http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–4 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2014.1001359
ORIGINAL ARTICLE
Effect of delivery mode on postpartum neonatal body temperatures
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Naci Topalog˘lu1, Fatih Ko¨ksal Binnetog˘lu1, S¸ ule Yıldırım1, Mustafa Tekin1, Nazan Kaymaz1, Hakan Aylanc¸1, Fatih Battal1, Hasan Ali Kiraz2, Meryem Gencer3, Esra Ba¸ser1, and Volkan Hancı4 1
Department of Pediatrics, Medical Faculty, 2Department of Anesthesiology and Reanimation, Medical Faculty, 3Department of Obstetrics and Gynecology, Medical Faculty, C¸anakkale Onsekiz Mart University, C¸anakkale, Turkey, and 4Department of Anesthesiology and Reanimation, Medical Faculty, Dokuz Eylu¨l University, _Izmir, Turkey Abstract
Keywords
Objective: It is known that general and local anesthesia practices disrupt the delicate balance of thermoregulation center which is already sensitive to very tiny differences of temperatures in a normal subject. We aimed to evaluate and compare the rectal temperatures of newborns born with normal vaginal delivery and cesarean section. Methods: We performed a prospective study of 106 term newborn – 40 born with normal vaginal delivery (group 1) and 66 born with cesarean section [51 spinal anesthesia (group 2), 15 general anesthesia (group 3)]. Only term babies were included in the study. Babies of eclamptic, pre-eclamptic and diabetic mothers and babies with chronic systemic diseases were excluded. Pregnants who underwent elective cesarean section were included in the study. Adolescent pregnants, pregnants with increased risks and pregnants with complicated operations were excluded. Mothers’ temperatures were measured before and after the interventions. Rectal temperatures of the babies were measured immediately after birth. Results: Environmental temperature was maintained at 22–24 C. Pre-operative mother temperatures were 36.31 ± 0.30 C in group 1, 36.36 ± 0.26 C in group 2 and 36.39 ± 0.19 C in group 3 (p ¼ 0.414). Post-operative mother temperatures were 36.39 ± 0.27 C in group 1, 36.29 ± 0.31 C in group 2 and 36.25 ± 0.28 C in group 3 (p ¼ 0.215). Rectal temperatures of the babies born with normal vaginal delivery were significantly higher than the others. It was lowest in the general anesthesia group (37.5 ± 0.6 C, 37.2 ± 0.2 C and 36.8 ± 0.4 C in group 1, 2 and 3, respectively). The temperature differences between groups were statistically significant p50.001). Conclusions: In conclusion, it is worthy to note that temperatures of the newborns can differ according to the delivery mode. Physicians and health professionals that take care of the newborns should be aware of this difference.
Anesthesia general, cesarean section, delivery, newborn, spinal, thermoregulation, vaginal
Introduction Hypothermia causing rapid energy loss in newborn increases glucose utilization as a compensatory mechanism and finally hypoglycemia and hypoglycemia-induced complications occur [1]. All newborn babies are susceptible to hypothermia but babies delivered by operative delivery are even at higher risk. In anesthesia-related processes, the control of normal body temperature cannot be achieved. Local and general anesthetics are known to impair the body temperature [2]. Hypothermia is one of the most common complications of surgery [3]. Besides the duration of anesthesia, anesthetic drugs also affect thermoregulation [4]. Therefore, all patients Address for correspondance: S ¸ ule Yıldırım, Department of Pediatrics, Medical Faculty, C¸anakkale Onsekiz Mart University, C¸anakkale ¨ niversitesi Tıp Faku¨ltesi Hastanesi, Cumhuriyet Onsekiz Mart U Mahallesi Sahil Yolu No 5, Kepez, C¸anakkale, Turkey. Tel: +90 505 828 07 07. Fax: +90 286 263 59 56. E-mail: [email protected]
History Received 9 March 2014 Revised 15 December 2014 Accepted 18 December 2014 Published online 8 January 2015
undergoing anesthesia should be considered in the risk of hypothermia [5]. In recent years, the frequency of elective caesarean has increased both in developed and developing countries. The World Health Organization (WHO) suggests the ideal frequency of cesarean births as 10–15% of all births. Levels exceeding 17% is considered very high. In our country this rate is about 40% of all births [6,7]. There are various studies reporting the changes of neonatal body temperature after general, spinal and epidural anesthesia [8,9]. Yentur et al. indicated that newborn rectal temperature was lower in babies of the epidural anesthesia than in babies of the general anesthesia immediately after birth [10]. In this study, we hypothesized that different modes of delivery can affect the postpartum neonatal body temperatures. The major outcome was rectal temperatures of the babies after normal vaginal delivery and general and spinal anesthesia delivery. To diagnose this hypothesis, we performed a study to
2
N. Topalog˘lu et al.
J Matern Fetal Neonatal Med, Early Online: 1–4
document effects of delivery mode on postpartum neonatal body temperatures.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
Methods One-hundred and six newborn babies, 40 born with normal delivery (ND; group 1) and 66 with cesarean section (CS) from September 2013 to December 2013 were included into this prospective study. Cesarean section group was further divided into two groups according to the type of anesthesia, 51 with spinal anesthesia (group 2) and 15 with general anesthesia (group 3). The parents were informed of the aim of the study and provided written consent and the local ethics committee of university approved the study. Maternal inclusion criteria were to have uncomplicated pregnancy and to undergo elective cesarean section for CS group. Adolescent pregnants, pregnants with increased risks and pregnants with complicated operations were excluded. Neonatal inclusion criteria were term babies without any chronic systemic diseases. Babies of eclamptic, pre-eclamptic and diabetic mothers and babies with chronic systemic diseases were excluded. CS operation Environmental temperature was maintained at 22–24 C. All intravenous infusion fluids were given at a degree of 37 C. After an 8 h fasting period, the pregnants in American Society of Anesthesiologists-I (ASA-I) risk group underwent spinal or general anesthesia for CS. Pulse oxymetry, electrocardiography, non-invasive blood pressure monitoring were administered to all women during operation. Patients were covered with standard surgical drape during the operation and any heating method was not utilized. General anesthesia was induced by 1 mg/kg lidocaine, 2 mg/kg propofol. Endotracheal intubation was carried out at the first minute of the 0.6 mg/kg rocuronium bromide administration. Incision was allowed after intubation was confirmed. Anesthesia was maintained with up to 50% O2 and 50% N2O until the baby is born. After the delivery, 2 mcg/kg fentanyl was administered and anesthesia was maintained with up to 40% O2, 60% room air, 0.5–1% MAC SevoraneÕ . At the need of the operation, the patients were antagonized by 0.03 mg/kg neostigmine and 0.015 mg/kg atropine. All patients undergoing spinal anesthesia were prehydrated with 500 ml lactated Ringer’s solution. Spinal anesthesia was performed in a seated position at L3–L4 or L4–L5 level. Skin was disinfected. Local anesthesia was achieved by infiltrating 1.5 ml of 2% lidocaine from the skin
to the ligamentum flavum. About 10 mg of 0.5% hyperbaric bupivacaine and 10 mcg of fentanyl were administered into subarachnoid space using 26 Gauge atraumatic spinal needles. Incision was allowed when the sensory block came to the T5 level. Measurements The body temperature of the babies were measured by digitaltipped thermometers (Rossmax TB 100ß) soon after birth at first minute. All babies received the standard care, i.e. put under the heater and after drying the body temperatures were measured. The body temperatures of the mothers in normal delivery group were measured before and after the delivery. The body temperatures of the mothers in cesarean section group were measured before and after anesthesia administration. A tympanic thermometer (Braun Thermoscan Irt 4520ß) was used for mothers. Two nurses (same nurse for babies and the other one for mothers) measured the temperatures. Statistical analysis Statistical analyses were performed using SPSS software version 13 (SPSS Inc., Chicago, IL). The variables were investigated using Kolmogorov–Simirnov/Shapiro–Wilk’s tests to determine whether or not they are normally distributed. Kruskal–Wallis tests were performed to compare abnormally distributed parameters. The Mann–Whitney U test was used to test the significance of pairwise differences using Bonferroni correction to adjust for multiple comparisons. An overall 5% type-I error was used to infer statistical significance.
Results The results of the study were summarized in Table 1. The age range of mothers was between 18 and 43. The age of the pregnants did not differ among the three groups, but it was higher in spinal anesthesia group. There was no statistical difference of body temperature of mothers before and after delivery in group 1 and pre-operative and post-operative in group 2. The mean rectal body temperatures of the newborns were as follows: 37.5 ± 0.6 after normal vaginal delivery, 37.2 ± 0.2 after spinal anesthesia, 36.8 ± 0.4 after general anesthesia, respectively, and these differences were statistically significant (p50.001; Table 1). Although Apgar scores in the first minute were higher in normal delivery, the difference was not significant statistically.
Table 1. Characteristics and body temperatures of mothers and babies in groups.
Mother age Pre-op mother temperature (tympanic) Post-op mother temperature (tympanic) Baby temperature (rectal) Birth weight Apgar first minute Apgar fifth minute
Group 1 (n ¼ 40)
Group 2 (n ¼ 51)
Group 3 (n ¼ 15)
p
28.2 ± 5.4 36.31 ± 0.30 36.39 ± 0.27 37.5 ± 0.6 3272 ± 429 8.6 ± 0.6 9.7 ± 0.5
30.6 ± 5.5 36.36 ± 0.26 36.29 ± 0.31 37.2 ± 0.2 3193 ± 484 8.3 ± 0.6 9.6 ± 0.5
28.0 ± 5.9 36.39 ± 0.19 36.25 ± 0.28 36.8 ± 0.4 3201 ± 397 8.3 ± 0.7 9.7 ± 0.5
0.081 0.414 0.215 50.001* 0.628 0.061 0.180
Delivery and neonatal temperature
DOI: 10.3109/14767058.2014.1001359
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
Discussion This study indicated that the mothers who underwent CS did not have statistically difference body temperature compared to mothers with ND but rectal temperatures of the newborn with ND were 0.7 C higher than the babies with general anesthesia and 0.3 C higher than the babies with spinal anesthesia. Lower environmental temperature, prolonged duration of surgery and higher doses of intravenous fluid infusion may cause to hypothermia [11–13]. Matsukawa et al. [14] reported that hypothermia in CS operations was an unexpected complication as they are not long lasting operations. Sessler et al. [15] has been reported that if general anesthesia duration takes over than 40 min, body temperature is reduced between 0.5 and 1.5 C. In our study, the mean duration time of general anesthesia was 70 min although the mothers’ temperatures did not change, babies with general anesthesia had lower body temperatures compared to babies with normal spontaneous vaginal way. Recent reports showed that epidural anesthesia may affect thermoregulation center [16,17]. In the studies of Staen et al. [18] and Washington et al. [19], the general anesthesia lowered the temperature threshold to 4 C. Our results were not compatible with these literatures. There is not a study comparing the body temperatures of newborn after normal vaginal delivery and general and spinal anesthesia delivery. However, Yentur et al. [10] measured the rectal temperatures of the mother and babies with epidural and general anesthesia. They determined that maternal hypothermia did not occur but umbilical vein pH, Apgar scores at the first minute and rectal temperature was lower in babies of the epidural anesthesia group. They also reported that epidural anesthesia needs more intravenous fluid transfusion and a longer period of time compared to general anesthesia, so epidural anesthesia involves a risk of a mild decline in baby temperature. However, Li et al. [9] investigated the effect of neonatal blood gases and adaptation scores on newborns with general and epidural anesthesia and they did not find a significant difference between two groups. In another study [8], shivering rates of mothers were equal both in spinal and epidural anesthesia but later on this rate was declined in spinal anesthesia, a rapid decrease in tympanic body temperature at the beginning of the spinal anesthesia was determined. Although we did not evaluate umbilical vein blood gas, the Apgar scores at first and fifth minutes did not differ significantly. There are many anesthetic agents which are known to influence the thermoregulatory center. Halothane, fentanyl/ nitric oxide which are used in normal clinical doses pull back the threshold of vasoconstriction to 34.5 C [4]. This effect of enflurane is minimal but the combination of nitric oxide and propofol has the maximum effect at this threshold [20,21]. In our study, lidocaine, propofol and rocuronium bromide were used before the baby was born in general anesthesia group. Fentanyl was added after the baby was born. In spinal anesthesia group, lidocaine, bupivocaine and fentanyl were used. In normal vaginal delivery group, no anesthetic agents were used. The body temperatures of the mothers of the three groups were similar. This result was committed to administration of low doses of anesthetic agents.
3
The body temperature of a newborn baby is higher than the mothers. The small changes in body temperatures activate the protective mechanisms to maintain the thermoregulation system [22] such as vasoconstriction of arteriovenous shunt and shivering reaction [23–25]. Perioperative hypothermia may increase shivering reaction and metabolic activity that may lead to coagulation abnormalities, negative nitrogen balance and delayed wound healing [26–29]. In our study, pre- and post-operative maternal body temperatures did not differ among groups and none of babies had hypothermia. The data about Apgar scores of babies with different delivery methods are confusing. Some studies indicated lower Apgar scores in general anesthesia while other studies did not show any difference between general and spinal anesthesia [30–32]. In the study of Yentur et al. [10], the Apgar scores of babies in general anesthesia group were lower than the epidural anesthesia group but our results showed no significant difference. In conclusion, the body temperatures of newborns may differ according to delivery method. Hypothermia may occur in babies after general and spinal anesthesia more common. Therefore, pediatricians, gynecologists, anesthetists, midwives and pediatric nurses should be alert to prevent hypothermia and hypothermia related complications both in mother and baby.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
References 1. Sofer S, Benkovivh E. Severe infantile hypothermia: short and long-term outcome. Intensive Care Med 2000;26:88–92. 2. Horn EP, Bein B, Steinfath M, et al. The incidence and prevention of hypothermia in newborn bonding after cesarean delivery: a randomized controlled trial. Anesth Analg 2014;118:997–1002. 3. Sessler DI. Perioperative heat balance. Anesthesiology 2000;92: 578–96. 4. Sessler DI. The thermoregulation story. Anesthesiology 2013;118: 181–6. 5. Fallis WM, Hamelin K, Symonds J, Wang X. Maternal and newborn outcomes related to maternal warming during cesarean delivery. J Obstet Gynecol Neonatal Nurs 2006;35:324–31. ¨ zdeg˘irmenci O ¨ . Optimal sezaryen hızı ne olmalıdır? _ O 6. Do¨len I, Tu¨rkiye’de ve Du¨nyada gu¨ncel nedir? TJOD Dergisi 2004;7:113–17. 7. Gabbe SG, Niebyl RJ, Simpson JL. Cesarean delivery. In: Gabbe SG, Niebyl RJ, Simpson JL, eds. Obstetrics normal and problem pregnancies. 4th ed. New York: Churchill Livingstone; 2002:539–606. 8. Saito T, Sessler DI, Fujita K, et al. Thermoregulatory effects of spinal and epidural anesthesia during cesarean delivery. Reg Anesth Pain Med 1998;23:418–23. 9. Li CH, Zhu CX, He J. Effects of general anesthesia for cesarean section on infants. Zhonghua Fu Chan Ke Za Zhi 2006;41:162–4. 10. Yentur EA, Topcu I, Ekici Z, et al. The effect of epidural and general anesthesia on newborn rectal temperature at elective cesarean section. Brazil J Med Biol Res 2009;42:863–7. 11. Vaughan MS, Vaughan RW, Cork RC. Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering to rewarming. Anesth Analg 1981;60:746–51. 12. Arkilic CF, Akca O, Taguchi A, et al. Temperature monitoring and management during neuraxial anesthesia: an observational study. Anesth Analg 2000;91:662–6. 13. Frank SM, Beattie C, Christopherson R, et al. Epidural versus general anesthesia, ambient operating room temperature, and
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N. Topalog˘lu et al. patient age as predictors of inadvertent hypothermia. Anesthesiology 1992;77:252–7. Matsukawa T, Sessler DI, Sessler AM, et al. Heat flow and distribution during induction of general anesthesia. Anesthesiology 1995;82:662–73. Sessler DI. Perianesthetic thermoregulation and heat balance in humans. FASEB J 1993;7:638–44. Negishi C, Ozaki M, Suzuki H, Ohno T. Temperature changes and thermoregulatory responses during epidural anesthesia in women undergoing cesarean delivery. Masui 1996;45:558–64. Glosten B, Sessler DI, Faure EAM, et al. Central temperature changes are not perceived during epidural anesthesia. Anesthesiology 1992;77:10–16. Staen R, Sessler DI. The thermoregulatory threshold is inversely proportional to isoflurane concentration. Anesthesiology 1990;72: 822–7. Washington D, Sessler DI, Moayeri A, et al. Thermoregulatory responses to hyperthermia during isoflurane anesthesia in humans. J Appl Physiol 1993;74:82–7. Hynson JM, Sessler DI, Belani K, et al. Thermoregulatory vasoconstriction during propofol/nitrous oxide anesthesia in humans: threshold and Spo2. Anesth Analg 1992;75:947–52. Washington DE, Sessler DI, McGuire J, et al. Painful stimulation minimally increases the thermoregulatory threshold for vasoconstriction during enfiurane anesthesia in humans. Anesthesiology 1992;77:286–90. Horn EP, Schroeder F, Gottschalk A, et al. Active warming during cesarean delivery. Anesth Analg 2002;94:409–14. Mekjavic IB. Core threshold temperatures for sweating. Can J Physiol Pharmacol 1989;67:1038–44.
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24. Rowell LB. Active neurogenic vasodilation in man. In: Vanhoutte PM, Leusen I, eds. Vasodilatation. New York: Raven Press; 1981:1–17. 25. Briick K. Thermoregulation: control mechanisms and neural processes. In: Sinclair JC, ed. Temperature regulation and energy metabolism in the newborn. New York: Grune & Stratton; 1978:157–85. 26. Sessler DI, Rubinstein EH, Moayeri A. Physiological responses to mild perianesthetic hypothermia in humans. Anesthesiology 1991; 75:594–610. 27. Valeri RC, Cassidy G, Khuri S, et al. Hypothermia-induced reversible platelet dysfunction. Ann Surg 1987;205:175–81. 28. Heier T, Caldwell JE, Sessler DI, Miller RD. Mild intraoperative hypothermia increases duration of action and spontaneous recovery of vecuronium blockade during nitrous oxide-isoflurane anesthesia in humans. Anesthesiology 1991;74:815–19. 29. Carli F, Emery PW, Freemantle CAJ. Effect of peroperative normothermia on postoperative protein metabolism in elderly patients undergoing hip arthroplasty. Br J Anaesth 1989;63: 276–82. 30. Hodgkinson R, Husain FJ, Hayashi RH. Systemic and pulmonary blood pressure during caesarean section in parturients with gestational hypertension. Can Anaesth Soc J 1980;27: 389–94. 31. Kolatat T, Somboonnanonda A, Lertakyamanee J, et al. Effects of general and regional anesthesia on the neonate (a prospective, randomized trial). J Med Assoc Thai 1999;82:40–5. 32. Yegin A, Ertug Z, Yilmaz M, Erman M. The effects of epidural anesthesia and general anesthesia on newborns at cesarean section. Turk J Med Sci 2003;33:311–14.
ORIGINAL ARTICLE
Effect of delivery mode on postpartum neonatal body temperatures
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
Naci Topalog˘lu1, Fatih Ko¨ksal Binnetog˘lu1, S¸ ule Yıldırım1, Mustafa Tekin1, Nazan Kaymaz1, Hakan Aylanc¸1, Fatih Battal1, Hasan Ali Kiraz2, Meryem Gencer3, Esra Ba¸ser1, and Volkan Hancı4 1
Department of Pediatrics, Medical Faculty, 2Department of Anesthesiology and Reanimation, Medical Faculty, 3Department of Obstetrics and Gynecology, Medical Faculty, C¸anakkale Onsekiz Mart University, C¸anakkale, Turkey, and 4Department of Anesthesiology and Reanimation, Medical Faculty, Dokuz Eylu¨l University, _Izmir, Turkey Abstract
Keywords
Objective: It is known that general and local anesthesia practices disrupt the delicate balance of thermoregulation center which is already sensitive to very tiny differences of temperatures in a normal subject. We aimed to evaluate and compare the rectal temperatures of newborns born with normal vaginal delivery and cesarean section. Methods: We performed a prospective study of 106 term newborn – 40 born with normal vaginal delivery (group 1) and 66 born with cesarean section [51 spinal anesthesia (group 2), 15 general anesthesia (group 3)]. Only term babies were included in the study. Babies of eclamptic, pre-eclamptic and diabetic mothers and babies with chronic systemic diseases were excluded. Pregnants who underwent elective cesarean section were included in the study. Adolescent pregnants, pregnants with increased risks and pregnants with complicated operations were excluded. Mothers’ temperatures were measured before and after the interventions. Rectal temperatures of the babies were measured immediately after birth. Results: Environmental temperature was maintained at 22–24 C. Pre-operative mother temperatures were 36.31 ± 0.30 C in group 1, 36.36 ± 0.26 C in group 2 and 36.39 ± 0.19 C in group 3 (p ¼ 0.414). Post-operative mother temperatures were 36.39 ± 0.27 C in group 1, 36.29 ± 0.31 C in group 2 and 36.25 ± 0.28 C in group 3 (p ¼ 0.215). Rectal temperatures of the babies born with normal vaginal delivery were significantly higher than the others. It was lowest in the general anesthesia group (37.5 ± 0.6 C, 37.2 ± 0.2 C and 36.8 ± 0.4 C in group 1, 2 and 3, respectively). The temperature differences between groups were statistically significant p50.001). Conclusions: In conclusion, it is worthy to note that temperatures of the newborns can differ according to the delivery mode. Physicians and health professionals that take care of the newborns should be aware of this difference.
Anesthesia general, cesarean section, delivery, newborn, spinal, thermoregulation, vaginal
Introduction Hypothermia causing rapid energy loss in newborn increases glucose utilization as a compensatory mechanism and finally hypoglycemia and hypoglycemia-induced complications occur [1]. All newborn babies are susceptible to hypothermia but babies delivered by operative delivery are even at higher risk. In anesthesia-related processes, the control of normal body temperature cannot be achieved. Local and general anesthetics are known to impair the body temperature [2]. Hypothermia is one of the most common complications of surgery [3]. Besides the duration of anesthesia, anesthetic drugs also affect thermoregulation [4]. Therefore, all patients Address for correspondance: S ¸ ule Yıldırım, Department of Pediatrics, Medical Faculty, C¸anakkale Onsekiz Mart University, C¸anakkale ¨ niversitesi Tıp Faku¨ltesi Hastanesi, Cumhuriyet Onsekiz Mart U Mahallesi Sahil Yolu No 5, Kepez, C¸anakkale, Turkey. Tel: +90 505 828 07 07. Fax: +90 286 263 59 56. E-mail: [email protected]
History Received 9 March 2014 Revised 15 December 2014 Accepted 18 December 2014 Published online 8 January 2015
undergoing anesthesia should be considered in the risk of hypothermia [5]. In recent years, the frequency of elective caesarean has increased both in developed and developing countries. The World Health Organization (WHO) suggests the ideal frequency of cesarean births as 10–15% of all births. Levels exceeding 17% is considered very high. In our country this rate is about 40% of all births [6,7]. There are various studies reporting the changes of neonatal body temperature after general, spinal and epidural anesthesia [8,9]. Yentur et al. indicated that newborn rectal temperature was lower in babies of the epidural anesthesia than in babies of the general anesthesia immediately after birth [10]. In this study, we hypothesized that different modes of delivery can affect the postpartum neonatal body temperatures. The major outcome was rectal temperatures of the babies after normal vaginal delivery and general and spinal anesthesia delivery. To diagnose this hypothesis, we performed a study to
2
N. Topalog˘lu et al.
J Matern Fetal Neonatal Med, Early Online: 1–4
document effects of delivery mode on postpartum neonatal body temperatures.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
Methods One-hundred and six newborn babies, 40 born with normal delivery (ND; group 1) and 66 with cesarean section (CS) from September 2013 to December 2013 were included into this prospective study. Cesarean section group was further divided into two groups according to the type of anesthesia, 51 with spinal anesthesia (group 2) and 15 with general anesthesia (group 3). The parents were informed of the aim of the study and provided written consent and the local ethics committee of university approved the study. Maternal inclusion criteria were to have uncomplicated pregnancy and to undergo elective cesarean section for CS group. Adolescent pregnants, pregnants with increased risks and pregnants with complicated operations were excluded. Neonatal inclusion criteria were term babies without any chronic systemic diseases. Babies of eclamptic, pre-eclamptic and diabetic mothers and babies with chronic systemic diseases were excluded. CS operation Environmental temperature was maintained at 22–24 C. All intravenous infusion fluids were given at a degree of 37 C. After an 8 h fasting period, the pregnants in American Society of Anesthesiologists-I (ASA-I) risk group underwent spinal or general anesthesia for CS. Pulse oxymetry, electrocardiography, non-invasive blood pressure monitoring were administered to all women during operation. Patients were covered with standard surgical drape during the operation and any heating method was not utilized. General anesthesia was induced by 1 mg/kg lidocaine, 2 mg/kg propofol. Endotracheal intubation was carried out at the first minute of the 0.6 mg/kg rocuronium bromide administration. Incision was allowed after intubation was confirmed. Anesthesia was maintained with up to 50% O2 and 50% N2O until the baby is born. After the delivery, 2 mcg/kg fentanyl was administered and anesthesia was maintained with up to 40% O2, 60% room air, 0.5–1% MAC SevoraneÕ . At the need of the operation, the patients were antagonized by 0.03 mg/kg neostigmine and 0.015 mg/kg atropine. All patients undergoing spinal anesthesia were prehydrated with 500 ml lactated Ringer’s solution. Spinal anesthesia was performed in a seated position at L3–L4 or L4–L5 level. Skin was disinfected. Local anesthesia was achieved by infiltrating 1.5 ml of 2% lidocaine from the skin
to the ligamentum flavum. About 10 mg of 0.5% hyperbaric bupivacaine and 10 mcg of fentanyl were administered into subarachnoid space using 26 Gauge atraumatic spinal needles. Incision was allowed when the sensory block came to the T5 level. Measurements The body temperature of the babies were measured by digitaltipped thermometers (Rossmax TB 100ß) soon after birth at first minute. All babies received the standard care, i.e. put under the heater and after drying the body temperatures were measured. The body temperatures of the mothers in normal delivery group were measured before and after the delivery. The body temperatures of the mothers in cesarean section group were measured before and after anesthesia administration. A tympanic thermometer (Braun Thermoscan Irt 4520ß) was used for mothers. Two nurses (same nurse for babies and the other one for mothers) measured the temperatures. Statistical analysis Statistical analyses were performed using SPSS software version 13 (SPSS Inc., Chicago, IL). The variables were investigated using Kolmogorov–Simirnov/Shapiro–Wilk’s tests to determine whether or not they are normally distributed. Kruskal–Wallis tests were performed to compare abnormally distributed parameters. The Mann–Whitney U test was used to test the significance of pairwise differences using Bonferroni correction to adjust for multiple comparisons. An overall 5% type-I error was used to infer statistical significance.
Results The results of the study were summarized in Table 1. The age range of mothers was between 18 and 43. The age of the pregnants did not differ among the three groups, but it was higher in spinal anesthesia group. There was no statistical difference of body temperature of mothers before and after delivery in group 1 and pre-operative and post-operative in group 2. The mean rectal body temperatures of the newborns were as follows: 37.5 ± 0.6 after normal vaginal delivery, 37.2 ± 0.2 after spinal anesthesia, 36.8 ± 0.4 after general anesthesia, respectively, and these differences were statistically significant (p50.001; Table 1). Although Apgar scores in the first minute were higher in normal delivery, the difference was not significant statistically.
Table 1. Characteristics and body temperatures of mothers and babies in groups.
Mother age Pre-op mother temperature (tympanic) Post-op mother temperature (tympanic) Baby temperature (rectal) Birth weight Apgar first minute Apgar fifth minute
Group 1 (n ¼ 40)
Group 2 (n ¼ 51)
Group 3 (n ¼ 15)
p
28.2 ± 5.4 36.31 ± 0.30 36.39 ± 0.27 37.5 ± 0.6 3272 ± 429 8.6 ± 0.6 9.7 ± 0.5
30.6 ± 5.5 36.36 ± 0.26 36.29 ± 0.31 37.2 ± 0.2 3193 ± 484 8.3 ± 0.6 9.6 ± 0.5
28.0 ± 5.9 36.39 ± 0.19 36.25 ± 0.28 36.8 ± 0.4 3201 ± 397 8.3 ± 0.7 9.7 ± 0.5
0.081 0.414 0.215 50.001* 0.628 0.061 0.180
Delivery and neonatal temperature
DOI: 10.3109/14767058.2014.1001359
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
Discussion This study indicated that the mothers who underwent CS did not have statistically difference body temperature compared to mothers with ND but rectal temperatures of the newborn with ND were 0.7 C higher than the babies with general anesthesia and 0.3 C higher than the babies with spinal anesthesia. Lower environmental temperature, prolonged duration of surgery and higher doses of intravenous fluid infusion may cause to hypothermia [11–13]. Matsukawa et al. [14] reported that hypothermia in CS operations was an unexpected complication as they are not long lasting operations. Sessler et al. [15] has been reported that if general anesthesia duration takes over than 40 min, body temperature is reduced between 0.5 and 1.5 C. In our study, the mean duration time of general anesthesia was 70 min although the mothers’ temperatures did not change, babies with general anesthesia had lower body temperatures compared to babies with normal spontaneous vaginal way. Recent reports showed that epidural anesthesia may affect thermoregulation center [16,17]. In the studies of Staen et al. [18] and Washington et al. [19], the general anesthesia lowered the temperature threshold to 4 C. Our results were not compatible with these literatures. There is not a study comparing the body temperatures of newborn after normal vaginal delivery and general and spinal anesthesia delivery. However, Yentur et al. [10] measured the rectal temperatures of the mother and babies with epidural and general anesthesia. They determined that maternal hypothermia did not occur but umbilical vein pH, Apgar scores at the first minute and rectal temperature was lower in babies of the epidural anesthesia group. They also reported that epidural anesthesia needs more intravenous fluid transfusion and a longer period of time compared to general anesthesia, so epidural anesthesia involves a risk of a mild decline in baby temperature. However, Li et al. [9] investigated the effect of neonatal blood gases and adaptation scores on newborns with general and epidural anesthesia and they did not find a significant difference between two groups. In another study [8], shivering rates of mothers were equal both in spinal and epidural anesthesia but later on this rate was declined in spinal anesthesia, a rapid decrease in tympanic body temperature at the beginning of the spinal anesthesia was determined. Although we did not evaluate umbilical vein blood gas, the Apgar scores at first and fifth minutes did not differ significantly. There are many anesthetic agents which are known to influence the thermoregulatory center. Halothane, fentanyl/ nitric oxide which are used in normal clinical doses pull back the threshold of vasoconstriction to 34.5 C [4]. This effect of enflurane is minimal but the combination of nitric oxide and propofol has the maximum effect at this threshold [20,21]. In our study, lidocaine, propofol and rocuronium bromide were used before the baby was born in general anesthesia group. Fentanyl was added after the baby was born. In spinal anesthesia group, lidocaine, bupivocaine and fentanyl were used. In normal vaginal delivery group, no anesthetic agents were used. The body temperatures of the mothers of the three groups were similar. This result was committed to administration of low doses of anesthetic agents.
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The body temperature of a newborn baby is higher than the mothers. The small changes in body temperatures activate the protective mechanisms to maintain the thermoregulation system [22] such as vasoconstriction of arteriovenous shunt and shivering reaction [23–25]. Perioperative hypothermia may increase shivering reaction and metabolic activity that may lead to coagulation abnormalities, negative nitrogen balance and delayed wound healing [26–29]. In our study, pre- and post-operative maternal body temperatures did not differ among groups and none of babies had hypothermia. The data about Apgar scores of babies with different delivery methods are confusing. Some studies indicated lower Apgar scores in general anesthesia while other studies did not show any difference between general and spinal anesthesia [30–32]. In the study of Yentur et al. [10], the Apgar scores of babies in general anesthesia group were lower than the epidural anesthesia group but our results showed no significant difference. In conclusion, the body temperatures of newborns may differ according to delivery method. Hypothermia may occur in babies after general and spinal anesthesia more common. Therefore, pediatricians, gynecologists, anesthetists, midwives and pediatric nurses should be alert to prevent hypothermia and hypothermia related complications both in mother and baby.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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