Comparison of spontaneous versus operative vaginal delivery using Obstetric Quality of Recovery-10 (ObsQoR-10): An observational cohort study

Quality of Recovery After Unplanned and Planned Cesarean Deliveries: A Prospective Observational Study Using the Obstetric Quality of Recovery-10 Tool

BACKGROUND

There is a paucity of literature examining the differences between patient-reported outcome measures after planned and unplanned cesarean delivery using a validated quality of recovery tool. The Obstetric Quality of Recovery-10 (ObsQoR-10) scoring tool has been validated to quantify functional recovery after cesarean delivery. We aimed to use the ObsQoR-10 to compare the postoperative recovery characteristics of patients undergoing planned and unplanned cesarean deliveries.

METHODS

We conducted a prospective single-center observational study. Patients undergoing planned and unplanned cesarean deliveries under neuraxial anesthesia were asked to complete the ObsQoR-10 questionnaire 24 hours, 48 hours, and 1 week postpartum. We collected information on total in-hospital postoperative opioid consumption and patients´ perception of readiness for discharge at 24 and 48 hours postpartum. Additionally, patient characteristics were collected to assess their correlation with our findings.

RESULTS

We included 112 patients (56 in each group). No statistical differences in ObsQoR-10 scores at 24 hours, 48 hours, and 1 week postpartum were observed between the planned and unplanned cesarean deliveries. Additionally, there was no difference between the groups in patients' perception of readiness for hospital discharge at 24 and 48 hours and opioid consumption in the first 2 days after surgery. Most patients in both groups did not think they would be ready for discharge at 24 hours postpartum. Analysis of the individual components of ObsQoR-10 at 24 hours showed a difference in the responses assessing the severity of shivering (higher in unplanned cesarean deliveries) and the ability to look after personal hygiene (lower in unplanned cesarean deliveries).

CONCLUSIONS

As assessed by the ObsQoR-10, no significant difference in the quality of recovery was observed between patients undergoing planned and unplanned cesarean delivery.

Association of inpatient postpartum recovery with patient-reported outcome measures following hospital discharge: a prospective cohort study

BACKGROUND

The relationship between the quality of inpatient versus outpatient obstetric postpartum recovery is under-explored. We examined the association between inpatient reported quality of recovery with outpatient global recovery, pain severity, pain interference, anxiety, and depression screening scores postpartum.

METHODS

We conducted a multicenter observational cohort study of women in labor who underwent vaginal, operative vaginal, or intrapartum cesarean birth. Subjects completed baseline assessments of pain, social support, anxiety, and depression in early labor. We assessed the Obstetric Quality of Recovery-10 (ObsQoR-10) on the day of discharge and the ObsQoR-10, Global Health Scale (GHVAS; 0-100), Brief Pain Inventory (BPI), and the Edinburgh Postnatal Depression Scale (EPDS) on postpartum day seven. We hypothesized that the ObsQoR-10 scores at discharge would be useful in predicting postpartum day seven measures of recovery and postpartum depression screening scores.

RESULTS

We consented 558 subjects, 551/558(98%) completed baseline assessments, 400/551(72%) completed the ObsQoR-10 tool, and 344/551(62%) completed an EPDS assessment. Median (1st, 3rd quartile) ObsQoR-10 scores were 78 (63, 90) at discharge and 85 (68,93) on postpartum day seven, (difference of 7 [99% CI 2 to 13], P < 0.001). GHVAS on postpartum day seven identified 204/344 (59%) of subjects with good recovery. An ObsQoR-10 score of > 86 at discharge had a RR of 1.5 [95% CI 1.2 to 1.8], P < 0.001 for good recovery at postpartum day seven, the EPDS identified 20/344 (5.8%) respondents with a score ≥ 13 on postpartum day seven. The area under the curve between the ObsQoR-10 at discharge with an EPDS ≥ 13 was 0.74 (99% CI 0.61 to 0.86, P < 0.001). The RR for an EPDS ≥ 13 on postpartum day seven with an ObsQoR-10 < 77 on the day of discharge was 7.8 (95% CI 1.8 to 33.8; P = 0.001).

CONCLUSIONS

ObsQoR-10 scores at discharge and postpartum day seven demonstrated increased obstetric recovery in the post-discharge period. The observed association between the ObsQoR-10 and the EPDS, suggests that the ObsQoR-10 might facilitate identification of women at increased risk of postpartum anxiety or depression. Identification of high-risk women at discharge may allow early interventions to reduce morbidity secondary to postpartum depression.

The correlation between quality of recovery and parturient outcomes after Cesarean delivery: a cohort study

PURPOSE

Recent studies have reported the use of the obstetric-specific quality of recovery tool (ObsQoR-10) to assess the quality of recovery in parturients after childbirth; however, the correlation between ObsQoR-10 scores and important postpartum outcomes are unclear. The primary aim of the present study was to investigate the correlations between ObsQoR-10 scores at 24 hr after Cesarean delivery and breastfeeding, depressive symptomatology, overall health, and pain at seven days postpartum.

METHODS

We recruited parturients who underwent elective Cesarean delivery at KK Hospital in Singapore. Parturients provided responses to post-Cesarean questionnaires at 1) 24 hr (ObsQoR-10, EuroQol EQ-Visual Analogue Scale, Edinburgh Postnatal Depression Scale), 2) 48 hr (ObsQoR-10, EQ-Visual Analogue Scale), and 3) seven days after Cesarean delivery (ObsQoR-10, Breastfeeding Self-Efficacy Scale-Short form, EQ-Visual Analogue Scale, Edinburgh Postnatal Depression Scale, pain survey).

RESULTS

We enrolled 222 participants, 200 (90%) of whom completed the seven-day follow-up between September 2022 and April 2023. There was limited correlation between ObsQoR-10 at 24 hr with the Edinburgh Postnatal Depression Scale (r = 0.135), EQ-Visual Analogue Scale (r = 0.158), Breastfeeding Self-Efficacy Scale-Short form (r = 0.225), and averaged pain scores (r = -0.107) at seven days postpartum. ObsQoR-10 breastfeeding sub-score at 24 hr was weakly correlated with Breastfeeding Self-Efficacy Scale-Short form at seven days postpartum (r = 0.307).

CONCLUSION

ObsQoR-10 at 24 hr postpartum had limited correlation with breastfeeding, depressive symptomatology, overall health, and pain at seven days.

STUDY REGISTRATION

ClinicalTrials.gov ( NCT04989894 ); first submitted 4 July 2021.

Impact of Neuraxial Preservative-Free Morphine in Vaginal Delivery on Opiate Consumption and Recovery: A Randomized Control Trial

BACKGROUND

Neuraxial opioids are commonly used after cesarean delivery (CD). However, they are not commonly used after vaginal delivery (VD) though some studies have suggested they may be beneficial from a pain perspective. However, they did not evaluate other potential benefits including patient satisfaction, impact on postpartum depression and breastfeeding (BF) success, or side effects such as pruritus.

METHODS

Parturients who delivered vaginally with epidural analgesia were randomized to receive either 2 mg of preservative-free morphine (4 mL) or saline (4 mL) via the epidural catheter within 1 hour of VD. Routine analgesics were unchanged and included q 6-hour dosing of acetaminophen 975 mg orally and ketorolac 30 mg intravenous (IV). Hydromorphone 2 mg or oxycodone 10 mg were offered for breakthrough pain. Our primary outcome was opiate consumption in the first 24 hours after drug administration. Secondary outcomes included pain scores at 24 hours and 1 week postpartum as well as opiate consumption up to 1 week postpartum. Additional end points such as obstetric quality of recovery score (OBS-QOR10) breast feeding success, and an Edinburgh Postnatal Depression Score (EPDS) were also obtained.

RESULTS

Data were analyzed for 157 parturients, 80 in the morphine group and 77 in the saline group. No difference was observed in the EDPS score predelivery or intention to BF. We found a statistically significant difference in the use of opioids in the first 24 hours, 3.8% (95% confidence interval [CI], 0.9%-11.3%) vs 14.3% (7.7%-24.5%) in the morphine and saline groups, respectively; and in total opioid dose, median (interquartile range, IQR [range]) of morphine milligram equivalent vs 0 (0-0 [0-47.5]) vs 0 (0-0 [0-72]), P = .023, in the morphine and saline groups, respectively. Verbal pain scores (0-10) at 24 hours were lower in the morphine group (median (IQR [range): 2.0 (1-4 [0-10]) vs 3.0 (1.5-5.0 [0-10]), P = .043. There was a greater incidence of pruritus in the morphine group versus saline group, 37.5% (95% CI, 27.1%-49.1%) vs 18.2% (95% CI, 10.6%-29.0%), P = .008. We did not find any differences in the OBS-QOR10, BF success, or EPDS at 6 weeks PP (P < .05).

CONCLUSIONS

A single epidural dose of 2 mg preservative-free morphine after VD was effective at decreasing pain and opioid use at 24 hours after VD but came at the cost of increased pruritus. We did not detect any differences in BF, recovery scores, or PPD. Future studies should focus on elucidating the role of neuraxial preservative-free morphine after VD.

Development and validation of a Spanish version of the Obstetric Quality of Recovery-10 item score (ObsQoR-10-Spanish)

Background

Spanish is the second most spoken language globally with around 475 million native speakers. We aimed to validate a Spanish version of the Obstetric Quality of Recovery-10 item (ObsQoR-10) patient-reported outcome measure.

Methods

ObsQoR-10-Spanish was developed using EuroQoL methodology. ObsQoR-10-Spanish was assessed in 100 Spanish-speaking patients undergoing elective Caesarean or vaginal delivery. Patients <38 weeks, undergoing an intrapartum Caesarean delivery, intrauterine death, or maternal admission to the intensive care unit (ICU) were excluded. Validity was assessed by evaluating (i) convergent validity-correlation with 24-h EuroQoL and global health visual analogue scale (GHVAS) scores (0-100); (ii) discriminant validity-difference in ObsQoR-10-Spanish score for patients with GHVAS scores >70 vs <70; (iii) hypothesis testing-correlation of ObsQoR score with maternal and neonatal factors; and (iv) cross-cultural validity assessed using differential item functioning analysis. Reliability was assessed by evaluating: (i) internal consistency; (ii) split-half reliability and (iii) test-retest reliability; and (iv) floor and ceiling effects.

Results

One hundred patients were approached, recruited, and completed surveys. Validity: (i) convergent validity: the ObsQoR 24-h score correlated moderately with the 24-h EuroQoL (r=-0.632) and GHVAS scores (r=0.590); (ii) discriminant validity: the ObsQoR-10-Spanish 24-h scores were higher in women who delivered vaginally compared to via Caesarean delivery, (mean [standard deviation] scores were 89 [9] vs 81 [12]; P<0.001). The 24-h ObsQoR-Spanish scores were lower in patients experiencing a poor vs a good recovery (mean [standard deviation] scores were 76 [12.3] vs 87.1 [10.6]; P=0.001); (iii) hypothesis testing: the ObsQoR-10 score correlated negatively with age (r=-0.207) and positively with 5-min (r=0.204) and 10-min (r=0.243) Apgar scores. Remaining correlations were not significant; and (iv) differential item functioning analysis suggested no potential bias among the 10 items. Reliability: (i) internal consistency was good (Cronbach alpha=0.763); (ii) split-half reliability was good (Spearman-Brown prophesy reliability estimate of 0.866); (iii) test-retest reliability was excellent with an intra-class correlation coefficient of 0.90; and (iv) floor and ceiling effects: six patients scored a maximum total ObsQoR-10 score.

Conclusions

The ObsQoR-10-Spanish patient-reported outcome measure is valid, reliable, and clinically feasible, and should be considered for use in Spanish-speaking women to assess quality of inpatient postpartum recovery.

A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture

This narrative review of the 2023 Gerard W. Ostheimer lecture presented at the Society for Obstetric Anesthesia and Perinatology 2023 annual meeting summarizes 2022 literature relevant to obstetric anesthesiologists.

ANTENATAL STUDIES

Neonatal morbidity is reduced with antenatal maternal buprenorphine compared with methadone for treatment of opioid use disorder. Antenatal pregnancy allergy testing is safe and feasible.

ANALGESIA AND ANESTHESIA STUDIES

Intrathecal (IT) 3% chloroprocaine for cervical cerclage results in faster sensory block resolution and discharge readiness compared with bupivacaine. The ED90 of 3% chloroprocaine (with IT fentanyl 10 µg) is 49.5 mg. Dural puncture epidural technique does not improve the quality of labor analgesia in obese parturients compared with epidural analgesia. Low- (>0.08 to ≤0.1%) and ultra-low (<0.08%) concentrations of bupivacaine for epidural analgesia maintenance result in similar maternal and neonatal outcomes. Lower doses of first line uterotonic agents are non-inferior to higher doses (oxytocin 0.5 IU vs. 5 IU and carbetocin 20 vs. 100 µg) in patients at low risk for postpartum hemorrhage. Supplemental analgesia or conversion to general anesthesia is necessary in approximately 15% of elective cesarean deliveries. Intravenous dexamethasone improves analgesia outcomes, however optimal dosing and timing remain unclear; it may induce neonatal hypoglycemia in the setting of gestational diabetes.

POSTPARTUM STUDIES

A core outcome set may help evaluate enhanced recovery protocol implementation. History of migraine and accidental dural puncture (ADP) above the L3 level are associated with epidural blood patch (EBP) failure and ADP at or below L3 and >48 h interval between ADP and EBP are associated with success.

Outcomes and outcome measures utilised in randomised controlled trials of postoperative caesarean delivery pain: a scoping review

BACKGROUND

Inadequately treated postoperative pain following caesarean delivery can delay recovery and the ability to care for a newborn. Effectiveness studies of interventions to treat postoperative caesarean delivery pain measure different outcomes, limiting data pooling for meta-analysis. We performed a comprehensive review of existing outcomes with the aim of recommending core outcomes for future research.

METHODS

A scoping review to identify all outcomes reported in randomised controlled trials (RCTs) and clinical trial registries of interventions to treat or prevent postoperative caesarean delivery pain, with postoperative pain as a primary outcome measure. We searched PubMed, Web of Science, CINAHL, LILACS, Embase, CDSR and CRCT for studies from May 2016 to 2021. Outcomes were extracted and frequencies tabulated.

RESULTS

Ninety RCTs and 11 trial registries were included. In total, 392 outcomes (375 inpatient and 17 outpatient) were identified and categorised. The most reported outcome domain was analgesia (n = 242/375, 64.5%), reported in 96% of inpatient studies, with analgesic consumption accounting for 108/375, 28.8% of analgesia outcomes. The second most common domain was pain intensity (n = 120/375, 32%), reported in 97% of inpatient studies, using the visual analogue scale (68/120, 59%) and the numerical reporting scale (37/120, 25%). Maternal and neonatal adverse effects accounted for 65/375 (17.3%) and 19/375 (5.1%) of inpatient outcomes, respectively.

CONCLUSIONS

Outcomes reported in RCTs for postoperative caesarean delivery pain vary widely. The results of this review suggest that standardisation is needed to promote research efficiency and aid future meta-analyses to identify optimal postoperative caesarean delivery pain management.

Use of the Obstetric Quality-of-Recovery score (ObsQoR-11) to measure the impact of an enhanced recovery programme for elective caesarean section

BACKGROUND

Enhanced recovery after caesarean (ERAC) has been shown to postoperatively reduce opioid consumption, reduce pain scores, and shorten hospital stay. Arguably, none of these measures provide for a patient-centred approach. We believe that patient-reported outcome measures (PROMs) represent a more holistic approach to the reporting of outcomes. One such PROM is the Obstetric Quality-of-Recovery Score (ObsQoR-11). This has been shown to be a valid and reliable assessment of recovery after elective caesarean section.

METHODS

This before-and-after quality improvement programme studied consecutive patients undergoing elective caesarean section. We implemented an ERAC pathway with the aim of improving quality of recovery and patient satisfaction. Our primary outcome was the change in the ObsQoR-11 score.

RESULTS

A total of 318 medical records were reviewed (n = 93 before ERAC, n = 225 after ERAC). There was a significant improvement in ObsQoR-11 score in ERAC patients compared with pre-ERAC patients (85.0 vs 82.3, P < 0.001). Morphine consumption (MMEQ) was reduced by 10% overall in the ERAC group, with no increase in pain scores at day 1 postoperatively and a decrease in pain scores on day 2 in the ERAC group (P = 0.02). The length of hospital stay was significantly shorter in ERAC patients (63.1 h vs 79.9 h, P < 0.001).

CONCLUSIONS

Our study demonstrated an improved ObsQoR-11 score after ERAC implementation. This is the first example in the literature of using ObsQoR-11 in ERAC. We believe this is a more comprehensive way to assess patient recovery and the impact of an ERAC programme.

The relationship between postpartum pain and mother-infant bonding: A prospective observational study

INTRODUCTION

Postpartum pain is associated with impaired maternal recovery and may influence mother-infant bonding.

METHODS

Participants who underwent a vaginal or cesarean delivery were assessed 24 h postpartum. Postpartum pain intensity was measured using the Verbal Numeric Score (VNS) (0-10) and classified as non-severe (<8) or severe pain (≥8). Maternal-infant bonding was evaluated using the Post-Partum Bonding Questionnaire (PBQ; 0-125), with a score > 5 defining impaired bonding. Demographic data included age, BMI, parity, education level, economic status, partnership, prior history of depression, familial history of depression, desire to breastfeed, epidural analgesia during labor, rooming in, and Edinburgh Postnatal Depression Scale (EPDS). Data were analyzed using 2 separate multivariable logistic regression models for vaginal and cesarean deliveries, where maximum postpartum pain was the independent variable and impaired postpartum bonding was the dependent variable and controlled for the other factors collected.

RESULTS

Severe postpartum pain (VNS ≥ 8) showed no significant relationship with impaired bonding when controlling for confounding variables. In vaginal deliveries, there was an association between a history of depression and impaired bonding (Odds Ratio 2.2 [1.07-4.65], p = 0.04) and EPDS > 10 and impaired bonding (OR 11.5 [3.2-73.6], p < 0.001). For cesarean deliveries, rooming in with the baby had a protective effect (OR 11.5 [3.2-73.6], p < 0.001).

CONCLUSIONS

Contrary to expectations, severe postpartum pain did not influence maternal-infant binding in the cohort of patients with vaginal and cesarean deliveries. Instead, factors such as maternal mental health and rooming-in practices appeared to exert more significant influence.

CLINICAL TRIAL REGISTRATION

NCT05206552.

Association of inpatient postpartum quality of recovery with postpartum depression: A prospective observational study

STUDY OBJECTIVE

To explore the relationship between Obstetric Quality of Recovery survey (ObsQoR-10-Heb) and Edinburgh postnatal depression scale (EPDS) measured 6 weeks after delivery, adjusted for potential confounding factors.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Large postpartum department, 13,000 annual deliveries, quaternary medical center in Israel.

PATIENTS

Women ≥18 years old, gestational age ≥ 37 weeks after term delivery (spontaneous vaginal, operative vaginal, planned, and unplanned cesarean delivery), with non-anomalous neonates not requiring special support after delivery or at the time of recruitment. Written informed consent was provided. Women unable to read or understand Hebrew were excluded.

INTERVENTIONS

No interventions were done.

MEASUREMENTS

We investigated the relationship between inpatient postpartum recovery and positive postpartum depression (PPD) screening at 6 weeks postpartum. Enrolled women completed the validated Hebrew version of ObsQoR-10 survey (ObsQoR-10-Heb; scored between 0 and 100 with 0 and 100 representing worst and best possible recovery) from 24 to 48 h after delivery, and the Edinburgh Postnatal Depression Scale (EPDS) at 6- and 12 weeks postpartum. We assessed the univariate association between ObsQoR-10-Heb; patient factors; obstetric factors; and positive PPD screening at 6 weeks postpartum. Potential confounders were adjusted in a multiple logistic regression model.

MAIN RESULTS

Inpatient ObsQoR-10-Heb has been completed by 325 postpartum women; 270 (83.1%) and 253 (77.9%) completed the 6- and 12 weeks EPDS respectively. Lower ObsQoR-10-Heb (aOR 0.95 (95% CI 0.92, 0.98); p = 0.001); depression or anxiety before delivery (aOR 4.53 (95% CI 1.88, 10.90); p = 0.001); and hospital readmission (aOR 9.08 (95% CI 1.23, 67.14); p = 0.031) were associated with positive screening for postpartum depression at 6 weeks.

CONCLUSIONS

Our study demonstrates that worse inpatient postpartum recovery is an independent risk factor for positive PPD screening at 6 weeks postpartum. Other risk factors found in our study were maternal hospital readmission and a previous history of anxiety or depression.

Development, women-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs): A systematic review

BACKGROUND

Measuring maternity care outcomes based on what women value is critical to promoting woman-centred maternity care. Patient-reported outcome measures (PROMs) are instruments that enable service users to assess healthcare service and system performance.

AIM

To identify and critically appraise the risk of bias, woman-centricity (content validity) and psychometric properties of maternity PROMs published in the scientific literature.

METHODS

MEDLINE, CINAHL Plus, PsycINFO and Embase were systematically searched for relevant records between 01/01/2010 and 07/10/2021. Included articles underwent risk of bias, content validity and psychometric properties assessments in line with COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidance. PROM results were summarised according to language subgroups and an overall recommendation for use was determined.

FINDINGS

Forty-four studies reported on the development and psychometric evaluation of 9 maternity PROMs, grouped into 32 language subgroups. Risk of bias assessments for the PROM development and content validity showed inadequate or doubtful methodological quality. Internal consistency reliability, hypothesis testing (for construct validity), structural validity and test-retest reliability varied markedly in sufficiency and evidence quality. No PROMs received a level 'A' recommendation, required for real-world use.

CONCLUSION

Maternity PROMs identified in this systematic review had poor quality evidence for their measurement properties and lacked sufficient content validity, indicating a lack of woman-centricity in instrument development. Future research should prioritise women's voices in deciding what is relevant, comprehensive and comprehensible to measure, as this will impact overall validity and reliability and facilitate real-world use.

Validation of Hindi version of the obstetric quality of recovery score-11 (ObsQoR-11 H) following elective caesarean section

Background and Aims

Obstetric quality of recovery score-11 (ObsQoR-11) was developed in English to evaluate the quality of recovery in the caesarean section. We aimed to validate the Hindi version of ObsQoR-11 (ObsQoR-11H) for Hindi-speaking patients to evaluate the quality of recovery following the elective caesarean section.

Methods

The ObsQoR-11 was translated into Hindi and assessed for validity, acceptability and feasibility. The questionnaire was administered postoperatively at 24 and 48 hours, and the Global Health Numeric Rating Scale (NRS) was used to evaluate recovery.

Results

The mean (standard deviation [SD]) (95% confidence interval [CI]) ObsQoR-11 H was 75.94 (4.09)(95% CI 75.1, 76.7) and 80.25 (4.08)(95% CI 79.5, 81) at 24 and 48 hours, respectively. The mean (SD) (95%CI) Global Health NRS scores were 71.22 (5.97)(95% CI 70, 72.4) and 77.37 (5.79)(95% CI 76.2, 78.5) at 24 and 48 hours, respectively. Convergent validity showed a strong correlation between ObsQoR-11H and Global Health NRS (Spearman's correlation coefficient [rs] >0.8 and 0.78) scores at 24 and 48 hours, respectively. Discriminant validity was significant in appreciating the difference between good and poor recovery (P < 0.001). Split-half coefficient of 0.69 and 0.65 and Cronbach's alpha (α) of 0.91 and 0.82 at 24 and 48 hours suggested good score reliability. The acceptability and feasibility of the score were also good.

Conclusion

The ObsQoR-11H discriminated well between 'good' and 'poor' recovery and correlated strongly with Global Health NRS scores. It was found to be a valid, reliable, acceptable and feasible tool for psychometric recovery evaluation after elective caesarean section in Hindi-speaking women.

Translation and validation of the French version of the ObsQoR-10 questionnaire for the evaluation of recovery after delivery: the ObsQoR-10-French

Background

The Obstetric Quality of Recovery-10 (ObsQoR-10) is a validated tool for assessing the quality of postpartum recovery. This study aimed to validate the French version of the ObsQoR-10 scale (ObsQoR-10-French).

Methods

After translating the ObsQoR-10 into French, we conducted a psychometric validation involving internal consistency, convergent validity, construct validity, reliability, responsiveness, scaling properties, acceptability, and feasibility. French women who underwent either a vaginal delivery (spontaneous or induced labour), or an emergency or elective Caesarean section (C-section) were prospectively included. They completed the ObsQoR-10-French before delivery and at 24 h (H24) and 48 h (H48) after delivery.

Results

Of the 500 women included, 431 (86%) completed the questionnaire at all three timepoints. A total of 352 women (82%) underwent vaginal delivery (with 228 [53%] experiencing spontaneous labour and 124 [29%] had labour induced), whereas 53 (12%) women underwent an emergency C-section and 26 (6%) an elective C-section. The ObsQoR-10-French demonstrated excellent internal consistency with a Cronbach's coefficient of 0.81, 95% confidence interval 0.78-0.84 at H24. The tool was correlated with an 11-item global health score (P<0.001). Of the list of hypotheses for evaluating the construct validity, 81% were confirmed (negative associations between ObsQoR-10-French and length of labour, hospital stay, the need for a C-section, and the emergency level of the C-section). The Cohen effect size at H24 was 0.58. The intra-class coefficient was 0.90, 95% confidence interval 0.86-0.93 at H24.

Conclusion

The ObsQoR-10-French is a valid and reliable psychometric questionnaire, capable of assessing the quality of postpartum recovery in French-speaking populations.

Clinical trial registration

NCT04489602.

Postpartum recovery of nulliparous women following scheduled cesarean delivery and spontaneous vaginal delivery: a prospective observational study

BACKGROUND

Inpatient postpartum recovery trajectories following cesarean delivery and spontaneous vaginal delivery are underexplored.

OBJECTIVE

This study primarily aimed to compare recovery following cesarean delivery and spontaneous vaginal delivery in the first postpartum week, and secondarily to evaluate psychometrically the Japanese version of the Obstetric Quality of Recovery-10 scoring tool.

STUDY DESIGN

Following institutional review board approval, the EQ-5D-3L (EuroQoL 5-Dimension 3-Level) questionnaire and a Japanese version of the Obstetric Quality of Recovery-10 measure were used to evaluate inpatient postpartum recovery in uncomplicated nulliparous parturients delivering via scheduled cesarean delivery or spontaneous vaginal delivery.

RESULTS

A total of 48 and 50 women who delivered via cesarean delivery and spontaneous vaginal delivery, respectively, were recruited. Women delivering via scheduled cesarean delivery experienced significantly worse quality of recovery on days 1 and 2 compared with those who had spontaneous vaginal delivery. Quality of recovery significantly improved daily, plateauing at days 4 and 3 for cesarean delivery and spontaneous vaginal delivery groups, respectively. Compared with cesarean delivery, spontaneous vaginal delivery was associated with prolonged time to analgesia requirement, decreased opioid consumption, reduced antiemetic requirement, and reduced times to liquid/solid intake, ambulation, and discharge. Obstetric Quality of Recovery-10-Japanese is a valid (correlates with the EQ-5D-3L including a global health visual analog scale, gestational age, blood loss, opioid consumption, time until first analgesic request, liquid/solid intake, ambulation, catheter removal, and discharge), reliable (Cronbach alpha=0.88; Spearman-Brown reliability estimate=0.94; and intraclass correlation coefficient=0.89), and clinically feasible (98% 24-hour response rate) measure.

CONCLUSION

Inpatient postpartum recovery is significantly better in the first 2 postpartum days following spontaneous vaginal delivery compared with scheduled cesarean delivery. Inpatient recovery is largely achieved within 4 and 3 days following scheduled cesarean delivery and spontaneous vaginal delivery, respectively. Obstetric Quality of Recovery-10-Japanese is a valid, reliable, and feasible measure of inpatient postpartum recovery.

Validation of the Thai version of the obstetric quality of recovery score (obsqor-10-Thai) after elective cesarean delivery

BACKGROUND

The Obstetric Quality of Recovery score (ObsQoR-10) is a questionnaire used to assess recovery after cesarean delivery. However, the original ObsQoR-10 is in English and was mainly validated in the Western population. We therefore evaluated the reliability, validity, and responsiveness of the ObsQoR-10-Thai in patients undergoing elective cesarean delivery.

METHODS

The original ObsQoR-10 was translated into Thai, and psychometric validation was performed to evaluate the quality of post-cesarean recovery. The ObsQoR-10-Thai, activities of daily living checklist, and 100-mm visual analog scale of global health (VAS-GH) questionnaires were administered to the study participants before and 24 and 48-h postpartum. Validity, reliability, responsiveness, and feasibility of the ObsQoR-10-Thai were assessed.

RESULTS

We included 110 patients undergoing elective cesarean delivery. The mean ObsQoR-10-Thai score at baseline and 24 and 48-h postpartum was 83.35 ± 11.15, 56.75 ± 11.6, and 70.96 ± 13.65, respectively. The ObsQoR-10-Thai score differed significantly between the two groups divided based on the VAS-GH (≥ 70 vs. < 70): 75.58 ± 13.81 and 52.56 ± 10.61, respectively (P < 0.001). The convergent validity between the ObsQoR-10-Thai and VAS-GH was good (r = 0.60, P < 0.001). The ObsQoR-10-Thai displayed good internal consistency (Cronbach's alpha = 0.87), split-half reliability (0.92), and test-retest reliability (0.99, 95% CI: 0.98-0.99). The median time to complete the questionnaire was 2 (IQR, 1-6) min.

CONCLUSIONS

Our findings indicate that the ObsQoR-10-Thai is valid and has good reliability, with a high degree of responsiveness in terms of assessment of recovery after elective cesarean delivery.

TRIAL REGISTRATION

This study was registered on the Thai Clinical Trials Registry, identifier TCTR20210204001, registered on 04/02/2021 (Prospectively registration).

The Effect of Pelvic Rocking Exercise with a Birth Ball and SP6 Acupressure on Duration of the First and Second Stage of Labor

Background: Long duration of labor increases the pain that a mother experiences. Several non-pharmacological methods, such as pelvic rocking exercises and SP6 acupressure, have been discovered to reduce pain and accelerate labor duration. It needs to be clarified which of the two methods is more effective.Purpose: This study aimed to assess the effectiveness of pelvic rocking exercise with a birth ball and SP6 acupressure in shortening the duration of the active phase in the first and the second stage of labor.Methods: This study used a quasi-experimental design involving 64 mothers in the first stage of normal delivery who were recruited using propensity score matching sampling. The participants were divided into two intervention groups (the pelvic rocking exercise with a birth ball and SP6 acupressure). Each respondent in the two intervention groups was monitored for progress of labor during the active phase in the first stage using a partograph starting from cervical dilatation of 4 cm to 10 cm. The duration of the second stage was assessed by calculating the length of time from cervical dilatation of 10 cm to the delivery of the entire baby. The Mann-Whitney U test was performed to assess the difference between the two interventions in the two stages of labor assessed.Results: There was a difference in the duration of labor in the first stage (p=0.00) and the second stage (p=0.001) between the groups given the pelvic rocking exercise with a birth ball and the SP6 acupressure. The pelvic rocking exercise with a birth ball was found to be more effective in shortening the duration of the active phase in the first stage (Mean rank=19.83) and the second stage of labor (Mean rank=24.56) compared to SP6 acupressure (Mean rank of the first stage=45.17 and Mean rank of the second stage=40.44).Conclusion: The pelvic rocking exercise was found to be more effective compared to SP6 acupressure in shortening the duration of the active phase in the first and the second stage of labor. Pelvic rocking exercise can be implemented to help accelerate labor duration so that mothers can feel more comfortable during the labor.

Validation of the Turkish version of the Obstetric Quality-of-Recovery score 11 (ObsQoR-11T) after cesarean delivery

BACKGROUND

To translate and validate the psychometric characteristics of a Turkish version of the Obstetric Quality-of-Recovery score 11 tool used to measure post-cesarean delivery recovery in Turkish-speaking patients.

METHODS

After the original English version of the Obstetric Quality-of-Recovery score 11 tool was translated into Turkish; it was psychometrically validated to assess the post-cesarean delivery quality of recovery. Validity, reliability, and feasibility were investigated. The Obstetric Quality-of-Recovery score 11 tool was administered to Turkish-speaking patients on postoperative day 1. On postoperative day 1, a global health visual analog scale was used to assess the patient's perceived global recovery.

RESULTS

One hundred and eighty-six patients completed their questionnaires, providing a completion rate of 97.38%. The Spearman rho (ρ) correlation coefficient between the Obstetric Quality-of-Recovery score and global health visual analog scale (0-100 points) was 0.850 at postoperative day 1 following surgery (P < 0.001). Internal consistency, measured using Cronbach's alpha, was 0.822. The split-half coefficient was 0.708. The Obstetric Quality-of-Recovery score differed significantly between the emergency and elective cesarean delivery groups (80 (41-104) vs. 83.3 (51-102); P < 0.05). The test-retest reliability of the Obstetric Quality-of-Recovery score items was more than 0.6 in 82% of cases, indicating good repeatability and reliability.

CONCLUSION

The Obstetric Quality-of-Recovery score 11 is a valid and reliable tool to measure the post-cesarean quality of recovery in Turkish-speaking patients. The psychometric properties of the Turkish version of the scale to measure the post-cesarean quality of recovery were similar to those of the seminal English version.

Patient-reported outcome measures evaluating postpartum maternal health and well-being: a systematic review and evaluation of measurement properties

OBJECTIVE

This study aimed to systematically review and evaluate postpartum health and well-being using patient-reported outcome measures across all domains of postpartum health using the COnsensus-based Standards for the selection of health Measurement INstruments guidelines.

DATA SOURCES

Based on a preprepared published protocol, a systematic search of PubMed, Embase, and CINAHL was undertaken to identify patient-reported outcome tools. The protocol was registered with the International Prospective Register of Systematic Reviews (registration number CRD42021283472), and this work followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines for systematic reviews.

STUDY ELIGIBILITY CRITERIA

Studies eligible for inclusion included those that assessed a patient-reported outcome measure examining postpartum women's health and well-being with no limitation on the domain. The included studies aimed to evaluate one or more measurement properties of the patient-reported outcome measure.

METHODS

Data extraction and the methodological assessment of the quality of the patient-reported outcome measure were assessed by 2 reviewers independently based on content validity, structural validity, internal consistency, cross-cultural validity or measurement invariance, reliability, measurement error, hypotheses testing for construct validity, and responsiveness, as defined by the COnsensus-based Standards for the selection of health Measurement INstruments. The standard used for content validity were the domains of importance to women in postpartum health and well-being proposed by the International Consortium for Health Outcomes Measurement. The outcome domains for patient-reported health status include mental health, health-related quality of life, incontinence, pain with intercourse, breastfeeding, and motherhood role transition. The quality of the methods was rated an overall rating of results, awarded a level of evidence, and assessed using the Grading of Recommendations, Assessment, Development, and Evaluations assessment tool, and a level of recommendation was awarded for each tool.

RESULTS

There were 10,324 studies identified in the initial search, of which 29 tools were identified from 41 eligible studies included in the review. Moreover, 21 tools were awarded an "A" grading of recommendation for use as a patient-reported outcome measure in postpartum women following the COnsensus-based Standards for the selection of health Measurement Instruments standards. Of the "A"-rated tools, 17 (80%) examined the domain of mental health, 5 examined health-related quality of life, 4 examined breastfeeding, and 6 represented role transition. No "A"-recommended tool examined postpartum incontinence or pain with intercourse. Of note, 3 tools did not cover domains as recommended by the International Consortium for Health Outcomes Measurement, and 5 tools were awarded a "B" rating, requiring more research before their recommendation for use. Here, most tools were awarded very low-moderate Recommendations, Assessment, Development, and Evaluations level of evidence. Moreover, the highest quality tool identified that covered multiple domains of postpartum health and well-being was the women's Postpartum Quality-of-Life Questionnaire.

CONCLUSION

This systematic review identified the best performing patient-reported outcome measures to assess postpartum health and well-being. No individual tool covers all 6 domains of postpartum health and well-being. Here, the highest quality tool found that covered multiple domains of postpartum health and well-being was the Postpartum Quality-of-Life Questionnaire. The Postpartum Quality-of-Life Questionnaire captures 4 of 6 domains of importance to women, with domains of incontinence and sexual health unevaluated. The domain of urinary incontinence was represented by the International Consultation on Incontinence Questionnaire Short Form, which requires further psychometric analysis before its recommended use. Postpartum sexual health, not represented by any tool, necessitates the development of a patient-reported outcome measure. A postpartum patient-reported outcome measure would be best provided by a combination of tools; however, further research is required before its implementation.

Development and validation of a Portuguese version of Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese)

BACKGROUND

We aimed to develop and validate a Portuguese version of the Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese) patient-reported outcome measure and evaluate its psychometric properties.

METHODS

After ethical approval, we recruited term pregnant women undergoing uncomplicated elective cesarean delivery in a single Brazilian institution. Women were invited to complete the translated ObsQoR-10-Portuguese and EuroQoL (EQ-5D) questionnaires (including a global health visual analog scale [GHVAS]) at 24 h (±6 h) following delivery, and a subset of women an hour later. We assessed validity and reliability of ObsQoR-10-Portuguese.

RESULTS

One hundred thirteen enrolled women completed the surveys at 24 h and 29 women at 25 h (100% response rate).

VALIDITY

(i) convergent validity: ObsQoR-10-Portuguese correlated moderately with EuroQoL score (r = -0.587) and GHVAS score (r = 0.568) at 24 h. (ii) Discriminant validity: ObsQoR-10 discriminated well between good versus poor recovery (GHVAS score ≥ 70 versus < 70; difference in mean scores 14.2; p < 0.001). (iii) Hypothesis testing: 24-h ObsQoR-10-Portuguese scores correlated with gestational age (r = 0.191; p = 0.043). (iv) Cross-cultural validity: differential item functioning analysis suggested bias in 2 items. Reliability: (i) internal consistency was good (Cronbach's alpha = 0.82 and inter-item correlation = 0.31). (ii) Split-half reliability was very good (Spearman-Brown Prophesy Reliability Estimate = 0.80). (iii) Test re-test reliability was excellent (intra-class correlation coefficient = 0.87). (iv) Floor and ceiling effects: < 5% women scored either 0 or 100 (lowest and highest scores, respectively).

CONCLUSION

ObsQoR-10-Portuguese is valid and reliable, and should be considered for use in Portuguese-speaking women to assess their quality of inpatient recovery following cesarean delivery.

Expert Consensus Regarding Core Outcomes for Enhanced Recovery after Cesarean Delivery Studies: A Delphi study

BACKGROUND

Heterogeneity among reported outcomes from enhanced recovery after cesarean delivery impact studies is high. This study aimed to develop a standardized enhanced recovery core outcome set for use in future enhanced recovery after cesarean delivery studies.

METHODS

An international consensus study involving physicians, patients and a director of Midwifery and Nursing Services, was conducted using a three-round modified Delphi approach (2 rounds of electronic questionnaires and a 3rd round e-discussion), to produce the core outcome set. An initial list of outcomes was based on a previously published systematic review. Consensus was obtained for the final core outcome set, including definitions for key terms, and preferred units of measurement. Strong consensus was defined as ≥70% agreement and weak consensus as 50-69% agreement. Of the 64 stakeholders who were approached, 32 agreed to participate. All 32, 31 and 26 stakeholders completed Rounds 1, 2 and 3, respectively.

RESULTS

The number of outcomes in the final core outcome set was reduced from 98 to 15. Strong consensus (≥70% stakeholder agreement) was achieved for 15 outcomes. The core outcome set included: length of hospital stay; compliance with enhanced recovery protocol; maternal morbidity (hospital re-admissions or unplanned consultations); provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption / requirement and incidence of nausea or vomiting); fasting times; breastfeeding success; and times to mobilization and urinary catheter removal. The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set. Areas identified as requiring further research included readiness for discharge and analysis of cost savings.

CONCLUSIONS

Results from an international consensus to develop a core outcome set for enhanced recovery after cesarean delivery are presented. These are outcomes that could be considered when designing future enhanced recovery studies.

Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.

Assessing quality of care in maternity services in low and middle-income countries: Development of a Maternity Patient Reported Outcome Measure

Globally, low and middle-income countries bear the greatest burden of maternal and newborn mortality. To reduce these high levels, the quality of care provided needs to be improved. This study aimed to develop a patient reported outcome measure for use in maternity services in low and middle-income countries, to facilitate improvements in quality of care. Semi-structured interviews and focus groups discussions were conducted with women who had recently given birth in selected healthcare facilities in Malawi and Kenya. Transcripts of these were analysed using a thematic approach and analytic codes applied. Draft outcomes were identified from the data, which were reviewed by a group of clinical experts and developed into a working copy of the Maternity Patient Reported Outcome Measure (MPROM). A further sample of new mothers were asked to evaluate the draft MPROM during cognitive debriefing interviews, and their views used to revise it to produce the final proposed measure. Eighty-three women were interviewed, and 44 women took part in 10 focus group discussions. An array of outcomes was identified from the data which were categorised under the domains of physical and psychological symptoms, social issues, and baby-related health outcomes. The draft outcomes were configured into 79 questions with answers provided using a five-point Likert scale. Minor revisions were made following cognitive debriefing interviews with nine women, to produce the final proposed MPROM. In conjunction with women from the target population and clinical experts, this study has developed what is believed to be the first condition-specific PROM suitable for assessing care quality in maternity services in low and middle-income countries. Following further validation studies, it is anticipated that this will be a useful tool in facilitating improvements in the quality of care provided to women giving birth in healthcare facilities in these settings.

Validation of translated Obstetric Quality of Recovery (ObsQoR-10A) score after nonelective cesarean delivery (CD) in an Arabic-speaking population

Background:

The ObsQoR-11 is a validated scale that assesses recovery after cesarean delivery (CD). This observational study aimed to evaluate the psychometric properties of its Arabic version.

Methods:

The original ObsQoR-11 was translated into an Arabic version (ObsQoR-10A). All participants completed the ObsQoR-10A at 24 h and 48 h postoperatively after CD. Validity, reliability, responsiveness, and feasibility were assessed.

Results:

The ObsQoR-10A correlated with Global Health Numerical Rating Scale (NRS) at 24 h (R = 0.68, 95% CI: 0.56–0.80, P < 0.001) and at 48 h (R = 0.66, 95% CI: 0.54–0.78, P < 0.001) and differentiated between good and poor recovery (median scores at 24 h 88 vs. 71, P < 0.001; at 48 h 95.5 vs. 70, P < 0.001). ObsQoR-10A correlated with hospital length of stay at 24 h (R = −0.21, 95% CI: −0.40 to −0.02, P = 0.03) and at 48 h (R = −0.21, 95% CI: −0.40 to −0.03, P = 0.02); gestational age at 24 h (R = 0.22, 95% CI: 0.03–0.40, P = 0.02); change in hemoglobin at 24 h (R = −0.30, 95% CI: 0.51 to −0.10, P < 0.01); and total opioids at 48 h (R = −0.45, 95% CI: −0.62 to −0.27, P < 0.001). There was a significant difference between 24 h and 48 h postoperative ObsQoR-10A scores (median difference: −18; P < 0.001 which shows responsiveness). Other key measures included a Cronbach's alpha of 0.87, split-half 0.75, and intra-class correlation >0.62 with no floor or ceiling effects. Median (IQR) completion time was 3 (3-5) and 3 (2.5-3.5) minutes at 24 h and 48 h.

Conclusions:

ObsQoR-10A is a valid, reliable, responsive, and a clinically feasible tool in an Arabic-speaking obstetric population.

Validation of an obstetric quality of recovery scoring tool (ObsQoR-11) after elective caesarean delivery in a developing country: a prospective observational study

BACKGROUND

The obstetric quality of recovery scoring tool (ObsQoR-11) was developed and validated in the United Kingdom for use after elective and emergency caesarean delivery. Quality of recovery scoring tools validated in one country may not be valid in other countries with significant cultural, socio-economic and linguistic variations. The aim of the current study was to validate a Hindi version of the ObsQoR-11.

METHODS

In this prospective observational study, 100 parturients who underwent elective caesarean delivery in a tertiary care obstetric referral university hospital in North India were asked to complete a Hindi version of the ObsQoR-11 scoring tool 24 h after surgery. The performance of the Hindi version of ObsQoR-11 was assessed using measures of validity, reliability, and feasibility.

RESULTS

The Hindi version of ObsQoR-11 correlated moderately with the global health visual analogue scale (r=0.45, 95% CI 0.27 to 0.59; P <0.0001) and discriminated well between good and poor recovery (mean (SD) score 84.6 (9.4) vs 75.0 (11.2); P <0.0001). The reliability and internal consistency were moderate (Cronbach's alpha=0.66; Spearman-Brown Prophesy Reliability estimate=0.57) with good repeatability (intraclass correlation coefficient 0.85, 95% CI 0.69 to 0.93; P <0.0001) and no floor or ceiling effects. All parturients completed the questionnaire (median (IQR) time of completion of 3 (1.5 - 5.5) min).

CONCLUSION

The Hindi version of the ObsQoR-11 questionnaire is a promising scoring tool to evaluate quality of recovery after elective caesarean delivery. Further research is needed to evaluate the Hindi tool in other institutions in India, as well as in other languages.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis

BACKGROUND

This meta-analysis explores the impact of enhanced recovery after cesarean delivery (ERAC) on maternal outcomes.

METHODS

We searched 4 databases (Web of Science, Embase, PubMed and CINAHL) in October 2020 without date limiters, for studies quantitatively comparing ERAC implementation to a control group. The primary outcome was length of hospital stay and secondary outcomes included time to mobilization and time to urinary catheter removal, opioid consumption, readmission rates and cost savings. Mean differences and odds ratios (MD and OR with 95% confidence intervals) were calculated. Levels of evidence were assessed using GRADE.

RESULTS

Twelve studies involving 17,607 patients (9693 without ERAC and 7914 with ERAC) were included. ERAC was associated with reduced: length of hospital stay (MD -0.51 days [-0.94, -0.09]; p = 0.018; I2 = 99%), time to first mobilization (MD -11.05 h [-18.64, -3.46]; p = 0.004; I2 = 98%), time to urinary catheter removal (MD -13.19 h [-17.59, -8.79]; p < 0.001; I2 = 97%) and opioid consumption (MD -21.85 mg morphine equivalents [-33.19, -10.50]; p = < 0.001; I2 = 91%), with no difference in maternal readmission rate (OR 1.23 [0.96, 1.57]; p = 0.10; I2 = 0%). Three studies reported cost savings associated with ERAC. The GRADE levels of evidence were rated as low or very low quality for all study outcomes.

CONCLUSION

ERAC is associated with reduction in length of stay, times to first mobilization and urinary catheter removal and opioid consumption. ERAC does not significantly affect maternal hospital readmission rates following discharge. Further studies are required to determine which ERAC interventions to implement and which outcomes best determine ERAC efficacy.

Proposed domains for assessing postpartum recovery: a concept elicitation study

OBJECTIVE

To propose postpartum recovery domains.

DESIGN

Concept elicitation study.

SETTING

Semi-structured interviews.

POPULATION

Ten writing committee members and 50 stakeholder interviews (23 postpartum women, nine general obstetricians, five maternal and fetal medicine specialists, eight nurses and five obstetric anaesthetists).

METHODS

Alternating interviews and focus group meetings until concept saturation was achieved (no new themes discussed in three consecutive interviews). Interviews were digitally recorded and transcribed, and an iterative coding process was used to identify domains.

MAIN OUTCOME MEASURES

The primary outcome was to identify recovery domains. We also report key symptoms and concerns. Discussion frequency and importance scores (0-100; 0 = not important; 100 = vitally important to recovery) were used to rank domains. Discussion frequency was used to rank factors helping and hindering recovery, and to determine the greatest challenges experienced postpartum.

RESULTS

Thirty-four interviews and two focus group meetings were performed. The 13 postpartum recovery domains identified, (ranked highest to lowest) were: psychosocial distress, surgical/medical factors, infant feeding and breast health, psychosocial support, pain, physical function, sleep, motherhood experience, infant health, fatigue, appearance, sexual function and cognition. The most frequently discussed factors facilitating postpartum recovery were: family support, lactation/breastfeeding support and partner support. The most frequently discussed factor hindering recovery was inadequate social support. The most frequent challenges reported were: breastfeeding (week 1), breastfeeding (week 3) and sleep (week 6).

CONCLUSIONS

We propose 13 domains that comprehensively describe recovery in women delivering in a single centre within the USA. This provides a novel framework to study the postpartum recovery process.

TWEETABLE ABSTRACT

We propose 13 postpartum recovery domains that provide a framework to study the recovery process following childbirth.

Use of Patient-Reported Outcome Measures to Assess Outpatient Postpartum Recovery: A Systematic Review

IMPORTANCE

Outpatient postpartum recovery is an underexplored area of obstetrics. There is currently no consensus regarding which patient-reported outcome measure (PROM) clinicians and researchers should use to evaluate postpartum recovery.

OBJECTIVE

To evaluate PROMs of outpatient postpartum recovery using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.

EVIDENCE REVIEW

An initial literature search performed in July 2019 identified postpartum recovery PROMs and validation studies. A secondary search in July 2020 identified additional validation studies. Both searches were performed using 4 databases (Web of Science, Embase, PubMed, and CINAHL), with no date limiters. Studies with PROMs evaluating more than 3 proposed outpatient postpartum recovery domains were considered. Studies were included if they assessed any psychometric measurement property of the included PROMs in the outpatient postpartum setting. The PROMs were assessed for the following 8 psychometric measurement properties, as defined by COSMIN: content validity, structural validity, internal consistency, cross-cultural validity and measurement invariance, reliability, measurement error, hypothesis testing, and responsiveness. Psychometric measurement properties were evaluated in each included study using the COSMIN criteria by assessing (1) the quality of the methods (very good, adequate, doubtful, inadequate, or not assessed); (2) overall rating of results (sufficient, insufficient, inconsistent, or indeterminate); (3) level of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations assessment tool; and (4) level of recommendation, which included class A (recommended for use; showed adequate content validity with at least low-quality evidence for sufficient internal consistency), class B (not class A or class C), or class C (not recommended).

FINDINGS

In total, 15 PROMs (7 obstetric specific and 8 non-obstetric specific) were identified, evaluating outpatient postpartum recovery in 46 studies involving 19 165 women. The majority of psychometric measurement properties of the included PROMs were graded as having very-low-level or low-level evidence. The best-performing PROMs that received class A recommendations were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF. The remainder of the evaluated PROMs had insufficient evidence to make recommendations regarding their use (and received class B recommendations).

CONCLUSIONS AND RELEVANCE

This review found that the best-performing PROMs currently available to evaluate outpatient postpartum recovery were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF; however, these tools all had significant limitations. This study highlights the need to focus future efforts on robustly developing and validating a new PROM that may comprehensively evaluate outpatient postpartum recovery.

Postpartum recovery: what does it take to get back to a baseline?

PURPOSE OF REVIEW

Limited guidance exists regarding how to assess postpartum recovery. In this article, we discuss various aspects of inpatient and outpatient postpartum recovery.

RECENT FINDINGS

The postpartum period for many women includes sleep deprivation, maternal-neonatal bonding, breastfeeding, and integrating a new life into the family unit. Factors which impact inpatient quality of recovery include pain, nausea or vomiting, dizziness, shivering, comfort, mobilization, ability to hold and feed the baby, personal hygiene maintenance, and feeling in control. Outpatient recovery domains include psychosocial distress, surgical/medical factors, feeding and breast health, psychosocial support, pain, physical function, sleep, motherhood experience, infant health, fatigue, appearance / cosmetic factors, sexual function, and cognition. Postpartum recovery is likely to take longer than six weeks; however, no consensus regarding recovery duration exists among professional societies. Obstetric quality of recovery (ObsQoR) is a recommended measure of inpatient postpartum recovery; however, studies are needed to determine the optimum outpatient recovery assessment tool.

SUMMARY

Postpartum recovery is an important area that requires clinical and research attention. Future studies should focus on identifying and developing valid, reliable, and responsive measures of recovery as well as tracking and optimizing recovery domains following all delivery modes.

SUPPLEMENTARY VIDEO ABSTRACT ALSO AVAILABLE

http://links.lww.com/COOG/A65.

Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review

This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.