# Effect of Maternal Table Tilt During Cesarean Delivery Under Spinal Anesthesia on Norepinephrine Requirements: A Prospective Observational Comparative Study

## TL;DR

This study found that tilting the mother during cesarean surgery does not reduce the need for blood pressure medication or improve baby outcomes when using standard treatment.

## Contribution

The study provides evidence that maternal tilt during cesarean delivery may not be necessary when using prophylactic vasopressors.

## Key findings

- Median norepinephrine infusion rates were similar between tilted and non-tilted groups.
- Neonatal outcomes like Apgar scores and blood gas parameters were not significantly different.
- Multivariable analysis showed no independent effect of tilt on vasopressor requirements.

## Abstract

Background: Left lateral tilt is traditionally recommended during cesarean delivery to reduce aortocaval compression and maintain maternal hemodynamic stability; however, with the widespread adoption of prophylactic vasopressor strategies recommended by current guidelines, the incremental benefit of routine tilt remains uncertain. Methods: We conducted a prospective, nonrandomized observational comparative study at the University Hospital Bratislava including 99 women undergoing elective cesarean delivery under spinal anesthesia. Participants were managed either with a standard ~15° left lateral tilt (n = 41) or in a flat supine position without tilt (n = 58), according to the day of surgery and routine anesthesiologist practice; all other anesthetic and surgical procedures were identical. A prophylactic norepinephrine infusion was initiated at 0.05 µg/kg/min and titrated to maintain systolic arterial pressure at 90–100% of baseline. The primary outcome was the average norepinephrine infusion rate (µg/kg/min) from induction of spinal anesthesia to neonatal delivery. Secondary outcomes included total norepinephrine dose to delivery, dose normalized per kilogram, and neonatal outcomes (Apgar scores and umbilical arterial blood gas parameters). Results: The median norepinephrine infusion rate was 0.03 µg/kg/min in both groups (tilt: IQR 0.01–0.04 vs. no-tilt: IQR 0.02–0.04; p = 0.325). Total norepinephrine dose to delivery (20 [15–35] µg; p = 0.89) and dose per kilogram (0.25 [0.15–0.33] µg/kg vs. 0.34 [0.17–0.44] µg/kg; p = 0.10) were also comparable. Neonatal outcomes, including Apgar scores and umbilical arterial blood gas parameters, did not differ significantly between groups. In a multivariable regression sensitivity analysis adjusting for maternal and procedural covariates, table tilt was not independently associated with norepinephrine requirements. Conclusions: In parturients undergoing cesarean delivery under spinal anesthesia with prophylactic norepinephrine infusion, a 15° left lateral tilt did not reduce vasopressor requirements or improve neonatal outcomes. Routine maternal tilt therefore appears unnecessary for hemodynamic optimization in this setting, and patient positioning can be individualized without compromising maternal or neonatal safety.