Effect on neonatal outcomes of maintenance of maternal blood pressure targets with noradrenaline after spinal anaesthesia for caesarean delivery: a multicentre, randomised, controlled trial.

Summary

In 1183 women randomized to systolic blood pressure targets of 90% vs 80% of baseline using noradrenaline, mean umbilical artery pH was similar, but neonatal acidaemia (pH < 7.2) was less frequent in the 90% group. Maternal hypotension, severe hypotension, and nausea/vomiting were also significantly reduced with the higher target, at the expense of more noradrenaline boluses.

Key Findings

• Neonatal acidaemia (umbilical artery pH < 7.2) was lower with SBP-90% vs SBP-80% (0.5% vs 2.2%; p=0.020).
• Maternal hypotension (<80% baseline) and severe hypotension (<60% baseline) were significantly less frequent with the 90% target.
• Nausea/vomiting was reduced with SBP-90% (9.8% vs 18.4%; p<0.001), though more noradrenaline boluses were required.

Clinical Implications

Target maternal systolic blood pressure above 90% of baseline with noradrenaline boluses during cesarean under spinal anesthesia to reduce neonatal acidaemia and maternal hypotension/nausea. Protocols should specify frequent monitoring and proactive dosing.

Limitations

• Primary endpoint (mean umbilical artery pH) was similar; rare events may limit power for neonatal outcomes.
• Short-term peridelivery outcomes only; generalizability to other vasopressors or infusion strategies is uncertain.

Future Directions

Evaluate continuous infusion strategies, individualized baselines, and longer-term neonatal neurodevelopmental outcomes; compare noradrenaline with phenylephrine in similar target-based protocols.