Cesarean section is the most common surgery in the obstetrics department.In recent years, cesarean section (CS) rates have risen markedly and now exceed a rate that is assumed to be optimal with respect to the well-being of the newborn and the mother. Mother and fetus well-being should be taken into the account while planning anaesthesia for cesarean delivery.1 Regional anaesthesia is safer for the mother than general anaesthesia and the most common method of anaesthesia for delivery because it allows the mother to be awake and immediately interact with her baby .The ideal method of anaesthesia for cesarean section should have good intra operative analgesia, alleviate the discomfort during the surgery as much as possible, reduce the incidence of post operative adverse reactions, and mitigate the adverse effects of cesarean section on the newborn.2 Spinal anaesthesia, as a classic method of anaesthesia in cesarean section, is recommended by relevant guidelines on anaesthesia. It is safe and has been widely used. Nevertheless, some patients still reject this method due to fear, anxiety, tension, and contraindications for anaesthesia. In contrast to regional anaesthesia, general anaesthesia offers a very rapid and reliable onset, control over the airway and ventilation and potentially less hypotension. The major adverse fetal effect of regional anaesthesia and its sympathetic blockade is utero-placental hypo- perfusion which leads to an acute fall in intervillous blood flow with the potential for fetal acidaemia.3 Studies on the effect of general versus regional anaesthesia on neonatal Apgar scores have shown mixed results. Some find no difference between the two groups, while others report lower scores and worse outcomes with general anaesthesia, possibly due to transient sedation from anaesthetic agents. Additionally, regional anaesthesia has been linked to increased neonatal acidosis, possibly due to maternal hypotension and the use of ephedrine to support blood pressure. Cesarean delivery is associated with more anaesthesia-related adverse events and perioperative morbidity than vaginal delivery. Obstetric ARAEs are usually preventable because they are often caused by substandard care. The risk of ARAEs during cesarean delivery is especially high when the procedure is unplanned, when it is performed under general anaesthesia, and in women with preexisting comorbidities. To minimize the risk of ARAEs, the ASA recommends neuraxial anaesthetic techniques for cesarean delivery, whenever possible.4 Maternal mortality remains a major issue in developing countries, accounting for over 98% of global deaths. Studies on maternal mortality often implicate hemorrhage, sepsis, hypertensive diseases of pregnancy, and induced abortion complications as the major risk factors. With this anaesthesia emerging as an additional concern.5,6 Anaesthesia-related deaths, though fewer, are often considered preventable. Improving anaesthesia care and reporting is crucial to reduce these avoidable fatalities.

Study design: Prospective observational study Study population: 165 patients who undergone cesarean delivery in obstetrics department Source of data: It is a prospective observational study which was conducted in patients who undergone cesarean delivery in obstetrics department applying following inclusion and exclusion criteria and after obtaining institutional ethical committee clearance Inclusion Criteria: • Patients more than 18 years. • Patient who is having term pregnancy (37 week) undergoing cesarean delivery in department of obstetrics due to various maternal and fetal indications. • Patients who categorized as ASA physical status class 2 and above. • All booked and non-booked patient • Patients who are willing to participate will be included in this study after an informed and written consent. Exclusion Criteria: • Patients who refuse to participate in this study. Data Collection: After taking ethical committee clearance, informed and written consent was obtained from patients who are all posted for cesarean delivery in obstetrics department. Pre operatively data was collected from medical history, obstetric history (age, ASA status, co- morbidities, demographic characteristics), basic investigations and special investigations based on obstetric history. On arrival to the operating room, basal vital parameters (Heart rate, Blood pressure, Respiratory rate, ECG) was recorded. Cesarean delivery was performed under neuraxial or general anaesthesia. The choice of anaesthesia method was determined based on medical history, obstetric history, co-morbidities and contraindications. Patients received standard anaesthesia as per institutional protocol. The mode of anaesthesia, dose and the drug used in anaesthesia was recorded. All data were collected prospectively from intra operative vitals monitoring for every 5 min,10 min,15 min, post baby extraction every 15 mins, vitals were recorded till procedure and patient was monitored for intra operative anaesthesia related adverse events including hypoxia, desaturation, hypotension, hypocarbia, pain, hypothermia, need for o2 supplementation, any other form of ventilator support, APGAR score at 1 min and 5 min, umbilical cord blood gas analysis, NICU admission. Patients were monitored post cesarean delivery in the post-operative care unit for 24 hours for adverse events like hypotension, shivering, postoperative nausea and vomiting, pain, desaturation and other forms of ventilatory support. Patient who was operated under spinal anaesthesia was asked for sensory and motor recovery. Patients who required post operative oxygen data was collected. Cord blood analysis data was collected on requirement by paediatrician..

Table 1: Incidence of perioperative anaesthesia related maternal adverse events PARAMETERS NO OF CASES PERCENTAGE Patients with perioperative adverse events 131 79.3 Patients without perioperative adverse events 34 20.6 Out of a total of 165 patients 130 patients (78.7%) experienced perioperative adverse events, indicating that a significant majority of the patients encountered complications during or around the time of surgery, 35 patients (21.2%) did not experience any perioperative adverse events. Table 2: Intraoperative anaesthesia related maternal adverse events Intra op maternal adverse events No of cases (%) Hypoxia 2 (1.2) Desaturation 4 (2.4) Hypocarbia 4 (2.4) Need for O2 supplementation 25 (15.0) Other forms of ventilatory support 16 (9.6) Hypotension 103 (62.4) Tachycardia 95 (57.6) Bradycardia 5 (3.0) Hyperthermia 1 (0.6) Hypothermia 38 (23.0) Nausea and vomiting 13 (7.8) Pain 3 (1.8) Difficult spinal 7 (78.0) High spinal anaesthesia 2 (22.0) Failed spinal anaesthesia 3 (33.0) Extra uterotonics usage 28 (17.0) The most common intraoperative adverse event was hypotension, affecting 103 patients (62.4%), which is a well-known side effect of neuraxial anaesthesia due to sympathetic blockade. Tachycardia was the second most frequent adverse event (95 patients, 57.6%), which may be secondary to hypotension or a response to surgical stress. Hypothermia occurred in 38 patients (23.0%), highlighting the importance of temperature management during cesarean delivery. Extra uterotonic usage was required in 28 patients (17.0%), indicating cases of uterine atony requiring additional intervention beyond standard oxytocin. Need for oxygen supplementation was observed in 25 patients (15.0%), and other forms of ventilatory support were needed in 16 patients (9.6%), suggesting respiratory compromise in a significant subset of patients. Nausea and vomiting occurred in 13 patients (7.8%), a common side effect of neuraxial anaesthesia and surgical stimulation. Less common adverse events included bradycardia (5 patients, 3.0%), desaturation and hypocarbia (both 4 patients, 2.4% each), pain (3 patients, 1.8%), hypoxia (2 patients, 1.2%), and hyperthermia (1 patient, 0.6%). There were also specific complications related to spinal anaesthesia, including difficult spinal administration (7 patients), high spinal anaesthesia (2 patients), and failed spinal anaesthesia (3 patients). The high incidence of hypotension and tachycardia underscores the need for vigilant hemodynamic monitoring during cesarean delivery. Table 3: Extra uterotonics usage Extra uterotonics usage No of cases (%) Oxytocin 17 (60.7) Oxytocin + misoprostol 2 (7.1) Oxytocin + carboprost 5 (17.9) Oxytocin + misoprostol + carboprost 3 (10.7) Oxytocin + carboprost + methylergometrine 1 (3.6) Total 28 (100.0) Among the 28 cases requiring extra uterotonics beyond the standard protocol, oxytocin alone was the most commonly used additional uterotonic agent (17 patients, 60.7% of extra uterotonic cases). The combination of oxytocin and carboprost was used in 5 patients (17.9% of extra uterotonic cases), while triple therapy with oxytocin, misoprostol, and carboprost was used in 3 patients (10.7% of extra uterotonic cases). Oxytocin with misoprostol was used in 2 patients (7.1% of extra uterotonic cases), and the most complex combination of oxytocin, carboprost, and methylergometrine was used in 1 patient (3.6% of extra uterotonic cases). This distribution indicates that most cases of uterine atony could be managed with additional oxytocin alone (60.7%), while a significant proportion (39.3%) required multiple uterotonics, indicating more severe cases of uterine atony. The need for multiple uterotonic agents in 11 patients (39.3% of those receiving extra uterotonics, or 6.7% of the total study population) suggests cases of refractory uterine atony that required escalating interventions to control postpartum haemorrhage. Table 4: Postoperative anaesthesia related maternal adverse events Post op maternal adverse events No of cases (%) Hypoxia 2 (1.2) Desaturation 3 (1.8) Need for O2 supplementation 24 (14.5) Other forms of ventilatory support 7 (4.2) Hypotension 5 (3.0) Tachycardia 10 (6.0) Hyperthermia 3 (1.8) Shivering 9 (5.4) Nausea and vomiting 4 (2.4) Others 7 (4.2) In the postoperative period, the need for oxygen supplementation was the most common adverse event, affecting 24 patients (14.5%), suggesting continued respiratory concerns after surgery. Tachycardia was observed in 10 patients (6.0%), which may reflect pain, anxiety, or ongoing physiological stress responses. Shivering, a common complication after neuraxial anaesthesia, affected 9 patients (5.4%). Other forms of ventilatory support were required in 7 patients (4.2%), indicating more severe respiratory compromise. Hypotension occurred in 5 patients (3.0%), a marked decrease from the intraoperative period (62.4%), demonstrating the resolution of anaesthesia-induced sympathetic blockade. Nausea and vomiting affected 4 patients (2.4%), lower than the intraoperative incidence (7.8%), suggesting improvement in this symptom postoperatively. Desaturation and hyperthermia each occurred in 3 patients (1.8%), while hypoxia was observed in 2 patients (1.2%). Other unspecified complications were reported in 7 patients (4.2%). The decreased incidence of hypotension, nausea, and vomiting in the postoperative period compared to intraoperative values suggests resolution of these anaesthesia-related side effects. Table 5: Other postoperative anaesthesia related maternal adverse events Others No of cases (%) Death 2 (28.6) Pulmonary edema 2 (28.6) Seizures 2 (28.6) Tachypnea 1 (14.3) Total 7 (100.0) Among the 7 cases with other postoperative complications, deaths, pulmonary edema, and seizures each accounted for 2 patients (28.6% of other complications, or 1.2% of the total study population), while tachypnoea occurred in 1 patient (14.3% of other complications, or 0.6% of the total study population). The occurrence of 2 maternal deaths represents a maternal mortality rate of 1.2% in this study population. Pulmonary oedema in 2 patients may be related to fluid management, pre-eclampsia, or cardiac dysfunction. The occurrence of seizures in 2 patients could be related to eclampsia or other neurological causes. Tachypnoea in 1 patient may indicate respiratory distress, pain, or anxiety. Table 6: Incidence of anaesthesia related neonatal adverse outcomes in terms of APGAR score: APGAR score Mean±SD 1 MIN 6.93±1.21 5 MIN 8.95±1.20 The mean APGAR score at 1 minute was 6.93±1.21, which is in the moderately depressed range (4-6). The mean APGAR score at 5 minutes increased to 8.95±1.20, which is in the normal range (7-10). This improvement in APGAR scores from 1 minute to 5 minutes (an increase of 2.02 points) is clinically significant and suggests appropriate neonatal care. The standard deviations of 1.21 and 1.20 indicate moderate variability in neonatal condition both at birth and at 5 minutes. Table 7: Incidence of anaesthesia related neonatal adverse outcomes in terms of NICU admission: NICU admission No of cases (%) Yes 23 (13.9) No 142 (86.1) Total 165 (100.0) Of the 165 neonates, 23 (13.9%) required admission to the Neonatal Intensive Care Unit (NICU), while 142 (86.1%) did not require such intensive care. This NICU admission rate of 13.9% is somewhat higher than typical rates for term pregnancies, which may reflect the study population's higher risk profile (all ASA 2 or higher). The majority of neonates (86.1%) not requiring NICU admission suggests that most had good outcomes following caesarean delivery despite the maternal co-morbidities present in this study population. Table 8: Incidence of anaesthesia related neonatal adverse outcomes in terms of cord blood analysis Cord blood analysis No of cases (%) Yes 22 (13.3) No 143 (86.6) Total 165 (100.0) Cord blood analysis was performed in 22 neonates (13.3%) and not performed in 143 neonates (86.6%). According to the study methodology, cord blood analysis was done only in newborns with APGAR score ≤ 6, which explains the similar proportion to NICU admissions (13.9%). The slight discrepancy (22 cord blood analyses vs. 23 NICU admissions) suggests that one neonate may have been admitted to the NICU for reasons other than low APGAR score (very low birth weight). The fact that 13.3% of neonates had cord blood analysis indicates a significant subset with potential acidemia or other metabolic derangements at birth. The close correspondence between cord blood analysis rates and NICU admission rates suggests a consistent approach to identifying and managing compromised neonates in this study. Table 9: Correlation between NICU admission and type of anaesthesia NICU admission No of cases Type of anaesthesia Chi square test Epidural anaesthesia Spinal anaesthesia General anaesthesia Spinal converting to GA χ2 value P value Yes 23 0 19 4 0 4 0.246 No 142 2 127 9 4 - - Total 165 2 146 13 4 - - There was no statistically significant association between the type of anaesthesia and NICU admission (p=0.246). Of the 23 neonates admitted to NICU, 19 (82.6%) were born to mothers who received spinal anaesthesia, and 4 (17.4%) to mothers who received general anaesthesia. No neonates born to mothers who received epidural anaesthesia or spinal converted to general anaesthesia required NICU admission. Proportionally, NICU admission rates were 13.0% for spinal anaesthesia (19 of 146 cases), 30.8% for general anaesthesia (4 of 13 cases), 0% for epidural anaesthesia (0 of 2 cases), and 0% for spinal converted to general anaesthesia (0 of 4 cases). The higher rate of NICU admission present in general anaesthesia, but not statistically significant.

Despite the high proportion of spinal anaesthesia use, technical difficulties were documented in a notable number of cases. Difficult spinal administration occurred in 7 of 146 spinal anaesthesia cases (4.8%), high spinal block in 2 cases (1.4%), and failed spinal anaesthesia in 3 cases (2.0%). These rates are consistent with the literature. Riley et al.7 reported a spinal anaesthesia failure rate of 2.7% in their multi center study, while Kinsella 8 documented difficult spinal placement in 5.6% of cases. These technical challenges highlight the importance of anaesthesiologist experience and preparedness for alternative techniques when neuraxial approaches prove challenging. Hypotension was the most common intraoperative complication (62.4%) in our study, followed by tachycardia (57.6%). The high incidence of hypotension is consistent with the known hemodynamic effects of neuraxial anaesthesia due to sympathetic blockade. Klohr et al.9 conducted a systematic review of 63 studies and reported hypotension incidence ranging from 7.4% to 74.1% following spinal anaesthesia for cesarean delivery, depending on th0.e definition used and preventive measures employed. Our finding of 62.4% falls within this range and is comparable to the 60.2% reported by Bao et al. 10 in their retrospective analysis in China. The presence of hypotension is clinically significant as it may lead to maternal nausea and vomiting, dizziness, and in severe cases, compromised uteroplacental perfusion affecting fetal wellbeing. Hypothermia, occurring in 23.0% of our patients, represents another significant intraoperative complication. This rate is comparable to findings from Cobb et al. 11, who reported a 21.6% incidence of intraoperative hypothermia during cesarean deliveries. Hypothermia during cesarean delivery is multifactorial, resulting from neuraxial anaesthesia-induced vasodilation, reduced thermogenesis, exposure to cool operating room environments, and administration of room-temperature intravenous fluids. The consequences of perioperative hypothermia include increased blood loss, cardiac events, wound infections, and prolonged drug effects, emphasizing the importance of temperature monitoring and warming strategies. Need for supplemental oxygen (15.0%) and other forms of ventilatory support (9.6%) were notable respiratory complications in our cohort. These rates are somewhat higher than those reported by Chau-in et al.5, who documented respiratory complications in 7.2% of cases in their large Thai study of 16,697 cesarean deliveries. The difference may reflect our study's focus on patients with ASA status 2 or higher, who may be more prone to respiratory complications due to underlying systemic disease. Hypertensive disorders were particularly associated with respiratory complications in our study, with 50% of cases requiring other forms of ventilatory support having hypertensive disorders. This association has been noted in previous research, with Bhatia et al.12 describing how pregnancy-induced hypertension can lead to laryngeal edema, pulmonary edema, and increased sensitivity to respiratory depressants, potentially complicating respiratory management during anaesthesia. The need for extra uterotonics in 17.0% of cases in our study represents an important obstetric complication with anaesthetic implications. Butwick et al. 13 reported a similar rate of 15.8% in their large retrospective study of cesarean deliveries. Interestingly, we found a significant association between anaesthesia type and extra uterotonic usage (p<0.001), with proportionally more cases requiring additional uterotonics after general anaesthesia (53.8%) compared to spinal anaesthesia (13.7%). This aligns with findings from Heesen et al.14, who reported decreased uterine tone with volatile anaesthetics during general anaesthesia, potentially necessitating additional uterotonics. The common use of oxytocin alone (60.7%) as the additional uterotonic in our study corresponds with standard obstetric protocols, with more complex combinations of uterotonics reserved for refractory cases. In the postoperative period, the need for oxygen supplementation remained the most common adverse event (14.5%), followed by tachycardia (6.0%) and shivering (5.4%). The persistence of respiratory concerns postoperatively, particularly after general anaesthesia, underscores the importance of vigilant postoperative monitoring. Bao et al.10 similarly reported that respiratory complications were among the most common postoperative issues after cesarean delivery, especially following general anaesthesia. Postoperative shivering, occurring in 5.4% of our patients, was exclusively associated with neuraxial anaesthesia. This incidence is somewhat lower than the 10- 33% reported in the literature. Severe complications in our study included maternal death (2 cases, 1.2%), pulmonary edema (2 cases, 1.2%), and seizures (2 cases, 1.2%). The maternal mortality rate of 1.2% is considerably higher than rates reported in developed countries. For comparison, Guglielminotti et al. 4 reported a maternal mortality rate of 0.0036% associated with cesarean delivery in New York State. Our higher rate may reflect the tertiary referral nature of our institution, receiving complex cases with higher inherent risks, or may indicate opportunities for improvement in perioperative care. Notably, both deaths in our study occurred after general anaesthesia, representing 15.4% of general anaesthesia cases. This significant association (p<0.001) between general anaesthesia and maternal mortality aligns with findings from the landmark study by Hawkins et al. 15, which documented a 16.7 times higher risk of maternal mortality with general versus neuraxial anaesthesia for cesarean delivery. The occurrence of pulmonary edema exclusively after spinal anaesthesia in our study (2 cases, 1.4% of spinal anaesthesia cases) is an interesting finding. Both cases were associated with hypertensive disorders, consistent with the known risk of pulmonary edema in preeclampsia due to altered capillary permeability and decreased colloid oncotic pressure. Dennis et al. 16 reported a similar association, with 85% of cases of pulmonary edema during pregnancy occurring in women with preeclampsia. Neonatal outcomes in our study were generally favourable, with mean APGAR scores of 6.93 at 1 minute and 8.95 at 5 minutes. The improvement from 1 to 5 minutes indicates good neonatal adaptation and effective resuscitation when needed. The NICU admission rate of 13.9% is comparable to rates reported in similar studies. Jawad et al. 6 reported NICU admission rates of 12% after spinal anaesthesia and 18% after general anaesthesia for cesarean delivery. Our study found no significant association between type of anaesthesia and NICU admission (p=0.246), although the proportion was higher after general anaesthesia (30.8%) compared to spinal anaesthesia (13.0%). This finding differs somewhat from Abdallah et al.3, who reported significantly higher NICU admission rates after general anaesthesia compared to combined spinal-epidural anaesthesia (22% vs. 10%, p<0.05). The lack of statistical significance in our study may be due to the smaller sample size of general anaesthesia cases or may reflect differences in NICU admission criteria.

Hypertensive disorders and anaemia were identified as major risk factors contributing to severe maternal complications such as pulmonary edema and death. Neonatal outcomes were generally favourable, though general anaesthesia correlated with increased neonatal interventions such as cord blood analysis and NICU admissions. These findings underscore the importance of careful anaesthetic planning, vigilant intraoperative management, and targeted optimization of maternal health conditions to minimize risks and improve outcomes for both mother and child during cesarean delivery.

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