Authors: Kumar M et al.
Cureus 17(11): e97895, 2025. DOI: 10.7759/cureus.97895
Summary
This randomized controlled trial evaluated how patient position during and immediately after spinal anesthesia affects maternal hemodynamics and neonatal outcomes in elective cesarean delivery. One hundred thirty-five healthy term parturients (ASA II, singleton pregnancies) scheduled for elective C-section were randomized into three groups (n = 45 each):
• Group S1 – spinal performed sitting, patient remained seated for 1 minute, then supine with left tilt
• Group S2 – spinal performed sitting, patient remained seated for 2 minutes, then supine with left tilt
• Group L – spinal performed in the left lateral position, then immediately supine with left tilt
All women received 2.5 mL of 0.5% hyperbaric bupivacaine at L3–4 with a 26G Quincke needle. Hemodynamics (MAP, HR, SpO₂) were recorded frequently for the first 30 minutes, then at longer intervals. Hypotension was defined as MAP drop >30% from baseline or SBP <90 mmHg and treated with IV mephentermine 6 mg boluses. Sensory block (to T4), motor block (Modified Bromage), vasopressor requirement, APGAR scores, patient satisfaction (7-point verbal scale), and complications (nausea, vomiting, bradycardia, shivering) were assessed.
Baseline demographics and pre-spinal hemodynamics were similar across groups. After spinal, MAP decreases were significantly greater in the sitting groups (S1 and S2) than in the lateral group at 2, 3, 5, and 10 minutes. Group L maintained the most stable MAP profile with fewer hypotensive episodes. Heart rate rose more in the sitting groups early after spinal; Group L showed a smoother HR response.
Block characteristics favored the lateral position. Time to reach T4 sensory level was shortest in Group L (4.2 ± 1.3 min) versus S1 (6.7 ± 1.0 min) and S2 (6.8 ± 1.1 min). Time to Bromage 3 motor block was also faster in Group L (6.4 ± 2.2 min) compared with S1 (8.5 ± 1.9 min) and S2 (8.9 ± 2.4 min). Maximal block levels were otherwise comparable.
Vasopressor use differed markedly: mean mephentermine dose was 6.4 ± 1.6 mg in Group L versus 14.3 ± 5.7 mg in S1 and 13.0 ± 5.6 mg in S2. Neonatal APGAR scores were higher in the lateral group at both 1 minute (7.2 vs about 5.0–5.5) and 5 minutes (9.2 vs about 7.7–7.9), though all groups were generally within acceptable ranges.
Patient satisfaction was highest in the lateral group (mean 5.6 on 7-point scale), compared with 4.4 in S1 and 4.1 in S2. The incidence of individual complications (nausea/vomiting, bradycardia, shivering) did not differ significantly, but overall complication burden was lower in Group L than in S1.
The authors conclude that performing spinal anesthesia for elective cesarean section in the lateral position yields better hemodynamic stability, reduces vasopressor requirement, speeds onset of sensory and motor block, improves neonatal APGAR scores, and enhances patient satisfaction compared with remaining seated for 1–2 minutes after spinal injection. Sitting remains acceptable, particularly where landmarks are challenging or the operator strongly prefers it, but the lateral position may be the preferred default when minimizing maternal hypotension is the priority.
What You Should Know
• Positioning around the time of spinal for C-section is not just about ease of landmark identification – it has measurable hemodynamic and neonatal consequences.
• A left lateral spinal with immediate supine/tilted positioning produced the most stable MAP and HR profile and the lowest vasopressor use.
• Sitting 1 or 2 minutes post-spinal before laying the patient down did not meaningfully differentiate S1 from S2, and both were inferior to lateral in terms of hypotension and vasopressor needs.
• Faster onset to T4 and full motor block in the lateral group may be clinically useful when OR turnover and surgical readiness are time-sensitive.
• Neonatal APGAR scores favored the lateral group, consistent with better maternal hemodynamics and uteroplacental perfusion.
• Patients reported higher satisfaction with lateral positioning despite the common perception that sitting is “easier” for the anesthesiologist.
• Complication profiles were similar, but overall events were numerically higher in the sitting groups.
Key Points
• Population: 135 ASA II term parturients for elective C-section under spinal anesthesia (hyperbaric bupivacaine 0.5%, 2.5 mL).
• Intervention: Spinal performed and maintained in left lateral (Group L) vs sitting with 1-minute delay (S1) vs sitting with 2-minute delay (S2) before supine.
• Hemodynamics: Lateral position significantly reduced MAP drops at early time points and required about half the mephentermine dose of sitting groups.
• Block dynamics: Lateral position yielded faster sensory (T4) and motor block onset without excessive cephalad spread or added complications.
• Neonates: APGAR scores at 1 and 5 minutes were significantly higher in the lateral group.
• Patient experience: Lateral positioning was associated with higher satisfaction and comparable or fewer minor side effects.
• Practice implication: For routine elective C-sections, a lateral spinal with prompt supine left tilt is a strong default choice when the goal is to minimize hypotension and vasopressor use, reserving sitting primarily for cases where anatomy or operator factors demand it.
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