Effects of Combined Warmed Preoperative Forced-air and Warmed Perioperative Intravenous Fluids on Maternal Temperature During Cesarean Section: a prospective, randomized, controlled clinical trial

Effects of Combined Warmed Preoperative Forced-air and Warmed Perioperative Intravenous Fluids on Maternal Temperature During Cesarean Section: a prospective, randomized, controlled clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Effects of Combined Warmed Preoperative Forced-air and Warmed Perioperative Intravenous Fluids on Maternal Temperature During Cesarean Section: a prospective, randomized, controlled clinical trial tingting Ni, Zhen-feng Zhou, Bo He, Qing-he Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.20668/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Feb, 2020 Read the published version in BMC Anesthesiology → Version 2 posted 3 You are reading this latest preprint version Show more versions Abstract Background: Preventing the frequent perioperative hypothermia incidents that occur during elective caesarean deliveries would be beneficial. This trial aimed at evaluating the effect of preoperative forced-air warming alongside perioperative intravenous fluid warming in women undergoing cesarean sections under spinal anesthesia. Methods: We randomly allocated135 women undergoing elective cesarean deliveries to either the intervention group (preoperative forced-air and intravenous fluid warmings, n = 69) or the control group (no active warming, n = 66). The primary outcome measure was the change from the core baseline temperature to that at the end of the procedure. Secondary outcomes included thermal comfort scores, the incidences of shivering and hypothermia (<36℃), the core temperature on arrival at the post-anesthesia care unit, neonatal axillary temperature at birth, and Apgar scores. Results: Two-way repeated measures ANOVA revealed significantly different core temperature changes (from the pre-spinal temperature to that at the end of the procedure) between groups ( F = 13.022, P <0.001). The thermal comfort scores were also higher in the intervention group than in the control group ( F = 9.847, P = 0.002). The overall incidence of perioperative hypothermia was significantly lower in the intervention group than in the control group (20.6% vs. 51.6%, P <0.0001). Conclusions: Warming preoperative forced-air and perioperative intravenous fluids may prevent maternal hypothermia, reduce maternal shivering, and improve maternal thermal comfort for patients undergoing cesarean sections under spinal anesthesia. Trial registration: The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800019117) on October26, 2018. Keywords: Cesarean section, Spinal anesthesia, Warming Anesthesiology & Pain Medicine Cesarean section Spinal anesthesia Warming Figures Figure 1 Figure 2 Figure 3 Background Neuraxial (spinal, epidural, or combined spinal–epidural techniques) anesthesia is the preferred anesthetic technique for cesarean deliveries. Perioperative hypothermia is a commonly reported side effect of regional anesthesia affecting up to 60% of patients undergoing cesarean deliveries under spinal anesthesia [1–4] . The hypothermia can cause numerous complications including postoperative wound infections, increased blood loss and transfusion requirements, myocardial ischemia, high risk of coagulopathy, shivering, increased hospital stay, and patient discomfort [5–12] . Neonatal outcomes such as birth temperature and Apgar scores have also been linked to maternal temperature [13,14] . Perioperative hypothermia under spinal anesthesia has different etiologies, but mostly it is caused by spinal anesthesia altering thermoregulation and reducing the threshold for vasoconstriction and shivering [15] . Neuraxial anesthesia decreases the thermoregulatory vasoconstriction below the sensory blockade level, leading to heat loss by redistribution of heat from the core to the periphery [16] . The core-to-peripheral redistribution of body heat is difficult to treat, but it should be preventable by prewarming the periphery compartment [17] . Prewarming increases the heat content in the periphery of the patient and reduces the core-to-peripheral tissue temperature gradient, which otherwise promotes the heat redistribution after spinal anesthesia [18] . Intraoperative forced-air warming has been shown to be uncomfortable for the patient and may affect the early maternal-newborn bonding [3] . Unlike the forced-air warming, warmed intravenous fluids do not disturb the operation during the surgical procedure. Despite the existence of prospective studies on active warming during cesarean delivery, no consensus regarding its efficacy exists. Studies have suggested that single-modality interventions to prevent hypothermia (forced-air or intravenous fluid warmings) result in only marginal or no benefit for patients undergoing cesarean sections [1,4,19,20] . Therefore, we aimed to evaluate the effect of the combined application of 30 minutes of preoperative warm forced-air and perioperative warm intravenous fluids in women receiving spinal anesthesia for cesarean deliveries and we assumed that combination of warmed preoperative forced-air and warmed perioperative intravenous fluids could prevent maternal hypothermia during cesarean sections under spinal anesthesia. Methods Study Design The Ethical Committee of Ningbo NO.7 Hospital approved this study, which follows the tenets of the Declaration of Helsinki, and we pre-registered it at http://www.chictr.org.cn /index.aspx (ChiCTR1800019117). This study adheres the applicable CONSORT guidelines. We enrolled healthy pregnant women undergoing elective cesarean deliveries under spinal anesthesia after obtaining their informed consents. American Society of Anesthesiologists physical status I-II parturients, aged 18 to 40 years, with more than 37-week gestations, singleton pregnancies, and scheduled for cesarean delivery under spinal anesthesia were eligible for enrollment. We excluded women with coagulation abnormalities, thyroid disease, cesarean delivery using epidural or general anesthesia, and baseline temperatures ≥37.5˚C. Study Protocol After obtaining the signed informed consents, we randomly allocated eligible participants to either the control or the intervention groups. Randomization was computer-generated using Microsoft Excel’s random number generator, and we concealed allocations using sequentially numbered opaque sealed envelopes. All parturients fasted for eight hours before the cesarean section. Once in the preoperative waiting area, the parturients in the intervention group received 30 minutes of upper body preoperative warming using a forced-air warming device (EQ-5000 230V, Smiths Medical ASD, Rockland, USA) set to 43˚C and nurses established intravenous accesses. The women in the intervention group received Ringer’s lactate solution pre-warmed to 37˚C through a 3MRanger TM Fluid Warmer until the end of the procedure. We monitored the patients during the interventions. We discontinued the intervention in cases in which the parturients experienced adverse side effects related to warming such as diaphoresis or nausea and vomiting, or if the core thermometer was >37.5˚C. After prewarming, we immediately transferred the term parturients to the operating room (OR).Participants in the intervention group received 30 minutes of upper body preoperative warming in the preoperative waiting area, and received IV fluid warming during the observation period(preoperative waiting area, OR and PACU ).The women in the control group received usual care consisting of no active warming and they received the intravenous fluid at room temperature throughout the procedure(preoperative waiting area, OR and PACU ). We recorded data on vital signs including heart rate, blood pressure, hemoglobin peripheral saturation, and baseline core temperature in the preoperative area. The same operator measured patients’ core temperatures using an infrared tympanic thermometer (PRO6000, Braun, Marlborough, MA USA 01752) with disposable covers, and recorded the average value of three measurements. The hospital maintained central control of the temperatures of the preoperative area, OR, and post-anesthesia care unit (PACU), and we obtained the temperature readings from the thermostat. An anesthesiologist not involved in the study applied all spinal anesthesias at the L3-4 interspace, with 2 mL of 0.5% plain bupivacaine, using a 25-gauge Quincke needle. The surgeon commenced the operations once a sensory blockade above the T4 level was achieved according to the results of pinprick tests. After the operation, all patients were transferred to the PACU covered with a cotton sheet and a blanket. We obtained values for core temperature, maternal thermal comfort scores, and the incidences of shivering and hypothermia at the following timepoints: T 0 = baseline, T 1 = pre-spinal, T 2 = post-spinal, T 3 = after 15 minutes in the OR, T 4 = after 30 minutes in the OR, T 5 = surgery end, T 6 = PACU arrival, T 7 = after 15 minutes in the PACU, T 8 = after 30 minutes in the PACU. According to Guidelines [21] , we defined maternal hypothermia as a core temperature <36˚C. We assessed thermal comfort scores using a verbal numerical scale on which we defined 0 as completely unsatisfied with the “thermal comfort” and 100 as completely satisfied. We graded shivering during and after the cesarean section according to the Bedside Shivering Assessment Scale (0, no shivering; 1, shivering localized to the core and neck; 2, shivering including the upper extremities; 3, total body shivering) [22] . The anesthesiologist provided meperidine according to their own criteria. A midwife recorded neonatal axillary temperature, and Apgar scores at 1 and 5 minutes after birth. Based on our institutional guidelines, if the core temperature was lower than 35.5°C, rescue warming would performed for the parturients by using a forced-air warming device. We defined bradycardia as a heart rate<50 beats/min, and treated it with 0.5 mg of intravenous atropine. When the systemic pressure decreased more than 30% of the baseline pressure or dropped below 90 mmHg, we administered ephedrine (5 mg).Mean arterial pressure and heart rate was measured at baseline, prespinal, postspinal and at the end of the procedure. We recorded demographic data (age, height, weight, parity, and gravidity) and surgical and anesthetic variables (Preoperative and total volume of intravenous fluids, estimated blood loss, duration of surgery, and the ambient temperatures in the preoperative area, OR, and PACU). Statistical Analyses The primary outcome measure was the core temperature change between two groups from baseline to the end of the surgical procedure.Secondary outcomes included thermal comfort scores during the operation, the incidence of shivering and hypothermia (<36˚C), the core temperature on the arrival at the PACU, neonatal axillary temperature at birth, and Apgar scores at 1 and 5 minutes). Analysis of covariance for repeated measures was under taken to calculate the sample size. A bonferroni correction for multiple pairwise comparisons was used, giving an adjusted P value level of significance ( P <0.01).A clinically significant difference in the core temperature between study groups was set at 0.4°C according to our pilot trial with a standard deviation of 0.5°C,which was also consistent with Chung et al' s study [23] .A sample size of120 patients, including 20% dropouts, was estimated to provide 90% power for detecting a statistically significant difference between groups at an α level of 0.01. We expressed normally distributed continuous data as means ± SDs, and compared variables between study groups using the Student t test. Nonparametric data are presented as medians (interquartile ranges), and compared between study groups using the Mann–Whitney U test. We investigated associations among discrete variables using the c2 or Fisher exact tests. Two-way repeated measures ANOVA was applied with change from baseline as the dependent variable, and the intervention, time, and the treatment multiplied by time interaction as independent variables. We also used two-way repeated measures ANOVA to assess the core temperature change and the thermal comfort between groups at each timepoint. We performed all statistical analyses using the SPSS software (version 22.0, SPSS, Chicago, IL, USA). We considered P-values <0.05 as statistically significant. Results Patients were enrolled in the study between January 2019and June 2019.We considered 144 patients for eligibility, and excluded 9 before randomization. In the end we randomly allocated 135 patients to one of the two groups (69 women to the intervention group, and 66 to the control group). We had to exclude one patient from the intervention group and two patients from the control group due to failed spinal anesthesia (Fig. 1). The demographic and obstetric characteristics, as well as the surgical and anesthetic values, were did not differ significantly between the two groups. Vital sign parameters such as peripheral oxygen saturation, heart rate, meanarterialpressuremeasurement at the each point, and the incidence of hypotension and vomiting, ephedrine dose administered also had no difference between two groups during the observation period. The room temperatures in the preoperative area, OR, and PACU were similar for the two groups (Table 1). Our two-way repeated measures ANOVA analysis revealed a significant difference in the core temperature changes fromtheT 1 toT 7 timepointsbetween the two groups ( F =13.022, P <0.001), and the group´time interaction difference was also significant ( F =23.195, P <0.001). The patients in the intervention group experienced higher perioperative mean temperatures during the procedure than those in the control group (T 1 -T 3 , P <0.001, T 4 -T 7 , P <0.05). In the control group, the core temperature was decreased at all the time points compared to the baseline. We also found a slight decline in the core temperatures from the baseline during the procedure (exceptT 1 andT 2 ) in the intervention group (Fig.2). Thermal comfort scores were higher in the intervention group than in the control group ( F =9.847, P =0.002 ), the group ´ time interaction difference was also significant ( F =2.750, P =0.008). The maternal thermal comfort scores differed significantly between two groups from the T 2 to T 6 timepoints(all P <0.05 or P <0.001). In comparisons with the baseline thermal comfort scores, the timepoints in the control group (except T 1 ) and those in the intervention group (except T 1 and T 6 ) all exhibited decreased thermal comfort scores (Fig. 3). Core temperatures on arrival at the PACU were greater in the intervention group (36.2 ± 0.4℃) than in the control group (35.5 ± 0.3℃), P = 0.007. The incidences of shivering were 56.3% in the control group and 19.1% in the intervention group during the surgical procedure ( P < 0.001), and the shivering assessment scores were higher in the control than in the intervention group. The overall incidence of perioperative hypothermia was significantly lower in the intervention group than in the control group ( P <0.001). Neonatal outcomes were similar between the two groups(Table 2). Discussion In our study, our intervention with 30 minutes preoperative forced-air warming and perioperative administration of warmed intravenous fluids reduced the extent of core temperature decline, decreased the incidence of preoperative hypothermia and shivering, and improved maternal comfort in patients undergoing cesarean section with spinal anesthesia as opposed to the outcomes in the control group patients. The results of our study are similar to those of the study by Chung et al in which preoperative forced-air warming prevented hypothermia and shivering in patients undergoing elective cesarean delivery with spinal anesthesia [23] . However, in that study the difference in maternal temperatures between groups was evident only at one timepoint (45 minutes after prewarming). Therefore, the impact of their single intervention was likely smaller than the impact of our combined warming of forced-air and intravenous fluids. The combined active warming modalities applied in our intervention group maintained a significantly higher mean temperature nearly throughout the entire surgical procedure (at the seven timepoints). The intervention group had a significantly higher temperature on arrival at the PACU compared with the control group. Similarly, our study also demonstrated that our combined warming technique can reduce the incidence of perioperative hypothermia significantly (20.6% in the intervention group compared with 56.3% in the control group). Unlike forced air-warming which warms the patient from the outside, the warming of intravenous fluids prevents hypothermia by offsetting the 0.25˚Creduction in body temperature that occurs with each liter of intravenous fluids administered at room temperature [24] . To minimize spinal hypotension, women undergoing caesarean delivery often receive large volumes of intravenous fluid intraoperatively. Thus, fluid warming may be particularly important and effective during caesarean deliveries [25] . These findings agree with those in other studies. Horn et al found that 15 minutes of preoperative warming provided additional efficacy when added to warmed intravenous fluids in the setting of epidural anesthesia, resulting in an average 1˚Cdifference between control and intervention groups at the end of the operations [13] .Unlike forced air-warming during all the surgical procedure [25] , brief period of prewarming, would be more acceptable to awake patients, easy to accommodate and could be combined with intraoperative warming, which is undoubtedly effective once the redistribution period has passed. The combined technique has the potential to minimize maternal temperature drops. Similarly, in a study by De Bernardiset al, thermal gowns and warmed intravenous fluids decreased the patient temperature drops and the incidence of shivering as compared to the same variables in the control group [26] . In contrast, in Munday et al’s study, 20 minutes of preoperative forced-air warming with intravenous fluid warming did not prevent temperature drops in women undergoing cesarean delivery [27] . However, the OR ambient temperature was lower in that study(21.4˚C).The time between the end of the warming regime and the OR entry was longer than those in our study. In their study, the time interval was smaller than 20 minutes, but some women may have experienced longer delays. Therefore, their study design may have been less powerful than ours to detect differences between two groups. In our study, shivering was significantly less common in the patients who were actively warmed, a finding that may be explained by the significantly higher core temperatures in the combined active warming patients than in the controls. The intensity and incidence of shivering may indicate the severity of hypothermia. Our study showed that the overall incidence of perioperative hypothermia decreased significantly in the intervention group compared to the incidence in the control group. Shivering is both thermogenic accompanied by vasoconstriction or non-thermogenic as that induced by catecholamines resulting from pain or anxiety [28] . A meta-analysis demonstrated that warmed intravenous fluids are effective at reducing the incidence of hypothermia and shivering [29] . In addition, our combined active warming interventions improved the thermal comfort scores of the patients in the intervention group as opposed to the score in the control group. Thermal comfort scores are subjective measures of patient comfort during the perioperative period, and may differ from actual temperature measurements and do not necessarily reflect recorded shivering episodes. Results of studies [20,30,31] and a meta-analysis [29] suggest that forced-air warming can improve thermal comfort scores. We found no significant differences in neonatal outcomes between the two groups, which is not surprising given our small sample size and our limited neonatal outcome measurements. Though our study found that the patients in the intervention group experienced higher temperatures at the time of delivery, but both groups all had normal core temperatures with a difference of0.6 degrees, which did not affect the neonatal temperature. Further studies specifically powered to evaluate the impact of active warming on neonatal outcomes are still required. We are aware of the limitations in our study. Our infrared tympanic thermometers lack evidence of their quality and accuracy. However, they are not invasive and provide an acceptable and comfortable measurement to patients. Also, we did not use intrathecal morphine as a spinal anesthetic. However, many institutions prefer to use intrathecal opioids for postoperative analgesia after cesarean delivery, so this may affect the generalizability of our study. A study has shown that intrathecal morphine administration may exacerbate hypothermia. [19] Finally, it was not a blinding clinical trial, and it may increase the bias. Conclusion In all, preoperative forced air-warming combined with perioperative intravenous fluid warming may prevent maternal hypothermia, reduce maternal shivering, and improve maternal thermal comfort in those undergoing cesarean section with spinal anesthesia. Abbreviations OR: operating room; PACU: post-anesthesia care unit; BMI: body mass index; ASA, American Society of Anesthesiologists. Declarations Ethics approval and consent to participate The study was approved by the local Ethics Committee (The Ethical Committee of NingboNO.7 Hospital). Written Informed consent to participate in the study was obtained from participants. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Science and Technology Commission of zhenhai District, Zhejiang Province[8]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors’ contributions QHZ: contributed to the design of the work, and writing the manuscript.TTN: contributed to performing all statistical analyses, drafting the manuscript.ZFZ: Suggestions for methods and results sections, tables, and figures.BH: acquisition of data. All authors read and approved the final manuscript. Acknowledgements None. Author details 1 Department of Anesthesiology, Ningbo NO.7 Hospital, Zhejiang Province, China 2 Department of Anesthesiology, Zhejiang Provincial People ' s Hospital (People ' s Hospital of Hangzhou Medicine College), Zhejiang Province, China 3 Department of Gynecology, Ningbo NO.7 Hospital, Zhejiang Province, China 4 Department of Anesthesiology, the First Affiliated Hospital, Jiaxing University, Zhejiang Province, China *Corresponding author:Department of Anesthesiology, The First Affiliated Hospital, Jiaxing University, Zhejiang Province, China Email： [email protected] References Yokoyama K, Suzuki M, Shimada Y, Matsushima T, Bito H, Sakamoto A. Effect of administration of pre-warmed intravenous fluids on the frequency of hypothermia following spinal anesthesia for Cesarean delivery. J Clin Anesth. 2009;21:242–8. Carpenter L, Baysinger CL. Maintaining perioperative normothermia in the patient undergoing cesarean delivery. ObstetGynecolSurv. 2012;67:436–46. Petsas A, Vollmer H, Barnes R. Peri-operative warming in Caesarean sections. Anaesthesia. 2009;64:921–2. Butwick AJ, Lipman SS, Carvalho B. Intraoperative forced air-warming during cesarean delivery under spinal anesthesia does not prevent maternal hypothermia. AnesthAnalg. 2007;105:1413–9, table of contents. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008;108:71–7. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet. 2001;358:876–80. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209–15. Flores-Maldonado A, Medina-Escobedo CE, Ríos-Rodríguez HM, Fernández-Domínguez R. Mild perioperative hypothermia and the risk of wound infection. Arch Med Res. 2001;32:227–31. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet. 1996;347:289–92. Hart SR, Bordes B, Hart J, Corsino D, Harmon D. Unintended Perioperative Hypothermia. Ochsner J. 2011;11:259–70. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997;277:1127–34. Peng RY, Bongard FS. Hypothermia in trauma patients. J Am Coll Surg. 1999;188:685–96. Horn E-P, Schroeder F, Gottschalk A, Sessler DI, Hiltmeyer N, Standl T, et al. Active warming during cesarean delivery. AnesthAnalg. 2002;94:409–14, table of contents. Suzuki M, Kinoshita T, Kikutani T, Yokoyama K, Inagi T, Sugimoto K, et al. Determining the plasma concentration of ketamine that enhances epiduralbupivacaine-and-morphine-induced analgesia. AnesthAnalg. 2005;101:777–84. Ozaki M, Kurz A, Sessler DI, Lenhardt R, Schroeder M, Moayeri A, et al. Thermoregulatory thresholds during epidural and spinal anesthesia. Anesthesiology. 1994;81:282–8. Matsukawa T, Sessler DI, Christensen R, Ozaki M, Schroeder M. Heat flow and distribution during epidural anesthesia. Anesthesiology. 1995;83:961–7. Hynson JM, Sessler DI. Intraoperative warming therapies: a comparison of three devices. J Clin Anesth. 1992;4:194–9. Hynson JM, Sessler DI, Moayeri A, McGuire J, Schroeder M. The effects of preinduction warming on temperature and blood pressure during propofol/nitrous oxide anesthesia. Anesthesiology. 1993;79:219–28, discussion 21A-22A. Hui C-K, Huang C-H, Lin C-J, Lau H-P, Chan W-H, Yeh H-M. A randomised double-blind controlled study evaluating the hypothermic effect of 150 microg morphine during spinal anaesthesia for Caesarean section. Anaesthesia. 2006;61:29–31. Horn E-P, Bein B, Steinfath M, Ramaker K, Buchloh B, Höcker J. The incidence and prevention of hypothermia in newborn bonding after cesarean delivery: a randomized controlled trial. AnesthAnalg. 2014;118:997–1002. Conforti A, Alviggi C, Mollo A, De Placido G, Magos A. The management of Asherman syndrome: a review of literature. Reprod Biol Endocrinol. 2013;11:118. Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008;39:3242–7. Chung SH, Lee B-S, Yang HJ, Kweon KS, Kim H-H, Song J, et al. Effect of preoperative warming during cesarean section under spinal anesthesia. Korean J Anesthesiol. 2012;62:454–60. Kurz A, Ikeda T, Sessler DI, Larson MD, Bjorksten AR, Dechert M, et al. Meperidine decreases the shivering threshold twice as much as the vasoconstriction threshold. Anesthesiology. 1997;86:1046–54. Cobb B, Cho Y, Hilton G, Ting V, Carvalho B. Active Warming Utilizing Combined IV Fluid and Forced-Air Warming Decreases Hypothermia and Improves Maternal Comfort During Cesarean Delivery: A Randomized Control Trial. AnesthAnalg. 2016;122:1490–7. de Bernardis RCG, Siaulys MM, Vieira JE, Mathias LAST. Perioperative warming with a thermal gown prevents maternal temperature loss during elective cesarean section. A randomized clinical trial. Braz J Anesthesiol. 2016;66:451–5. Munday J, Osborne S, Yates P, Sturgess D, Jones L, Gosden E. Preoperative Warming Versus no Preoperative Warming for Maintenance of Normothermia in Women Receiving Intrathecal Morphine for Cesarean Delivery: A Single-Blinded, Randomized Controlled Trial. AnesthAnalg. 2018;126:183–9. Webb PJ, James FM, Wheeler AS. Shivering during epidural analgesia in women in labor. Anesthesiology. 1981;55:706–7. Sultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: a meta-analysis. Br J Anaesth. 2015;115:500–10. Woolnough M, Allam J, Hemingway C, Cox M, Yentis SM. Intra-operative fluid warming in elective caesarean section: a blinded randomised controlled trial. Int J ObstetAnesth. 2009;18:346–51. Fallis WM, Hamelin K, Symonds J, Wang X. Maternal and newborn outcomes related to maternal warming during cesarean delivery. J ObstetGynecol Neonatal Nurs. 2006;35:324–31. Tables Table1. Demographic, surgical, and anesthetic characteristics of the study population. Intervention(n=68) Control(n=64) Age, y 28.5± 5.1 27.5± 4.6 BMI, kg/m 2 28.1± 3.2 28.4± 3.4 Gestation, weeks 38.6± 1.4 38.7± 1.3 Gravidity 2.0 [1.0-3.5] 2.0 [1.0-3.0] Parity 1.0 [0.0-1.0] 1.0 [0.0-1.0] ASA I, n(%) 56(82.4%) 52(81.3%) Hypotension, n(%) 30(44.1%) 28(43.8%) Ephedrine ,mg 13.6±9.7 12.5±8.5 Vomiting, n(%) 7(10.3%) 6(9.4%) Estimated blood loss, mL 272± 70 267± 74 Exposed time, min duration ,min 50.2±7.7 48.9± 8.1 Baseline temperature , ˚C 36.7± 0.4 36.7± 0.3 Prespinal temperature, ℃ 37.0± 0.3 36.6± 0.3 Preoperative ambient temperature, ˚C 22.6± 0.6 22.9± 0.8 OR ambient temperature, ˚C 23.9± 0.7 24.2± 0.8 PACU ambient temperature, ˚C 23.2± 0.6 22.8± 0.6 Preoperative crystalloid amount, mL crystalloid amount 371±55 363±55 Total crystalloid amount, mL 1291± 246 1343±264 Data are expressed as means ± SDs, medians [ interquartile ranges ], or numbers (%). BMI: body mass index; ASA: American Society of Anesthesiologists; OR: operating room; PACU: post-anesthesia care unit. Exposed time: including surgery duration, clean up time, and finding sheets time. Table 2. Secondary maternal and neonatal outcomes. Intervention (n = 68) Control (n = 64) P value PACU arrival temperature ˚C 36.2± 0.4 35.5± 0.3 0.007 Delivery temperature ˚C 36.6±0.3 36.0±0.3 <0.0001 Perioperative shivering 13(19.1%) 36(56.3%) <0.0001 Shivering assessment score 0 [0-0] 1 [0-2] 0.01 Perioperative hyperthermia 14(20.6%) 33(51.6%) <0.0001 Apgar score 1 min 9 [9-9] 9 [9-9] 0.21 5 min 10 [10-10] 10 [10-10] 0.43 Neonatal temperature ˚C 36.3±0.3 36.3±0.4 0.350 Data are expressed as means ± SDs, medians [ interquartile ranges ], or numbers (%). OR: operating room; PACU: post-anesthesia care unit. Bedside Shivering Assessment Scale: 0 = no shivering; 1 = shivering localized to the core and neck; 2 = shivering including the upper extremities; 3 = total body shivering. Supplementary Files CONSORTchecklist.doc Cite Share Download PDF Status: Published Journal Publication published 25 Feb, 2020 Read the published version in BMC Anesthesiology → Version 2 posted Editor assigned by journal 17 Feb, 2020 Submission checks completed at journal 16 Feb, 2020 Editor invited by journal 16 Feb, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-11269","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":357399,"identity":"e9dcddb6-c588-4f57-9acf-cb79815ad20c","order_by":1,"name":"tingting Ni","email":"","orcid":"","institution":"hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"tingting","middleName":"","lastName":"Ni","suffix":""},{"id":357400,"identity":"20bce1e3-f94f-4a3c-96ed-ee61272909b2","order_by":2,"name":"Zhen-feng Zhou","email":"","orcid":"","institution":"hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhen-feng","middleName":"","lastName":"Zhou","suffix":""},{"id":357401,"identity":"49212603-45f0-43b6-9bd7-df678f18a1df","order_by":3,"name":"Bo He","email":"","orcid":"","institution":"Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"He","suffix":""},{"id":357402,"identity":"688e2495-b4c8-407c-adbb-bd25a68c3545","order_by":4,"name":"Qing-he Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnElEQVRIiWNgGAWjYFACHsYHEqRqYTYgWQsbiTrk23OPVVi22SQ2sB8+uoEoLYw979JuSJxJS2zgSUu7QZQWZokcsxsSFYcTGyR4zIjTwgbUUiBh8J8ELTxALQwSFQdI0CLB88ZYQuJMsnEb0X6Rb88x/CzZZifbz374GHFaGBgSgEHAwODYRqRyiBbGDwwM9iToGAWjYBSMgpEGAGhJKjkpi5sQAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Qing-he","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2020-01-10 12:13:53","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.2.20668/v2","doiUrl":"https://doi.org/10.21203/rs.2.20668/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-020-00970-7","type":"published","date":"2020-02-26T02:41:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":510268,"identity":"1fd6267c-94a1-4492-b68a-1503a9f07404","added_by":"auto","created_at":"2020-02-18 18:59:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67688,"visible":true,"origin":"","legend":"Flow diagram outlining the enrollment and randomization of the study procedure.","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/11a9ae3d-3f97-46f1-a2b1-19e43c6ff8be/v2/1.jpg"},{"id":510269,"identity":"7c8fe74b-3a68-464e-bea4-53727b439474","added_by":"auto","created_at":"2020-02-18 18:59:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":112907,"visible":true,"origin":"","legend":"Core tympanic temperatures during the procedure. Compared with control group, the patients in intervention group experienced higher perioperative mean temperatures during the procedure (T1-T3,P\u003c0.001, T4-T7,P\u003c0.05).\nTimepoints: T0 = baseline, T1 = pre-spinal, T2 = post-spinal, T3 = after 15 minutes in the OR, T4 = after 30 minutes in the OR, T5 = surgery end, T6 = PACU arrival, T7 = after 15 minutes in the PACU, T8 = after 30 minutes in the PACU.\nOR: operating room; PACU: post-anesthesia care unit. \n*P\u003c0.001,#P\u003c0.05 refer to statistically significant differences between the intervention and the control groups.\n+P\u003c0.001,-P\u003c0.05 refer to comparisons with the baseline (T0).","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/11a9ae3d-3f97-46f1-a2b1-19e43c6ff8be/v2/2.png"},{"id":510270,"identity":"bcaec1e7-270b-48c8-bf4f-14bf7fe51ae0","added_by":"auto","created_at":"2020-02-18 18:59:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":107800,"visible":true,"origin":"","legend":"Maternal comfort scores during the procedure. The maternal thermal comfort scores differed significantly between two groups from the T2 to T6 timepoints (all P\u003c0.05 or P\u003c0.001).\nTimepoints: T0 = baseline, T1 = pre-spinal, T2 = post-spinal, T3 = after 15 minutes in the OR, T4 = after 30 minutes in the OR, T5 = surgery end, T6 = PACU arrival, T7 = after 15 minutes in the PACU,T8 = after 30 minutes in the PACU.\nWe measured thermal comfort scores using a verbal numerical scale in which 0 was defined as completely unsatisfied with their “thermal comfort” and 100 as completely satisfied.\n*P\u003c0.001,#P\u003c0.05 refer to statistically significant difference between the intervention and the control groups.\n+P\u003c0.001,-P\u003c0.05 refer to comparisons with baseline (T0).","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/11a9ae3d-3f97-46f1-a2b1-19e43c6ff8be/v2/3.png"},{"id":13489827,"identity":"b9d200ef-0c1e-4183-a2c9-ffc88a5661e6","added_by":"auto","created_at":"2021-09-16 22:20:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":599702,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-11269/v2/3596309c-6842-4d8f-a1af-238a8d9a1c9c.pdf"},{"id":510267,"identity":"493d7351-ff7b-4a67-8514-2f1be40fca81","added_by":"auto","created_at":"2020-02-18 18:59:37","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":369152,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORTchecklist.doc","url":"https://assets-eu.researchsquare.com/files/11a9ae3d-3f97-46f1-a2b1-19e43c6ff8be/v2/CONSORT checklist.doc"}],"financialInterests":"","formattedTitle":"Effects of Combined Warmed Preoperative Forced-air and Warmed Perioperative Intravenous Fluids on Maternal Temperature During Cesarean Section: a prospective, randomized, controlled clinical trial","fulltext":[{"header":"Background","content":"\u003cp\u003eNeuraxial (spinal, epidural, or combined spinal\u0026ndash;epidural techniques) anesthesia is the preferred anesthetic technique for cesarean deliveries. Perioperative hypothermia is a commonly reported side effect of regional anesthesia affecting up to 60% of patients undergoing cesarean deliveries under spinal anesthesia \u003csup\u003e[1\u0026ndash;4]\u003c/sup\u003e. The hypothermia can cause numerous complications including postoperative wound infections, increased blood loss and transfusion requirements, myocardial ischemia, high risk of coagulopathy, shivering, increased hospital stay, and patient discomfort\u003csup\u003e[5\u0026ndash;12]\u003c/sup\u003e. Neonatal outcomes such as birth temperature and Apgar scores have also been linked to maternal temperature \u003csup\u003e[13,14]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePerioperative hypothermia under spinal anesthesia has different etiologies, but mostly it is caused by spinal anesthesia altering thermoregulation and reducing the threshold for vasoconstriction and shivering\u003csup\u003e[15]\u003c/sup\u003e. Neuraxial anesthesia decreases the thermoregulatory vasoconstriction below the sensory blockade level, leading to heat loss by redistribution of heat from the core to the periphery\u003csup\u003e[16]\u003c/sup\u003e. The core-to-peripheral redistribution of body heat is difficult to treat, but it should be preventable by prewarming the periphery compartment \u003csup\u003e[17]\u003c/sup\u003e. Prewarming increases the heat content in the periphery of the patient and reduces the core-to-peripheral tissue temperature gradient, which otherwise promotes the heat redistribution after spinal anesthesia \u003csup\u003e[18]\u003c/sup\u003e. Intraoperative forced-air warming has been shown to be uncomfortable for the patient and may affect the early maternal-newborn bonding\u003csup\u003e[3]\u003c/sup\u003e. Unlike the forced-air warming, warmed intravenous fluids do not disturb the operation during the surgical procedure. Despite the existence of prospective studies on active warming during cesarean delivery, no consensus regarding its efficacy exists. Studies have suggested that single-modality interventions to prevent hypothermia (forced-air or intravenous fluid warmings) result in only marginal or no benefit for patients undergoing cesarean sections \u003csup\u003e[1,4,19,20]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTherefore, we aimed to evaluate the effect of the combined application of 30 minutes of preoperative warm forced-air and perioperative warm intravenous fluids in women receiving spinal anesthesia for cesarean deliveries and we assumed that combination of warmed preoperative forced-air and warmed perioperative intravenous fluids could prevent maternal hypothermia during cesarean sections under spinal anesthesia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethical Committee of Ningbo NO.7 Hospital approved this study, which follows the tenets of the Declaration of Helsinki, and we pre-registered it at \u003ca href=\"http://www.chictr.org.cn\"\u003ehttp://www.chictr.org.cn\u003c/a\u003e/index.aspx (ChiCTR1800019117). This study adheres the applicable CONSORT guidelines. We enrolled healthy pregnant women undergoing elective cesarean deliveries under spinal anesthesia after obtaining their informed consents. American Society of Anesthesiologists physical status I-II parturients, aged 18 to 40 years, with more than 37-week gestations, singleton pregnancies, and scheduled for cesarean delivery under spinal anesthesia were eligible for enrollment. We excluded women with coagulation abnormalities, thyroid disease, cesarean delivery using epidural or general anesthesia, and baseline temperatures \u0026ge;37.5˚C.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter obtaining the signed informed consents, we randomly allocated eligible participants to either the control or the intervention groups. Randomization was computer-generated using Microsoft Excel\u0026rsquo;s random number generator, and we concealed allocations using sequentially numbered opaque sealed envelopes.\u003c/p\u003e\n\u003cp\u003eAll parturients fasted for eight hours before the cesarean section. Once in the preoperative waiting area, the parturients in the intervention group received 30 minutes of upper body preoperative warming using a forced-air warming device (EQ-5000 230V, Smiths Medical ASD, Rockland, USA) set to 43˚C and nurses established intravenous accesses. The women in the intervention group received Ringer\u0026rsquo;s lactate solution pre-warmed to 37˚C through a 3MRanger\u003csup\u003eTM\u003c/sup\u003eFluid Warmer until the end of the procedure. We monitored the patients during the interventions. We discontinued the intervention in cases in which the parturients experienced adverse side effects related to warming such as diaphoresis or nausea and vomiting, or if the core thermometer was \u0026gt;37.5˚C.\u003c/p\u003e\n\u003cp\u003eAfter prewarming, we immediately transferred the term parturients to the operating room (OR).Participants in the intervention group received 30 minutes of upper body preoperative warming in the preoperative waiting area, and received IV fluid warming during the observation period(preoperative waiting area, OR and PACU ).The women in the control group received usual care consisting of no active warming and they received the intravenous fluid at room temperature throughout the procedure(preoperative waiting area, OR and PACU ). We recorded data on vital signs including heart rate, blood pressure, hemoglobin peripheral saturation, and baseline core temperature in the preoperative area. The same operator measured patients\u0026rsquo; core temperatures using an infrared tympanic thermometer (PRO6000, Braun, Marlborough, MA USA 01752) with disposable covers, and recorded the average value of three measurements. The hospital maintained central control of the temperatures of the preoperative area, OR, and post-anesthesia care unit (PACU), and we obtained the temperature readings from the thermostat.\u003c/p\u003e\n\u003cp\u003eAn anesthesiologist not involved in the study applied all spinal anesthesias at the L3-4 interspace, with 2 mL of 0.5% plain bupivacaine, using a 25-gauge Quincke needle. The surgeon commenced the operations once a sensory blockade above the T4 level was achieved according to the results of pinprick tests. After the operation, all patients were transferred to the PACU covered with a cotton sheet and a blanket.\u003c/p\u003e\n\u003cp\u003eWe obtained values for core temperature, maternal thermal comfort scores, and the incidences of shivering and hypothermia at the following timepoints: T\u003csub\u003e0 \u003c/sub\u003e= baseline, T\u003csub\u003e1 \u003c/sub\u003e= pre-spinal, T\u003csub\u003e2 \u003c/sub\u003e= post-spinal, T\u003csub\u003e3 \u003c/sub\u003e= after 15 minutes in the OR, T\u003csub\u003e4 \u003c/sub\u003e= after 30 minutes in the OR, T\u003csub\u003e5 \u003c/sub\u003e= surgery end, T\u003csub\u003e6 \u003c/sub\u003e= PACU arrival, T\u003csub\u003e7 \u003c/sub\u003e= after 15 minutes in the PACU, T\u003csub\u003e8 \u003c/sub\u003e= after 30 minutes in the PACU. According to Guidelines\u003csup\u003e[21]\u003c/sup\u003e, we defined maternal hypothermia as a core temperature \u0026lt;36˚C. We assessed thermal comfort scores using a verbal numerical scale on which we defined 0 as completely unsatisfied with the \u0026ldquo;thermal comfort\u0026rdquo; and 100 as completely satisfied. We graded shivering during and after the cesarean section according to the Bedside Shivering Assessment Scale (0, no shivering; 1, shivering localized to the core and neck; 2, shivering including the upper extremities; 3, total body shivering)\u003csup\u003e[22]\u003c/sup\u003e. The anesthesiologist provided meperidine according to their own criteria. A midwife recorded neonatal axillary temperature, and Apgar scores at 1 and 5 minutes after birth. Based on our institutional guidelines, if the core temperature was lower than 35.5\u0026deg;C, rescue warming would performed for the parturients by using a forced-air warming device.\u003c/p\u003e\n\u003cp\u003eWe defined bradycardia as a heart rate\u0026lt;50 beats/min, and treated it with 0.5 mg of intravenous atropine. When the systemic pressure decreased more than 30% of the baseline pressure or dropped below 90 mmHg, we administered ephedrine (5 mg).Mean arterial pressure and heart rate was measured at baseline, prespinal, postspinal and at the end of the procedure.\u003c/p\u003e\n\u003cp\u003eWe recorded demographic data (age, height, weight, parity, and gravidity) and surgical and anesthetic variables (Preoperative and total volume of intravenous fluids, estimated blood loss, duration of surgery, and the ambient temperatures in the preoperative area, OR, and PACU).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome measure was the core temperature change between two groups from baseline to the end of the surgical procedure.Secondary outcomes included thermal comfort scores during the operation, the incidence of shivering and hypothermia (\u0026lt;36˚C), the core temperature on the arrival at the PACU, neonatal axillary temperature at birth, and Apgar scores at 1 and 5 minutes).\u003c/p\u003e\n\u003cp\u003eAnalysis of covariance for repeated measures was under taken to calculate the sample size. A bonferroni correction for multiple pairwise comparisons was used, giving an adjusted \u003cem\u003eP\u003c/em\u003e value level of significance (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01).A clinically significant difference in the core temperature between study groups was set at 0.4\u0026deg;C according to our pilot trial with a standard deviation of 0.5\u0026deg;C,which was also consistent with Chung et al' s study\u003csup\u003e[23]\u003c/sup\u003e.A sample size of120 patients, including 20% dropouts, was estimated to provide 90% power for detecting a statistically significant difference between groups at an \u0026alpha; level of 0.01.\u003c/p\u003e\n\u003cp\u003eWe expressed normally distributed continuous data as means \u0026plusmn; SDs, and compared variables between study groups using the Student t test. Nonparametric data are presented as medians (interquartile ranges), and compared between study groups using the Mann\u0026ndash;Whitney U test. We investigated associations among discrete variables using the c2 or Fisher exact tests. Two-way repeated measures ANOVA was applied with change from baseline as the dependent variable, and the intervention, time, and the treatment multiplied by time interaction as independent variables. We also used two-way repeated measures ANOVA to assess the core temperature change and the thermal comfort between groups at each timepoint. We performed all statistical analyses using the SPSS software (version 22.0, SPSS, Chicago, IL, USA). We considered P-values \u0026lt;0.05 as statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatients were enrolled in the study between January 2019and June 2019.We considered 144 patients for eligibility, and excluded 9 before randomization. In the end we randomly allocated 135 patients to one of the two groups (69 women to the intervention group, and 66 to the control group). We had to exclude one patient from the intervention group and two patients from the control group due to failed spinal anesthesia (Fig. 1). The demographic and obstetric characteristics, as well as the surgical and anesthetic values, were did not differ significantly between the two groups. Vital sign parameters such as peripheral oxygen saturation, heart rate, meanarterialpressuremeasurement at the each point, and the incidence of hypotension and vomiting, ephedrine dose administered also had no difference between two groups during the observation period. The room temperatures in the preoperative area, OR, and PACU were similar for the two groups (Table 1).\u003c/p\u003e\n\u003cp\u003eOur two-way repeated measures ANOVA analysis revealed a significant difference in the core temperature changes fromtheT\u003csub\u003e1 \u003c/sub\u003etoT\u003csub\u003e7\u003c/sub\u003etimepointsbetween the two groups (\u003cem\u003eF\u003c/em\u003e=13.022, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and the group\u0026acute;time interaction difference was also significant (\u003cem\u003eF\u003c/em\u003e=23.195, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). The patients in the intervention group experienced higher perioperative mean temperatures during the procedure than those in the control group (T\u003csub\u003e1\u003c/sub\u003e-T\u003csub\u003e3\u003c/sub\u003e,\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001, T\u003csub\u003e4\u003c/sub\u003e-T\u003csub\u003e7\u003c/sub\u003e,\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). In the control group, the core temperature was decreased at all the time points compared to the baseline. We also found a slight decline in the core temperatures from the baseline during the procedure (exceptT\u003csub\u003e1\u003c/sub\u003eandT\u003csub\u003e2\u003c/sub\u003e) in the intervention group (Fig.2).\u003c/p\u003e\n\u003cp\u003eThermal comfort scores were higher in the intervention group than in the control group (\u003cem\u003eF\u003c/em\u003e=9.847, \u003cem\u003eP\u003c/em\u003e=0.002\u003cem\u003e),\u003c/em\u003e the group \u0026acute; time interaction difference was also significant (\u003cem\u003eF\u003c/em\u003e=2.750,\u003cem\u003e P\u003c/em\u003e=0.008). The maternal thermal comfort scores differed significantly between two groups from the T\u003csub\u003e2\u003c/sub\u003e to T\u003csub\u003e6\u003c/sub\u003e timepoints(all \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 or \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). In comparisons with the baseline thermal comfort scores, the timepoints in the control group (except T\u003csub\u003e1\u003c/sub\u003e) and those in the intervention group (except T\u003csub\u003e1\u003c/sub\u003eand T\u003csub\u003e6\u003c/sub\u003e) all exhibited decreased thermal comfort scores (Fig. 3).\u003c/p\u003e\n\u003cp\u003eCore temperatures on arrival at the PACU were greater in the intervention group (36.2 \u0026plusmn; 0.4℃) than in the control group (35.5 \u0026plusmn; 0.3℃),\u003cem\u003e P \u003c/em\u003e= 0.007. The incidences of shivering were 56.3% in the control group and 19.1% in the intervention group during the surgical procedure (\u003cem\u003eP \u003c/em\u003e\u0026lt; 0.001), and the shivering assessment scores were higher in the control than in the intervention group. The overall incidence of perioperative hypothermia was significantly lower in the intervention group than in the control group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). Neonatal outcomes were similar between the two groups(Table 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, our intervention with 30 minutes preoperative forced-air warming and perioperative administration of warmed intravenous fluids reduced the extent of core temperature decline, decreased the incidence of preoperative hypothermia and shivering, and improved maternal comfort in patients undergoing cesarean section with spinal anesthesia as opposed to the outcomes in the control group patients.\u003c/p\u003e\n\u003cp\u003eThe results of our study are similar to those of the study by Chung et al in which preoperative forced-air warming prevented hypothermia and shivering in patients undergoing elective cesarean delivery with spinal anesthesia\u003csup\u003e[23]\u003c/sup\u003e. However, in that study the difference in maternal temperatures between groups was evident only at one timepoint (45 minutes after prewarming). Therefore, the impact of their single intervention was likely smaller than the impact of our combined warming of forced-air and intravenous fluids. The combined active warming modalities applied in our intervention group maintained a significantly higher mean temperature nearly throughout the entire surgical procedure (at the seven timepoints). The intervention group had a significantly higher temperature on arrival at the PACU compared with the control group. Similarly, our study also demonstrated that our combined warming technique can reduce the incidence of perioperative hypothermia significantly (20.6% in the intervention group compared with 56.3% in the control group).\u003c/p\u003e\n\u003cp\u003eUnlike forced air-warming which warms the patient from the outside, the warming of intravenous fluids prevents hypothermia by offsetting the 0.25˚Creduction in body temperature that occurs with each liter of intravenous fluids administered at room temperature \u003csup\u003e[24]\u003c/sup\u003e. To minimize spinal hypotension, women undergoing caesarean delivery often receive large volumes of intravenous fluid intraoperatively. Thus, fluid warming may be particularly important and effective during caesarean deliveries\u003csup\u003e[25]\u003c/sup\u003e. These findings agree with those in other studies. Horn et al found that 15 minutes of preoperative warming provided additional efficacy when added to warmed intravenous fluids in the setting of epidural anesthesia, resulting in an average 1˚Cdifference between control and intervention groups at the end of the operations\u003csup\u003e[13]\u003c/sup\u003e.Unlike forced air-warming during all the surgical procedure\u003csup\u003e[25]\u003c/sup\u003e, brief period of prewarming, would be more acceptable to awake patients, easy to accommodate and could be combined with intraoperative warming, which is undoubtedly effective once the redistribution period has passed.\u003c/p\u003e\n\u003cp\u003eThe combined technique has the potential to minimize maternal temperature drops. Similarly, in a study by De Bernardiset al, thermal gowns and warmed intravenous fluids decreased the patient temperature drops and the incidence of shivering as compared to the same variables in the control group\u003csup\u003e[26]\u003c/sup\u003e. In contrast, in Munday et al\u0026rsquo;s study, 20 minutes of preoperative forced-air warming with intravenous fluid warming did not prevent temperature drops in women undergoing cesarean delivery\u003csup\u003e[27]\u003c/sup\u003e. However, the OR ambient temperature was lower in that study(21.4˚C).The time between the end of the warming regime and the OR entry was longer than those in our study. In their study, the time interval was smaller than 20 minutes, but some women may have experienced longer delays. Therefore, their study design may have been less powerful than ours to detect differences between two groups.\u003c/p\u003e\n\u003cp\u003eIn our study, shivering was significantly less common in the patients who were actively warmed, a finding that may be explained by the significantly higher core temperatures in the combined active warming patients than in the controls. The intensity and incidence of shivering may indicate the severity of hypothermia. Our study showed that the overall incidence of perioperative hypothermia decreased significantly in the intervention group compared to the incidence in the control group. Shivering is both thermogenic accompanied by vasoconstriction or non-thermogenic as that induced by catecholamines resulting from pain or anxiety \u003csup\u003e[28]\u003c/sup\u003e. A meta-analysis demonstrated that warmed intravenous fluids are effective at reducing the incidence of hypothermia and shivering\u003csup\u003e[29]\u003c/sup\u003e. In addition, our combined active warming interventions improved the thermal comfort scores of the patients in the intervention group as opposed to the score in the control group. Thermal comfort scores are subjective measures of patient comfort during the perioperative period, and may differ from actual temperature measurements and do not necessarily reflect recorded shivering episodes. Results of studies \u003csup\u003e[20,30,31]\u003c/sup\u003e and a meta-analysis\u003csup\u003e[29]\u003c/sup\u003esuggest that forced-air warming can improve thermal comfort scores.\u003c/p\u003e\n\u003cp\u003eWe found no significant differences in neonatal outcomes between the two groups, which is not surprising given our small sample size and our limited neonatal outcome measurements. Though our study found that the patients in the intervention group experienced higher temperatures at the time of delivery, but both groups all had normal core temperatures with a difference of0.6 degrees, which did not affect the neonatal temperature. Further studies specifically powered to evaluate the impact of active warming on neonatal outcomes are still required.\u003c/p\u003e\n\u003cp\u003eWe are aware of the limitations in our study. Our infrared tympanic thermometers lack evidence of their quality and accuracy. However, they are not invasive and provide an acceptable and comfortable measurement to patients. Also, we did not use intrathecal morphine as a spinal anesthetic. However, many institutions prefer to use intrathecal opioids for postoperative analgesia after cesarean delivery, so this may affect the generalizability of our study. A study has shown that intrathecal morphine administration may exacerbate hypothermia.\u003csup\u003e[19]\u003c/sup\u003eFinally, it was not a blinding clinical trial, and it may increase the bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn all, preoperative forced air-warming combined with perioperative intravenous fluid warming may prevent maternal hypothermia, reduce maternal shivering, and improve maternal thermal comfort in those undergoing cesarean section with spinal anesthesia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOR: operating room; PACU: post-anesthesia care unit; BMI: body mass index; ASA, American Society of Anesthesiologists.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the local Ethics Committee (The Ethical Committee of NingboNO.7 Hospital). Written Informed consent to participate in the study was obtained from participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Science and Technology Commission of zhenhai District, Zhejiang Province[8]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQHZ: contributed to the design of the work, and writing the manuscript.TTN: contributed to performing all statistical analyses, drafting the manuscript.ZFZ: Suggestions for methods and results sections, tables, and figures.BH: acquisition of data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003eDepartment of Anesthesiology, Ningbo NO.7 Hospital, Zhejiang Province, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003eDepartment of Anesthesiology, Zhejiang Provincial People\u003csup\u003e'\u003c/sup\u003es Hospital (People\u003csup\u003e'\u003c/sup\u003es Hospital of Hangzhou Medicine College), Zhejiang Province, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003eDepartment of Gynecology, Ningbo NO.7 Hospital, Zhejiang Province, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003eDepartment of Anesthesiology, the First Affiliated Hospital, Jiaxing University, Zhejiang Province, China\u003c/p\u003e\n\u003cp\u003e*Corresponding author:Department of Anesthesiology, The First Affiliated Hospital, Jiaxing University, Zhejiang Province, China\u003c/p\u003e\n\u003cp\u003eEmail：\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYokoyama K, Suzuki M, Shimada Y, Matsushima T, Bito H, Sakamoto A. Effect of administration of pre-warmed intravenous fluids on the frequency of hypothermia following spinal anesthesia for Cesarean delivery. J Clin Anesth. 2009;21:242\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eCarpenter L, Baysinger CL. Maintaining perioperative normothermia in the patient undergoing cesarean delivery. ObstetGynecolSurv. 2012;67:436\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003ePetsas A, Vollmer H, Barnes R. Peri-operative warming in Caesarean sections. Anaesthesia. 2009;64:921\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eButwick AJ, Lipman SS, Carvalho B. Intraoperative forced air-warming during cesarean delivery under spinal anesthesia does not prevent maternal hypothermia. AnesthAnalg. 2007;105:1413\u0026ndash;9, table of contents.\u003c/li\u003e\n\u003cli\u003eRajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008;108:71\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMelling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet. 2001;358:876\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eKurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eFlores-Maldonado A, Medina-Escobedo CE, R\u0026iacute;os-Rodr\u0026iacute;guez HM, Fern\u0026aacute;ndez-Dom\u0026iacute;nguez R. Mild perioperative hypothermia and the risk of wound infection. Arch Med Res. 2001;32:227\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eSchmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet. 1996;347:289\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eHart SR, Bordes B, Hart J, Corsino D, Harmon D. Unintended Perioperative Hypothermia. Ochsner J. 2011;11:259\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eFrank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997;277:1127\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003ePeng RY, Bongard FS. Hypothermia in trauma patients. J Am Coll Surg. 1999;188:685\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eHorn E-P, Schroeder F, Gottschalk A, Sessler DI, Hiltmeyer N, Standl T, et al. Active warming during cesarean delivery. AnesthAnalg. 2002;94:409\u0026ndash;14, table of contents.\u003c/li\u003e\n\u003cli\u003eSuzuki M, Kinoshita T, Kikutani T, Yokoyama K, Inagi T, Sugimoto K, et al. Determining the plasma concentration of ketamine that enhances epiduralbupivacaine-and-morphine-induced analgesia. AnesthAnalg. 2005;101:777\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eOzaki M, Kurz A, Sessler DI, Lenhardt R, Schroeder M, Moayeri A, et al. Thermoregulatory thresholds during epidural and spinal anesthesia. Anesthesiology. 1994;81:282\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eMatsukawa T, Sessler DI, Christensen R, Ozaki M, Schroeder M. Heat flow and distribution during epidural anesthesia. Anesthesiology. 1995;83:961\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eHynson JM, Sessler DI. Intraoperative warming therapies: a comparison of three devices. J Clin Anesth. 1992;4:194\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eHynson JM, Sessler DI, Moayeri A, McGuire J, Schroeder M. The effects of preinduction warming on temperature and blood pressure during propofol/nitrous oxide anesthesia. Anesthesiology. 1993;79:219\u0026ndash;28, discussion 21A-22A.\u003c/li\u003e\n\u003cli\u003eHui C-K, Huang C-H, Lin C-J, Lau H-P, Chan W-H, Yeh H-M. A randomised double-blind controlled study evaluating the hypothermic effect of 150 microg morphine during spinal anaesthesia for Caesarean section. Anaesthesia. 2006;61:29\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eHorn E-P, Bein B, Steinfath M, Ramaker K, Buchloh B, H\u0026ouml;cker J. The incidence and prevention of hypothermia in newborn bonding after cesarean delivery: a randomized controlled trial. AnesthAnalg. 2014;118:997\u0026ndash;1002.\u003c/li\u003e\n\u003cli\u003eConforti A, Alviggi C, Mollo A, De Placido G, Magos A. The management of Asherman syndrome: a review of literature. Reprod Biol Endocrinol. 2013;11:118.\u003c/li\u003e\n\u003cli\u003eBadjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008;39:3242\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eChung SH, Lee B-S, Yang HJ, Kweon KS, Kim H-H, Song J, et al. Effect of preoperative warming during cesarean section under spinal anesthesia. Korean J Anesthesiol. 2012;62:454\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eKurz A, Ikeda T, Sessler DI, Larson MD, Bjorksten AR, Dechert M, et al. Meperidine decreases the shivering threshold twice as much as the vasoconstriction threshold. Anesthesiology. 1997;86:1046\u0026ndash;54.\u003c/li\u003e\n\u003cli\u003eCobb B, Cho Y, Hilton G, Ting V, Carvalho B. Active Warming Utilizing Combined IV Fluid and Forced-Air Warming Decreases Hypothermia and Improves Maternal Comfort During Cesarean Delivery: A Randomized Control Trial. AnesthAnalg. 2016;122:1490\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003ede Bernardis RCG, Siaulys MM, Vieira JE, Mathias LAST. Perioperative warming with a thermal gown prevents maternal temperature loss during elective cesarean section. A randomized clinical trial. Braz J Anesthesiol. 2016;66:451\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eMunday J, Osborne S, Yates P, Sturgess D, Jones L, Gosden E. Preoperative Warming Versus no Preoperative Warming for Maintenance of Normothermia in Women Receiving Intrathecal Morphine for Cesarean Delivery: A Single-Blinded, Randomized Controlled Trial. AnesthAnalg. 2018;126:183\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eWebb PJ, James FM, Wheeler AS. Shivering during epidural analgesia in women in labor. Anesthesiology. 1981;55:706\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: a meta-analysis. Br J Anaesth. 2015;115:500\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eWoolnough M, Allam J, Hemingway C, Cox M, Yentis SM. Intra-operative fluid warming in elective caesarean section: a blinded randomised controlled trial. Int J ObstetAnesth. 2009;18:346\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eFallis WM, Hamelin K, Symonds J, Wang X. Maternal and newborn outcomes related to maternal warming during cesarean delivery. J ObstetGynecol Neonatal Nurs. 2006;35:324\u0026ndash;31.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eTable1. Demographic, surgical, and anesthetic characteristics of the study population.\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:31.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-family:\u0026quot;TimesNewRomanPS-BoldMT\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid black 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:31.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003eIntervention(n=68)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid black 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:31.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003eControl(n=64)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eAge, y\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e28.5± 5.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e27.5± 4.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;color:black;\"\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e28.1± 3.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e28.4± 3.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family: \u0026quot;Times New Roman\u0026quot;,serif;color:black;\"\u003eGestation, weeks\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e38.6± 1.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e38.7± 1.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family: \u0026quot;Times New Roman\u0026quot;,serif;\"\u003eGravidity\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e2.0 [1.0-3.5]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e2.0 [1.0-3.0]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family: \u0026quot;Times New Roman\u0026quot;,serif;\"\u003eParity\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height: 150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e1.0 [0.0-1.0]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e1.0 [0.0-1.0]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family: \u0026quot;Times New Roman\u0026quot;,serif;\"\u003eASA I, n(%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPS-BoldMT\u0026quot;,serif;\"\u003e56(82.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPS-BoldMT\u0026quot;,serif;\"\u003e52(81.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eHypotension, n(%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e30(44.1%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e28(43.8%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eEphedrine ,mg\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e13.6±9.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e12.5±8.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eVomiting, n(%)\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e7(10.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e6(9.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eEstimated blood loss, mL\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e272± 70\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e267± 74\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eExposed time, min\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;duration ,min\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e50.2±7.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e48.9± 8.1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eBaseline\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e\u0026nbsp;temperature\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e,\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.7± 0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.7± 0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003ePrespinal temperature,\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family: SimSun;\"\u003e℃\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e37.0± 0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.6± 0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003ePreoperative ambient temperature,\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e22.6± 0.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e22.9± 0.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eOR ambient temperature,\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e23.9± 0.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e24.2± 0.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003ePACU ambient temperature,\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e23.2± 0.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e22.8± 0.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003ePreoperative\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;crystalloid amount, mL crystalloid amount\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e371±55\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e363±55\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:182.55pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"42.78169014084507%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eTotal crystalloid amount, mL\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:123.5pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"29.049295774647888%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e1291± 246\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:120.05pt;border:none;border-bottom:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"28.169014084507044%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e1343±264\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eData are expressed as means ± SDs, medians [\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003einterquartile ranges\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e], or numbers (%).\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eBMI: body mass index; ASA: American Society of Anesthesiologists; OR: operating room; PACU: post-anesthesia care unit.\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eExposed time: including surgery duration, clean up time, and finding sheets time.\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cbr\u003e\n\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cbr\u003e\n\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cbr\u003e\n\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cbr\u003e\n\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eTable 2. Secondary maternal and neonatal outcomes.\u003c/span\u003e\u003c/p\u003e\n\u003cdiv align=\"center\" style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:32.3pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid black 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:32.3pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;line-height: 150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eIntervention (n = 68)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid black 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:32.3pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;line-height: 150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eControl (n = 64)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border-top:solid black 1.0pt;border-left: none;border-bottom:solid black 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;height:32.3pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eP\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003evalue\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003ePACU arrival temperature\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.2± 0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e35.5± 0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:normal;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e0.007\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eDelivery temperature\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.6±0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.0±0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e\u0026lt;0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003ePerioperative shivering\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e13(19.1%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36(56.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e\u0026lt;0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eShivering assessment score\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e0 [0-0]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e1 [0-2]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003ePerioperative hyperthermia\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e14(20.6%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e33(51.6%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e\u0026lt;0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eApgar score\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e1 min\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e9 [9-9]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e9 [9-9]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e0.21\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e5 min\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e10 [10-10]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e10 [10-10]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e0.43\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:156.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"37.65765765765766%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eNeonatal temperature\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u0026nbsp;˚C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:111.75pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"26.846846846846848%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.3±0.3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:94.5pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"22.7027027027027%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e36.3±0.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.05pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.7pt;\" width=\"12.792792792792794%\"\u003e\n \u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:center;line-height:150%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:150%;font-family:\u0026quot;TimesNewRomanPSMT\u0026quot;,serif;\"\u003e0.350\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eData are expressed as means ± SDs, medians [\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003einterquartile ranges\u003c/span\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e], or numbers (%).\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eOR: operating room; PACU: post-anesthesia care unit.\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:200%;font-size:14px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-size:15px;line-height:200%;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003eBedside Shivering Assessment Scale: 0 = no shivering; 1 = shivering localized to the core and neck; 2 = shivering including the upper extremities; 3 = total body shivering.\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cesarean section, Spinal anesthesia, Warming","lastPublishedDoi":"10.21203/rs.2.20668/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.20668/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Preventing the frequent perioperative hypothermia incidents that occur during elective caesarean deliveries would be beneficial. This trial aimed at evaluating the effect of preoperative forced-air warming alongside perioperative intravenous fluid warming in women undergoing cesarean sections under spinal anesthesia. Methods: We randomly allocated135 women undergoing elective cesarean deliveries to either the intervention group (preoperative forced-air and intravenous fluid warmings, n = 69) or the control group (no active warming, n = 66). The primary outcome measure was the change from the core baseline temperature to that at the end of the procedure. Secondary\u0026nbsp;outcomes included thermal comfort scores, the incidences of shivering and hypothermia (\u0026lt;36℃), the core temperature on arrival at the post-anesthesia care unit, neonatal axillary temperature at birth, and Apgar scores. Results: Two-way repeated measures ANOVA revealed significantly different core temperature changes (from the pre-spinal temperature to that at the end of the procedure) between groups ( F = 13.022, P \u0026lt;0.001). The thermal comfort scores were also higher in the intervention group than in the control group ( F = 9.847, P = 0.002). The overall incidence of perioperative hypothermia was significantly lower in the intervention group than in the control group (20.6% vs. 51.6%, P \u0026lt;0.0001). Conclusions: Warming preoperative forced-air and perioperative intravenous fluids may prevent maternal hypothermia, reduce maternal shivering, and improve maternal thermal comfort for patients undergoing cesarean sections under spinal anesthesia. Trial registration: The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800019117) on October26, 2018. Keywords: Cesarean section, Spinal anesthesia, Warming\u003c/p\u003e","manuscriptTitle":"Effects of Combined Warmed Preoperative Forced-air and Warmed Perioperative Intravenous Fluids on Maternal Temperature During Cesarean Section: a prospective, randomized, controlled clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-02-18 18:59:36","doi":"10.21203/rs.2.20668/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2020-02-17T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-16T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-16T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-01-15 19:16:35","doi":"10.21203/rs.2.20668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-02-06T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nVery well conducted study and well written.\nCouple of suggestions.\nPage 5- Can you clarify if the forced warm air device was continued in the OR or not.\nAlso state clerly when the warmed IV fluids were started. Did they start in the preop area when the IV was placed, prior to spinal placement in the OR or after the placement of spinal ?\n- The cotton sheet/blanket used to transport patient, was it from a warmer or is it at room temperature.\n\nWas there any account of the time the patient was exposed ( Surgery, cleaning, finding sheets/gown etc) compared in the groups.\n\nPage 8 - 162-163. I would sugeest to use room temperatures in the preop, OR PACU etc....\n\nWorth mentioning - Probably the temperatures at the time of delivery would have been more relevant given there was no difference in the neonatal temperatures at birth.\n"},{"type":"decision","content":"Minor revision","date":"2020-02-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-27T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nThank you for the opportunity to review this manuscript. This is a prospective randomized trial,which tested the effect of preoperative forced-air warming combined with perioperative fluid warming on core temperature change and on secondary outcomes as thermal discomfort, shivering, hypothermia and neonatal outcomes in women undergoing elective C-section during spinal anesthesia.\n\nThe manuscript is generally well written, the scientific question is reasonable and the outlined methods are adequate.\n\nI have some minor comments and suggestions:\n\nBackground:\nAt the end of the method section one sentence explaining the specifically tested primary hypothesis should be added.\n\nMethods:\nWas there any plan for rescue warming, when core temperature dropped below a certain threshold, i.e. 35.5 degree C; what is the institution's current standard of care in these cases.\nBlinding: Was the investigator, who evaluated the outcomes during the postoperative period blinded to the pre/intraoperative treatment? If not,this fact should be discussed as a limitation.\nPower analysis and actual number of patients:According to the presented power analysis the actual number of randomized patients remains inconclusive and should be explained.\n\nResults:\nIn which time period were patients included?\nVitalsign parameters as stated in the method section are missing in the result section or tables, specifically no information about hypotensive events and treatment in both groups is provided.\nWere there any side effects of pre-warming?\n\nTable 1: How much fluid was specifically administered preoperatively in both groups.\nDecimal places reported with the given amounts of crystalloids and blood loss are not reasonable.\n\nFigure (legens). How was significance between the groups at each time point evaluated. Summary measures should be applied. This information is missing in the legend."},{"type":"reviewerAgreed","content":"","date":"2020-01-17T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-01-10T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-01-09T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-01-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-01-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-01-08T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-12-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5a1bd84-cbb7-4932-b234-0339e8321e27","owner":[],"postedDate":"February 18th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":49966,"name":"Anesthesiology \u0026 Pain Medicine"}],"tags":[],"updatedAt":"2021-08-20T02:41:56+00:00","versionOfRecord":{"articleIdentity":"rs-11269","link":"https://doi.org/10.1186/s12871-020-00970-7","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2020-02-26 02:41:56","publishedOnDateReadable":"February 26th, 2020"},"versionCreatedAt":"2020-02-18 18:59:36","video":"","vorDoi":"10.1186/s12871-020-00970-7","vorDoiUrl":"https://doi.org/10.1186/s12871-020-00970-7","workflowStages":[]},"version":"v2","identity":"rs-11269","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-11269","version":["v2"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}