Neonatal Neurobehavior After Cesarean Delivery

William Reid Camann, MD

Disclosures

February 17, 2005

Question

What are the current guidelines on assessment of neonatal neurobehavioral performance following ketamine supplementation during anesthesia for cesarean section?

S.K. Singh, MD

Response from William Reid Camann, MD

Neonatal neurobehavior following cesarean delivery, a complex topic, is influenced by a variety of factors. Of most importance are the obstetric variables, including the indication for the cesarean section, which may predispose the child to postdelivery problems. For example, prematurity, prolonged labor, intrapartum infection, intrapartum non-reassuring fetal status, maternal hemorrhage, and hemodynamic instability are likely to have predictable neonatal consequences.

The question asked concerns possible effects of anesthetic drugs used during cesarean delivery. Regional anesthesia (spinal or epidural) is most commonly used for these operations, and these types of anesthetics are found only in minimal quantities in maternal and neonatal blood, and consequently behavioral effects on the neonate are minimal. Of far greater concern are drugs used for general anesthesia or sedation during a cesarean. First, the use of general anesthesia is uncommon, at least in the United States, and is most often associated with some of the confounding variables noted above, thus making conclusions difficult to draw with regard to neonatal behavior. Virtually all general anesthetic drugs, such as induction agents, inhalation gases, narcotics, hypnotics, and sedatives, all readily cross the placental barrier and can possibly contribute to neonatal depression. Nonetheless, in general, most babies are fairly vigorous even when delivered after maternal general anesthesia. Obviously, only drugs administered before delivery will have any effect on the neonate; hence when general anesthesia is used, it is important for the obstetrician to minimize -- as much as possible -- the time from induction of anesthesia to delivery. In contrast, induction-to-delivery intervals are of less importance when regional anesthesia is used.

All of the drugs used for anesthesia or sedation during cesarean are also used for pediatric anesthesia or sedation during pediatric diagnostic procedures. The effects on the child are exactly as one would expect: dose-related: sedation, muscle weakness, and difficulty feeding. Ketamine, specifically, is a sedative/hypnotic that also has some dysphoric or hallucinatory side effects. It is also a drug that does not tend to lower blood pressure or suppress respiration, hence it is often used in situations of marginal hemodynamic stability. These are situations in which there would clearly be other reasons for neonatal depression following delivery. Owing to the common maternal hallucinatory or dysphoric effects of ketamine, I do not recommend ketamine for routine use during cesareans. Ketamine is commonly used for sedation during pediatric diagnostic procedures, where it is particularly useful because it can be administered intramuscularly, hence convenient for the initial approach to the combative or uncooperative child who does not have an intravenous line in place.

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