General versus Spinal Anesthesia for Cesarean Delivery: Neonatal Apnea and Immediate Respiratory Outcomes in a Prospective Observational Cohort Study
-
Ali Dabbagh
,
Marzieh Shahrabi
,
Naseer Waheeb-Mohammed
,
Ebtehaj Heshmatkhah
,
Dariush Abtahi
,
Shideh Ariana
,
Seyedeh Samira Abdollahzadeh
Abstract
Background: The choice of anesthetic technique for cesarean section remains a critical consideration due to potential impacts on neonatal well-being. This study aimed to compare immediate neonatal respiratory outcomes, specifically the incidence of neonatal apnea, between general anesthesia (GA) and spinal anesthesia (SA).
Methods: We conducted a prospective observational cohort study at a tertiary academic medical center. Maternal and neonatal variables were collected for cesarean deliveries under GA or SA. The primary endpoint was the incidence of neonatal apnea. Secondary outcomes included respiratory distress, requirements for positive pressure ventilation (PPV), and NICU admission. Data were analyzed using SPSS 26.0, employing chi-square, Mann-Whitney U tests, and multivariable binary logistic regression to adjust for potential confounders.
Results: A total of 100 cases were analyzed. While neonatal apnea was numerically higher in the GA group (14% vs. 10% in SA), and PPV was required exclusively in neonates born under GA (p = 0.012), multivariable analysis demonstrated that anesthetic technique was not an independent predictor of neonatal apnea (OR 1.465, p = 0.538). Conversely, acute fetal compromise (OR 4.567, p = 0.024) and the primary indication for cesarean delivery (adjusted OR 7.03, p = 0.022) were identified as independent risk factors for neonatal apnea. No statistically significant differences were observed in umbilical arterial pH, Apgar scores, or NICU admission rates.
Conclusion: Cesarean indication, especially acute fetal compromise, was the main determinant of neonatal apnea and early respiratory adaptation. Although positive pressure ventilation occurred more often after general anesthesia, anesthetic technique was not an independent predictor after adjustment. These findings suggest that underlying maternal–fetal conditions may influence neonatal respiratory outcomes more than the anesthetic method itself.
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[2] WHO Session. J Obstet Gynaecol Res. 2023; 49 Suppl 1:87-89.
[3] Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med. 2018; 15(1):e1002494.
[4] Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018; 392(10155):1349-57.
[5] Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018; 392(10155):1341-8.
[6] Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018; 392(10155):1358-68.
[7] Rollins M, Lucero J. Overview of anesthetic considerations for Cesarean delivery. Br Med Bull. 2012; 101:105-25.
[8] Wadhwa G, Singh UK, Anand R, Swain BP, Nag DS, Sen B. Spinal anesthesia for cesarean delivery: does ropivacaine offer hemodynamic advantages over bupivacaine? Cureus. 2025; 17(5):e84809.
[9] Hawkins JL. Epidural analgesia for labor and delivery. N Engl J Med. 2010; 362(16):1503-10.
[10] Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol. 2011; 117(1):69-74.
[11] Kinsella SM, Walton B, Sashidharan R, Draycott T. Category-1 caesarean section: a survey of anaesthetic and peri-operative management in the UK. Anaesthesia. 2010; 65(4):362-8.
[12] Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M, et al. Urgency of caesarean section: a new classification. J R Soc Med. 2000; 93(7):346-50.
[13] Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology. 2005; 103(3):645-53.
[14] Jenkins JG, Khan MM. Anaesthesia for Caesarean section: a survey in a UK region from 1992 to 2002. Anaesthesia. 2003; 58(11):1114-8.
[15] Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology. 1998; 88(6):1467-74.
[16] Yeganegi M, Bahrami R, Azizi S, Marzbanrad Z, Hajizadeh N, Mirjalili SR, et al. Caesarean section and respiratory system disorders in newborns. Eur J Obstet Gynecol Reprod Biol X. 2024; 23:100336.
[17] Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008; 336(7635):85-7.
[18] Langer S, Lim G, Qiu Y, Biaesch J, Neuman MD. Neonatal outcomes with regional versus general anesthesia for cesarean delivery: a meta-analysis of randomized controlled trials. Anesthesiology. 2026; 144(2):325-36.
[19] Shi X, Xu C, Wen Y, Jiang M, Yu H, Wang X, et al. Perinatal outcome of emergency cesarean section under neuraxial anesthesia versus general anesthesia: a seven-year retrospective analysis. BMC Anesthesiol. 2024; 24(1):33.
[20] Kavak ZN, Başgül A, Ceyhan N. Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study. Eur J Obstet Gynecol Reprod Biol. 2001; 100(1):50-4.
[21] Cojocaru L, Salvatori C, Sharon A, Seung H, Nyman K, Kodali BS, et al. General versus regional anesthesia and neonatal data: a propensity-score-matched study. Am J Perinatol. 2023; 40(3):227-34.
[22] Liu H, Miao JK, Cai M, Gan L, Zhao HQ, Lei XF, et al. Anesthetic drug concentrations and placental transfer rate in fetus between term and preterm infants, twins, and singletons. Front Pharmacol. 2023; 14:1213734.
[23] Veeser M, Hofmann T, Roth R, Klöhr S, Rossaint R, Heesen M. Vasopressors for the management of hypotension after spinal anesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesthesiol Scand. 2012; 56(9):1204.
[24] Ebrahim Elgzar WT, Ebrahim Said H, Ebrahim HA. Effect of lower leg compression during cesarean section on post-spinal hypotension and neonatal hemodynamic parameters: nonrandomized controlled clinical trial. Int J Nurs Sci. 2019; 6(4):478.
[25] Moisa RC, Negrut N, Macovei IC, Aur C, Botea MO, Maghiar PB, et al. The impact of maternal spinal anesthesia on newborn out-comes: a clinical perspective. Children (Basel). 2025; 12(4):450.
[26] Pečlin P, Pavlica M, Druškovič M, Kavšek G, Verdenik I, Pintarič TS. Effect of anesthetic modality on decision-to-delivery interval and maternal-neonatal outcomes in category 2 and 3 cesarean deliveries. J Clin Med. 2024; 13(24):7528.
[27] Nourkami-Tutdibi N, Tutdibi E, Faas T, Wagenpfeil G, Draper ES, Johnson S, et al. Neonatal morbidity and mortality in advanced aged mothers-maternal age is not an independent risk factor for infants born very preterm. Front Pediatr. 2021; 9:747203.
[28] Rodrigues I, Soares H, Rocha G, Azevedo I. Impact of advanced maternal age on neonatal morbidity: a systematic review. J Matern Fetal Neonatal Med. 2023; 36(2):2287981.
[29] Schwartz A, Many A, Shapira U, Rosenberg Friedman M, Yogev Y, Avnon T, et al. Perinatal outcomes of pregnancy in the fifth decade and beyond- a comparison of very advanced maternal age groups. Sci Rep. 2020; 10(1):1809.
[30] Yang F, Liu H, Ding C. Gestational diabetes mellitus and risk of neonatal respiratory distress syndrome: a systematic review and meta-analysis. Diabetol Metab Syndr. 2024; 16(1):294.
[31] Roguin N, Gutvirtz G, Wainstock T, Sheiner E. The impact of maternal chronic hypertension in pregnancy on offspring long-term respiratory morbidity. Pregnancy Hypertens. 2026; 43:101405.
[32] Brown HK, Fung K, Cohen E, Dennis CL, Grandi SM, Rosella LC, et al. Multiple maternal chronic conditions and risk of severe neonatal morbidity and mortality. JAMA Netw Open. 2026; 9(1):e2555558.
[33] Seo N, Lee YM, Kim YJ, Sung JH, Hur KY, Choi SJ, et al. Obesity is associated with higher risk of adverse maternal and neonatal outcomes than supervised gestational diabetes. J Korean Med Sci. 2023; 38(33):e268.
[34] Reed J, Case S, Rijhsinghani A. Maternal obesity: perinatal implications. SAGE Open Med. 2023; 11:20503121231176128.
[35] Langer S, Lim G, Qiu Y, Biaesch J, Neuman MD. Neonatal outcomes with regional versus general anesthesia for cesarean delivery: a meta-analysis of randomized controlled trials. Anesthesiology. 2026; 144(2):325-36.
[36] Cocchi E, Pini R, Gallipoli A, Stella M, Antonazzo P, Marchetti F, et al. Impact of general vs. neuraxial anesthesia on neonatal outcomes in non-elective cesarean sections. Front Pediatr. 2025; 13:1518456.
[37] Watson SE, Richardson AL, Lucas DN. Neuraxial and general anaesthesia for caesarean section. Best Pract Res Clin Anaesthesiol. 2022; 36(1):53-68.
[38] Saygı Aİ, Özdamar Ö, Gün İ, Emirkadı H, Müngen E, Akpak YK. Comparison of maternal and fetal outcomes among patients undergoing cesarean section under general and spinal anesthesia: a randomized clinical trial. Sao Paulo Med J. 2015; 133(3):227-34.
[39] Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008; 336(7635):85-7.
[2] WHO Session. J Obstet Gynaecol Res. 2023; 49 Suppl 1:87-89.
[3] Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med. 2018; 15(1):e1002494.
[4] Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018; 392(10155):1349-57.
[5] Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018; 392(10155):1341-8.
[6] Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018; 392(10155):1358-68.
[7] Rollins M, Lucero J. Overview of anesthetic considerations for Cesarean delivery. Br Med Bull. 2012; 101:105-25.
[8] Wadhwa G, Singh UK, Anand R, Swain BP, Nag DS, Sen B. Spinal anesthesia for cesarean delivery: does ropivacaine offer hemodynamic advantages over bupivacaine? Cureus. 2025; 17(5):e84809.
[9] Hawkins JL. Epidural analgesia for labor and delivery. N Engl J Med. 2010; 362(16):1503-10.
[10] Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol. 2011; 117(1):69-74.
[11] Kinsella SM, Walton B, Sashidharan R, Draycott T. Category-1 caesarean section: a survey of anaesthetic and peri-operative management in the UK. Anaesthesia. 2010; 65(4):362-8.
[12] Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M, et al. Urgency of caesarean section: a new classification. J R Soc Med. 2000; 93(7):346-50.
[13] Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology. 2005; 103(3):645-53.
[14] Jenkins JG, Khan MM. Anaesthesia for Caesarean section: a survey in a UK region from 1992 to 2002. Anaesthesia. 2003; 58(11):1114-8.
[15] Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology. 1998; 88(6):1467-74.
[16] Yeganegi M, Bahrami R, Azizi S, Marzbanrad Z, Hajizadeh N, Mirjalili SR, et al. Caesarean section and respiratory system disorders in newborns. Eur J Obstet Gynecol Reprod Biol X. 2024; 23:100336.
[17] Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008; 336(7635):85-7.
[18] Langer S, Lim G, Qiu Y, Biaesch J, Neuman MD. Neonatal outcomes with regional versus general anesthesia for cesarean delivery: a meta-analysis of randomized controlled trials. Anesthesiology. 2026; 144(2):325-36.
[19] Shi X, Xu C, Wen Y, Jiang M, Yu H, Wang X, et al. Perinatal outcome of emergency cesarean section under neuraxial anesthesia versus general anesthesia: a seven-year retrospective analysis. BMC Anesthesiol. 2024; 24(1):33.
[20] Kavak ZN, Başgül A, Ceyhan N. Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study. Eur J Obstet Gynecol Reprod Biol. 2001; 100(1):50-4.
[21] Cojocaru L, Salvatori C, Sharon A, Seung H, Nyman K, Kodali BS, et al. General versus regional anesthesia and neonatal data: a propensity-score-matched study. Am J Perinatol. 2023; 40(3):227-34.
[22] Liu H, Miao JK, Cai M, Gan L, Zhao HQ, Lei XF, et al. Anesthetic drug concentrations and placental transfer rate in fetus between term and preterm infants, twins, and singletons. Front Pharmacol. 2023; 14:1213734.
[23] Veeser M, Hofmann T, Roth R, Klöhr S, Rossaint R, Heesen M. Vasopressors for the management of hypotension after spinal anesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesthesiol Scand. 2012; 56(9):1204.
[24] Ebrahim Elgzar WT, Ebrahim Said H, Ebrahim HA. Effect of lower leg compression during cesarean section on post-spinal hypotension and neonatal hemodynamic parameters: nonrandomized controlled clinical trial. Int J Nurs Sci. 2019; 6(4):478.
[25] Moisa RC, Negrut N, Macovei IC, Aur C, Botea MO, Maghiar PB, et al. The impact of maternal spinal anesthesia on newborn out-comes: a clinical perspective. Children (Basel). 2025; 12(4):450.
[26] Pečlin P, Pavlica M, Druškovič M, Kavšek G, Verdenik I, Pintarič TS. Effect of anesthetic modality on decision-to-delivery interval and maternal-neonatal outcomes in category 2 and 3 cesarean deliveries. J Clin Med. 2024; 13(24):7528.
[27] Nourkami-Tutdibi N, Tutdibi E, Faas T, Wagenpfeil G, Draper ES, Johnson S, et al. Neonatal morbidity and mortality in advanced aged mothers-maternal age is not an independent risk factor for infants born very preterm. Front Pediatr. 2021; 9:747203.
[28] Rodrigues I, Soares H, Rocha G, Azevedo I. Impact of advanced maternal age on neonatal morbidity: a systematic review. J Matern Fetal Neonatal Med. 2023; 36(2):2287981.
[29] Schwartz A, Many A, Shapira U, Rosenberg Friedman M, Yogev Y, Avnon T, et al. Perinatal outcomes of pregnancy in the fifth decade and beyond- a comparison of very advanced maternal age groups. Sci Rep. 2020; 10(1):1809.
[30] Yang F, Liu H, Ding C. Gestational diabetes mellitus and risk of neonatal respiratory distress syndrome: a systematic review and meta-analysis. Diabetol Metab Syndr. 2024; 16(1):294.
[31] Roguin N, Gutvirtz G, Wainstock T, Sheiner E. The impact of maternal chronic hypertension in pregnancy on offspring long-term respiratory morbidity. Pregnancy Hypertens. 2026; 43:101405.
[32] Brown HK, Fung K, Cohen E, Dennis CL, Grandi SM, Rosella LC, et al. Multiple maternal chronic conditions and risk of severe neonatal morbidity and mortality. JAMA Netw Open. 2026; 9(1):e2555558.
[33] Seo N, Lee YM, Kim YJ, Sung JH, Hur KY, Choi SJ, et al. Obesity is associated with higher risk of adverse maternal and neonatal outcomes than supervised gestational diabetes. J Korean Med Sci. 2023; 38(33):e268.
[34] Reed J, Case S, Rijhsinghani A. Maternal obesity: perinatal implications. SAGE Open Med. 2023; 11:20503121231176128.
[35] Langer S, Lim G, Qiu Y, Biaesch J, Neuman MD. Neonatal outcomes with regional versus general anesthesia for cesarean delivery: a meta-analysis of randomized controlled trials. Anesthesiology. 2026; 144(2):325-36.
[36] Cocchi E, Pini R, Gallipoli A, Stella M, Antonazzo P, Marchetti F, et al. Impact of general vs. neuraxial anesthesia on neonatal outcomes in non-elective cesarean sections. Front Pediatr. 2025; 13:1518456.
[37] Watson SE, Richardson AL, Lucas DN. Neuraxial and general anaesthesia for caesarean section. Best Pract Res Clin Anaesthesiol. 2022; 36(1):53-68.
[38] Saygı Aİ, Özdamar Ö, Gün İ, Emirkadı H, Müngen E, Akpak YK. Comparison of maternal and fetal outcomes among patients undergoing cesarean section under general and spinal anesthesia: a randomized clinical trial. Sao Paulo Med J. 2015; 133(3):227-34.
[39] Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008; 336(7635):85-7.
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| Cesarean section General anesthesia Spinal anesthesia Neonatal apnea. | ||
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How to Cite
1.
Dabbagh A, Shahrabi M, Waheeb-Mohammed N, Heshmatkhah E, Abtahi D, Ariana S, Abdollahzadeh SS. General versus Spinal Anesthesia for Cesarean Delivery: Neonatal Apnea and Immediate Respiratory Outcomes in a Prospective Observational Cohort Study. Arch Anesth & Crit Care. 2026;.
