title: Cardiac index in term pregnant women in the sitting, lateral, and supine positions: an observational, crossover study.
abstract: BACKGROUND
  Aortocaval compression may affect maternal hemodynamic indices and fetal well-being in various maternal positions. There has been much debate regarding the optimal position for performing neuraxial blockade for labor analgesia and cesarean delivery. We hypothesized that in pregnant women at term, cardiac index (CI) may be improved in the lateral positions as compared with the flexed sitting position. Our primary outcome was to measure CI as assessed by suprasternal Doppler.
  
  
  METHODS
  A prospective, observational, crossover study was conducted in 25 ASA physical status I/II women with uncomplicated pregnancies presenting for elective cesarean delivery at term. Hemodynamic indices were measured in 4 positions in random order: supine with a 15-degree left tilt, sitting with neck and hips flexed, and flexed left lateral and flexed right lateral positions. Maternal CIs were measured using a noninvasive suprasternal Doppler device and upper arm noninvasive arterial blood pressure. Umbilical Dopplers were performed simultaneously to measure the fetal heart rate and umbilical artery pulsatility and resistivity indices.
  
  
  RESULTS
  CI differed by position (P = 0.01); it was higher in the right lateral position compared with the sitting and supine positions (by 8.8% and 8.1%, respectively) and in the left lateral compared with sitting position (by 7.8%) (P < 0.05). Maternal stroke volume index, heart rate, and systolic blood pressure were higher in the lateral positions compared with the sitting and supine-tilt positions. We found no significant differences in fetal heart rate, pulsatility index, or resistivity index among positions.
  
  
  CONCLUSIONS
  Positioning for neuraxial anesthesia may influence maternal hemodynamic variables. We found no difference in healthy fetal blood flow indices among positions, suggesting that these changes are not clinically significant. This study provides new physiological information on the changes that occur in a group in whom it has not been practical to study previously. Further study is necessary to determine whether these changes are significant in the presence of neuraxial anesthesia or in the high-risk parturient.
authors.affiliation: Department of Anaesthesia, University College London Hospitals, 235 Euston Rd., London NW1 2BU, UK. drsaraharmstrong@gmail.com
authors.forename: Sarah
authors.initials: S
authors.lastname: Armstrong
authors.forename: Roshan
authors.initials: R
authors.lastname: Fernando
authors.forename: Malachy
authors.initials: M
authors.lastname: Columb
authors.forename: Tanya
authors.initials: T
authors.lastname: Jones
mesh_terms: D000328:Adult; D000773:Anesthesia, Obstetrical; D002302:Cardiac Output / Q000502:physiology*; D018592:Cross-Over Studies; D005260:Female; D006339:Heart Rate / Q000502:physiology; D006340:Heart Rate, Fetal; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D010920:Placenta / Q000098:blood supply; D011187:Posture / Q000502:physiology*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular; D012039:Regional Blood Flow / Q000502:physiology; D018401:Sample Size; D013318:Stroke Volume / Q000502:physiology; D016683:Supine Position / Q000502:physiology*; D018608:Ultrasonography, Doppler; D014470:Umbilical Cord / Q000000981:diagnostic imaging; D014599:Uterus / Q000098:blood supply