA) to obtain baseline vital signs (non-invasive systolic, diastolic and mean arterial blood pressures, heart rate, respiratory rate, arterial saturation of oxygen and electrocardiograph).
The subarachnoid block was performed in sitting or left lateral position as appropriate under aseptic condition. The space between third and fourth lumbar spine was identified and lumbar puncture was done with 25 gauge size spinal needle and hyperbaric Bupivacaine 0.5 %, 2 ml was administered into the subarachnoid space. Immediately after injection of Bupivacaine patient was placed in supine position with wedge under the right hip for left uterine displacement. Monitoring of haemodynamic parameters (PR, SBP, DBP, MAP, RR and SpO2) was done every 2 min intervals until patients were stable.
The type of anaesthesia (general anaesthetic, regional or any other) was determined by the indication and/or preoperative condition of the mother as well as the ASA PS class. Opioid analgesics (intravenous morphine 0.1 mg/kg) were withheld until baby’s umbilical cord had been clamped in those who received a general anaesthetics.
Caesarean section was performed using pfannenstiel or midline vertical incision and time from surgical incision to baby’s delivery was noted. The neonatal Apgar score was assessed by the neonatologist or the physician anaesthetist at 0, 1 and 5 min after the umbilical cord had been clamped. However assessment of Apgar scores was repeated every 5 min for up to 20 min after cord clamping in neonate with Apgar score of less than 7 at 5 min. A poor neonatal outcome was defined as either death within 24 h or an Apgar scores less than 7 at 5 min while good neonatal outcome was defined as a live baby with an Apgar scores greater than or equal to 7 at 5 min.
Criteria for Special Care Baby Unit (SCBU) admission was by any neonate requiring more than 3 min of continuous bag mask ventilation during resuscitation as per SCBU protocols.
Data collected were analyzed using Statistical Package for Social Sciences, version 22.0 (SPSS Inc., SPSS Statistics for Windows, Chicago, IL, USA. A chi-square (χ2) test was used for categorical data. Where the criteria for applying χ2 test were not met, Fishers’ Exact test was used, and the P < 0.05 was considered to be statistically significant.
| Results|| |
The study was carried out from 1st August, 2018, to 31st January, 2019. Sixty-six pregnant women were enrolled during the study period. The mean age (±SD) of the pregnant women was 29.4±5.58 years. The median and modal age were 30 years respectively. Their median parity was two.
Majority of the patients were within the age groups of 30-34 years (31.8%) and 25–29 years (27.3%) [Table 1]. A larger proportion of the patients were Hausa/Fulani (71.2%) and attained tertiary level of education (54.5%).
|Table 1: Socio-demographic and procedure-related characteristics of the patients|
Click here to view
Majority of the caesarean sections were done by senior registrars 44 (67.0%). See [Figure 1]. Fifty nine (89.4%) of the patients received subarachnoid block (SAB) by mainly senior registrars 29 (43.9%) and registrars 21 (31.8%) [Table 1]. Only seven (12.1%) patients had normal BMI; 27 (46.6%) were overweight and more than one third of the patients (39.7%) were obese.
A significant proportion of the patients 36 (54.5%) were delivered within 10 minutes following administration of anesthesia. Only five (7.6%) of the delivery took 20-31 minutes after administration of anesthesia [Figure 2].
Most of the patients on admission had normal blood pressure 49 (74.2%), SpO2 65 (98.5%), hemoglobin concentration 58 (87.9%) and ASA PS class II 35 (53.0%) [Table 2].
Similarly, most of the neonates had normal heart rate 65 (98.5%), Apgar scores at 1st and 5th minutes (51 (77.3%), 62 (93.9%) respectively), and normal birth weight 51 (77.3%) [Table 3].
Only 14 neonates had SCBU admission and 10 (71.4%) were discharged within 5 days. See [Figure 3]. [Figure 4] depicts the number of indications for caesarean section. Majority of the patients 45 (68.0%) had only one indication while 18 (27.0%) had two indications.
[Table 4] shows cross-tabulation between different variables and neonatal Apgar Scores at 5th minutes. Only ASA PS class was found to be statistically associated with normal neonatal Apgar scores at 5th minutes (Fisher’s Exact Test = 0.039).
|Table 4: Cross tabulations between variables and fetal Apgar scores at 5th minutes|
Click here to view
The mean gestational age at presentation/delivery was 38.3±2.03 weeks. All patients were in the third trimester of pregnancy. The mean duration of labour (±SD) for the emergency cases was 8.0±4.90 hours. The mean (±SD) anesthesia delivery interval was 12.4±6.3 minutes.
The mean (±SD) fetal heart rate was 138.9±11.20 beats/min. The mean Apgar scores at 1st and 5th minutes were 7.5±1.44 and 8.8±1.41 respectively. Only three neonates had extended Apgar. The mean Apgar (extended) was 8.0±1.00. The mean (±SD) birth weight was 3.0±0.69 kg All neonates had normal body temperature following delivery. The mean (±SD) temperature of the neonates was 36.2±0.76 °C (normal range (skin) 36.2 °C–37.2 °C).
Dubowitz and ponderal index of the neonates were 37.7±1.40 and 2.5±0.48 respectively.
Fourteen neonates were admitted to SCBU (21.2%), and all were discharged alive (100.0%).
| Discussion|| |
Apgar score is used as a quick and convenient tool to convey information about a neonate’s overall status immediately and at intervals after delivery. An Apgar score of 7 − 10 is regarded as a reassuring score and in this study, 77.3% of the neonates had a reassuring score at the 1st minute, a percentage that increased to 93.95 at the 5th minute. However, the number of neonates with a low Apgar score 0 − 3 at both 1st and 5th minutes remained the same (1.5%).
Apgar score has its own limitations and a low Apgar score is not a definite predictor of a neonatal outcome, whether an adverse neurological sequel or mortality. However, a low Apgar score at 5th minute has been found to correlate with neonatal mortality in large populations, and clearly confers an increased relative risk of cerebral palsy.,,, Apgar score can also be used to assess the responsiveness of the neonate to the resuscitation measures instituted, in this study there was a 16.65% change in the number of neonates whose Apgar scores improve from a moderate Apgar score at 1st minute to a reassuring Apgar scores at 5th minute. Apgar score can also be used as a tool to assess the success and efficiency of a neonatal resuscitation program or protocol.
Spinal anaesthesia is the recommended anaesthetic technique of choice internationally based on the obstetric anaesthesia guidelines. This is because of the association between general anaesthesia and the increased risk of resuscitation of neonates delivered from mothers which had general anaesthesia. In this study, reassuring Apgar score was found to be higher in neonates delivered by mothers who had spinal anaesthesia (86.4%) than those delivered from mothers who had general anaesthesia (6.1%).The mean aneasthesia delivery interval was found to be 12.4±6.3 minutes. Although majority of the patients had SAB (89.4%), in few patients that had general anesthesia (9.1%), the exposure to anesthetic agents to the fetuses was also limited to less than a quarter of an hour. This is very important despite the fact that effects of fetal exposure to anesthetic agents are clinically irrelevant. We found statistically significant association between ASA PS class with neonatal Apgar scores (Fisher’s Exact Test 0.039 respectively). Other variables such as maternal haemoglobin, BMI, maternal age, Anesthesia type, surgeon’s and anesthetic cadres were not associated with neonatal Apgar Scores (Fisher’s Exact Test >0.05). Mekonnen and Desta in a study on effects of types of anesthesia on neurobehavioral response and Apgar score in neonates delivered with Cesarean section in Dilla University Referral Hospital revealed that Spinal Anesthesia is associated with good neonatal outcomes even in emergency caesarean section with non-touching rapid sequence spinal anesthesia technique. They recommended that general anesthesia should be preserved for cases contraindicated with spinal anesthesia. Our findings were dissimilar. Smaller sample size could be responsible for the difference.
In conclusion, subarachnoid block was the main anesthesia type for caesarean section even though there was no significant association between the types of anesthesia and neonatal outcomes. More than half of the patients were delivered following administration of anesthesia within 10 minutes with excellent Apgar Scores. We found statistically significant association between ASA PS class and neonatal Apgar scores.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Niino Y. The increasing cesarean rate globally and what we can do about it. Biosci Trends 2011;5:139-50.
Sule ST, Matawal BI. Comparison of indications for cesarean section in Zaria, Nigeria: 1985 and 1995. Ann Afr Med 2003;2:77-9.
Okonta PI, Otoide VO, Okogbenin SA. Caesarean section at the University of Benin Teaching Hospital Revisited. Trop J Obstet Gynecol 2003;20.
Feyi-Waboso PA, Aluka Kamami CI. Emergency caesarean section at Aba-Nigeria. Trop J Obstet Gynaecol 2000;19:24.
Ugwa E, Ashimi A, Abubakar MY. Caesarean section and perinatal outcomes in a sub-urban tertiary hospital in North-West Nigeria. Niger Med J 2015;56:180-4.
] [Full text]
Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 2001;344:467-71.
Ehrenstein V. Association of Apgar scores with death and neurologic disability. Clin Epidemiol 2009;1:45-53.
Moster D, Lie RT, Irgens LM, Bjerkedal T, Markestad T. The association of Apgar score with subsequent death and cerebral palsy: a population-based study in term infants. J Pediatr 2001;138:798-803.
Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics 1981;68:36-44.
Practice Guidelines for Obstetric Anesthesia. An updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia and the society for obstetric anesthesia and perinatology. Anesthes 2016;124:270-300.
Dick WF. Anaesthesia for caesarean section (epidural and general): effects on the neonate. European Journal of Obstetrics and Gynecology and Reproductive Biology 1995;59:S61-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]