The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: a meta-analysis

The Effects of Actively Warming the Patient on Maternal and Infant Well-Being in a Cesarean Section Operation

PURPOSE

Intraoperative warming is recommended for surgical patients under anesthesia, but there are insufficient studies on this topic in cesarean delivery patients under spinal anesthesia. The purpose of this study was to determine the effects of active warming on the mother and newborn during elective cesarean section.

DESIGN

This research was carried out in an experimental design with a pretest-posttest randomized intervention and control group.

METHODS

The research was conducted with 34 women (17 intervention and 17 control), who gave birth by cesarean section. The study examined outcomes for both mother and newborn. Women in the intervention group were heated by both active (warmed with carbon fiber resistive underbody heaters during surgery) and passive heating (preoperative- socks, nonelectrified wool blankets, etc). Only passive heating methods were applied to the women in the control group (preoperative). Neonatal Activity - Pulse - Grimace - Appearence - Respiration (APGAR) score, body temperature, cortisol, and blood glucose levels in the intervention and control groups were evaluated, while body temperature and shivering conditions were evaluated in the mother.

FINDINGS

Body temperature and first minute APGAR score of the infants in the intervention and control groups after cesarean section were 36.88 ± 0.27, 36.52 ± 0.32 (P = .002); 7.00 ± 0.36, 7.47 ± 0.64 (P = .009), respectively. Cortisol and blood glucose levels in the intervention and control groups were 3.55 ± 1.09, 4.51 ± 0.70 (P = .010), 77.94 ± 7.07, 72.47 ± 10.24 (P > .05), respectively. The body temperatures of the women in the intervention and control groups at 15, 30, and 45 minutes were significantly different (P < .05), while they were similar (P > .05) at 60 minutes. Oxygen saturation measured at 30 minutes during the operation was 97.10 ± 1.41 in the intervention group and 95.20 ± 1.78 in the control group (P < .05).

CONCLUSIONS

Active warming before, during, and after cesarean section affected body temperature, pulse, respiration, blood pressure, and oxygen saturation of women, and while it increased the body temperature and APGAR score of newborns, it decreased cortisol level.

Perioperative Hypothermia in Elderly Patients During Pelvic Floor Reconstruction Surgery: An Observational Study

INTRODUCTION AND HYPOTHESIS

The potential predictors of pelvic floor reconstruction surgery hypothermia remain unclear. This prospective cohort study was aimed at identifying these predictors and evaluating the outcomes associated with perioperative hypothermia.

METHODS

Elderly patients undergoing pelvic floor reconstruction surgery were consecutively enrolled from April 2023 to September 2023. Perioperative temperature was measured at preoperative (T1), every 15 min after the start of anesthesia (T2), and 15 min postoperative (T3) using a temperature probe. Perioperative hypothermia was defined as a core temperature below 36°C at any point during the procedure. Multivariate logistic regression analysis was conducted to determine factors associated with perioperative hypothermia.

RESULTS

A total of 229 patients were included in the study, with 50.7% experiencing hypothermia. Multivariate analysis revealed that the surgical method involving pelvic floor combined with laparoscopy, preoperative temperature < 36.5°C, anesthesia duration ≥ 120 min, and the high levels of anxiety were significantly associated with perioperative hypothermia. The predictive value of the multivariate model was 0.767 (95% CI, 0.706 to 0.828).

CONCLUSIONS

This observational prospective study identified several predictive factors for perioperative hypothermia in elderly patients during pelvic floor reconstruction surgery. Strategies aimed at preventing perioperative hypothermia should target these factors. Further studies are required to assess the effectiveness of these strategies, specifically in elderly patients undergoing pelvic floor reconstruction surgery.

Evidence-based cesarean delivery: preoperative management (part 7)

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Non-pharmacological treatments for shivering post neuraxial anaesthesia for caesarean section: a scoping review

BACKGROUND

Shivering occurs more frequently for women having caesarean section under neuraxial anaesthesia compared to other patient groups and causes an increase in pain and interrupts bonding with her newborn.

AIM

This study aimed to report the evidence on non-pharmacological methods to treat shivering, defined as uncontrollable shaking, because of being cold, frightened, or excited, post neuraxial anaesthesia; the use of local anaesthesia inserted around the nerves of the central nervous system such as spinal anaesthesia and epidural in women having a caesarean section.

METHODS

A scoping review was conducted using six electronic health databases that were searched with no restrictions placed on language, date, or study type.

FINDINGS

Of the 1399 studies identified, following screenings only one study was deemed suitable for inclusion. The study, a randomised controlled trial, compared forced air warming blankets (intervention) with the usual care of warmed cotton blankets (control) and its impact on maternal and newborn outcomes. The only statistically significant difference found was the perceived thermal comfort of the mother.

DISCUSSION

Non-pharmacological treatments for shivering are underrepresented in the literature; only one study identified where the impact of active warming was compared to warmed cotton blankets (usual care) for the measures of: oral temperature; degree of shivering; and thermal comfort pain scores. There was a decline in temperature in both groups at odds with some women reporting feeling too warm such that they asked for the active warmer to be turned down.

CONCLUSION

Social engagement strategies are interventions that send a signal of safety to the nervous system leading to a sense of calm and wellbeing and have biological plausibility and warrant evaluation. Recommendations for further research: design a robust study to test the effectiveness of social engagement strategies on shivering for women having caesarean section under neuraxial anaesthesia.

Prewarming Parturients for Cesarean Section Does Not Raise Wound Temperature But Body Heat and Level of Comfort: A Randomized Trial

PURPOSE

Prewarming before cesarean section lowers the rates of surgical site infections (SSIs). We hypothesized that this effect is explained due to a higher core temperature resulting in a higher wound temperature.

DESIGN

We conducted an open-labeled randomized study with on-term parturients scheduled for elective cesarean section under spinal anesthesia. Participants were randomized into an intervention group (prewarming) and a control group.

METHODS

Core and wound temperature, comfort level, and examination results were taken at defined times until discharge from the postanesthesia care unit (PACU). There was a follow-up visit and interview 1 day after the procedure. The primary outcome was a difference in wound temperature. The secondary outcomes were differences in core temperature, patient comfort, blood loss, SSI, and neonatal outcome.

FINDINGS

We randomized a total of 60 patients, 30 per group. Prewarming lead to a significantly higher core temperature. Additionally, patient comfort was significantly higher in the prewarming group even after discharge from PACU. We did not find a difference in wound temperature, SSI, neonatal outcome, or blood loss.

CONCLUSIONS

Prewarming before cesarean section under spinal anesthesia maintains core temperature and improves patient comfort but does not affect wound temperature.

Refocusing on work-based hazards for the anaesthesiologist in a post-pandemic era

The coronavirus pandemic has raised public awareness of one of the many hazards that healthcare workers face daily: exposure to harmful pathogens. The anaesthesia workplace encompasses the operating room, interventional radiology suite, and other sites that contain many other potential occupational and environmental hazards. This review article highlights the work-based hazards that anaesthesiologists and other clinicians may encounter in the anaesthesia workplace: ergonomic design, physical, chemical, fire, biological, or psychological hazards. As the anaesthesia work environment enters a post-COVID-19 pandemic phase, anaesthesiologists will do well to review and consider these hazards. The current review includes proposed solutions to some hazards and identifies opportunities for future research.

The effect of forced-air warming in the cesarean section on maternal hypothermia, shivering, and thermal comfort: A randomized controlled trial

This trial was carried out to investigate the effect of forced air warming in various body areas of women on hypothermia during cesarean delivery. The patients in the study groups (n = 76) were assigned to the full-body warming group, upper-extremity warming group, lower-extremity warming group, and control groups. The intervention groups received forced-air warming 30 min before the surgery and continued until 30 min after surgery. The incidence of hypothermia was significantly higher in the control group than in the other groups at the 60th minute of the operation (p < 0.01). The intervention and control groups showed significant differences in the frequency of shivering at the entrance to the PACU (p = 0.001). Thermal comfort scores have significant difference between the control group and all of the intervention groups (p<.001). It is said that the full-body forced-air warming technique prevents hypothermia, shivering, and thermal discomfort in women Cesarean Section (CS).

Combined Forced Air Warming and Warm Intravenous Fluid Strategy for Perioperative Hypothermia in Cesarean Delivery: A Systematic Review and Meta-Analysis

PURPOSE

Evaluate the effect of a combined forced-air warming (FAW) and warm intravenous fluid (IVF) modality on maternal and neonatal outcomes in cesarean delivery under neuraxial anesthesia.

DESIGN

Systematic Review and Meta-analysis.

METHODS

An extensive search was conducted using PubMed, Cochrane Library, MEDLINE, CINAHL, Google Scholar, and other grey literature. Only randomized controlled trials examining the combined modality on maternal temperatures were included. Risk ratio (RR), mean difference (MD), and standardized mean difference (SMD) were used to estimate outcomes with suitable effect models. Quality of evidence was assessed using the Risk of Bias and GRADE system.

FINDINGS

Nine trials involving 595 patients were included. Combined strategy showed a smaller change in maternal temperature from baseline by 0.42°C (MD, -0.42; 95% CI, -0.62 to -0.22; P < .0001), higher temperature on PACU arrival (MD, 0.46; 95% CI, 0.11-0.82; P = .01), 15 minutes (MD, 0.43; 95% CI, 0.19-0.67; P = .0004) and 30 minutes after surgery (MD, 0.38; 95% CI, 0.12-0.64; P = .005). Combined strategy also reduced the incidence of hypothermia (RR, 0.55; 95% CI, 0.31-0.95; P = .03), and shivering (RR, 0.40; 95% CI, 0.28-0.58; P < .00001) with improvement in maternal comfort score (SMD; 0.38; 95% CI, 0.08-0.69; P = .01). However, there were no differences in clinical indicators of adverse neonatal outcomes. Lack of participants blinding, and substantial heterogeneity were limitations of this review.

CONCLUSION

The use of combined FAW and warm IVF is an effective strategy in mitigating perioperative hypothermia in cesarean delivery under neuraxial anesthesia.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Development and validation of a risk prediction scale for hypothermia during cesarean section: A prospective study

Background

Evidence shows that active insulation can reduce the incidence of hypothermia during cesarean section; however, compliance is lower than recommended. Moreover, several aspects of temperature management via active heat preservation remain unclear, including patient indications, timing, methods, and duration. Therefore, promptly identifying parturients at a high risk for hypothermia during cesarean section is crucial.

Objective

To develop and validate a scale for predicting hypothermia in parturients during cesarean section.

Design

Prospective study.

Setting

Three grade A hospitals in Hunan Province, China.

Participants

The prediction scale was developed based on data from 369 parturients who underwent cesarean section from July 2018 to January 2019. Inclusion criteria were as follows: cesarean section under lumbar anesthesia, epidural anesthesia, or combined lumbar and epidural anesthesia; voluntary participation in the study and completion of the informed consent form; age >18 years.

Methods

Univariate and multivariate analyses were used to determine factors influencing hypothermia and establish the predictive model for hypothermia risk during cesarean section. The Hosmer-Lemeshow test was used to determine the goodness of fit of the prediction tool, and the area under the receiver operating characteristic curve was used to determine the predictive ability of the proposed scale. The cutoff value of the prediction scale was determined according to the Youden index.

Results

In the logistic regression prediction model, the Hosmer-Lemeshow goodness-of-fit test yielded a p-value of 0.425. The area under the receiver operating characteristic curve was 0.888. The model exhibited a good fitting effect and discriminant validity. Total risk scores for hypothermia ranged from 0 to 11. A score of 7 was used as the diagnostic cutoff value. Parturients during the operation who had total scores of ≥7 and <7 were considered the high-risk and low-risk groups, respectively. The area under the receiver operating characteristic curve for the scale was 0.891. The authenticity evaluation indicated that the incidence of hypothermia was significantly higher in the high-risk group than in the low-risk group.

Conclusions

The risk prediction scale developed in this study exhibits moderately predictive efficiency, sensitivity, and specificity for identifying parturients at high risk of hypothermia during cesarean section. Implementing this scale in clinical practice may help to decrease the incidence of hypothermia in such patients.

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abstract

This new predictive model can identify women who are at a high risk of hypothermia during cesarean section.

Risk factors associated with intraoperative shivering during caesarean section: a prospective nested case-control study

BACKGROUND

To study the incidence and risk factors of shivering in pregnant women during cesarean section.

METHODS

We performed a prospective nested case-control study involving parturients scheduled for cesarean sections between July 2018 and May 2021. The overall incidence of intraoperative shivering and its potential risk factors were investigated. The potential risk factors evaluated were pain, anxiety, emergency surgery, transfer from the delivery room, epidural labor analgesia, membrane rupture, labor, and the timing of the surgery. Shivering and body temperature at different time points during the cesarean section were also recorded. The selected seven time points were: entering the operating room, post-anesthesia, post-disinfection, post-delivery, post-oxytocin, post additional hysterotonics, and before leaving the operating room.

RESULTS

We analyzed 212 cesarean section parturients. The overall incidence of shivering was 89 (42.0%). Multivariate logistic regression showed that anxiety, emergency delivery, and transfer from the delivery room to the operating room increased the overall shivering incidence (odds ratio = 1.77, 2.90, and 3.83, respectively). The peak shivering incidence occurred after skin disinfection (63, 29.7%), and the lowest body temperature occurred after oxytocin treatment (36.24 ± 0.30 °C). Stratified analysis of surgery origin showed that emergency delivery was a risk factor for shivering (odds ratio = 2.99) in women transferred from the obstetric ward to the operating room.

CONCLUSION

Shivering occurred frequently during cesarean sections, with the peak incidence occurring after skin disinfection. Anxiety, emergency delivery, and transfer from the delivery room to the operating room increased the risk of shivering development during cesarean sections.

TRIAL REGISTRATION

The study protocol was registered online at China Clinical Registration Center (registration number: ChiCTR-ROC-17010532, Registered on 29 January 2017).

Effectiveness of Combined Strategies for the Prevention of Hypothermia Measured by Noninvasive Zero-Heat Flux Thermometer During Cesarean Section

Background: Perioperative hypothermia (body temperature <36°C) is a common complication of anesthesia increasing the risk for maternal cardiovascular events and coagulative disorders, and can also influence neonatal health. The aim of our work was to evaluate the impact of combined warming strategies on maternal core temperature, measured with the SpotOn. We hypothesized that combined modalities of active warming prevent hypothermia in pregnant women undergoing cesarean delivery with spinal anesthesia. Methods: Seventy-eight pregnant women were randomly allocated into three study groups receiving warmed IV fluids and forced-air warming (AW), warmed IV fluids (WF), or no warming (NW). Noninvasive core temperature device (SpotOn) measured maternal core temperature intraoperatively and for 30 min after surgery. Maternal mean arterial pressure, incidence of shivering, thermal comfort and newborn's APGAR, axillary temperature, weight, and blood gas analysis were also recorded. Results: Incidence of hypothermia was of 0% in AW, 4% in WF, and 47% in NW. Core temperature in AW was constantly higher than WF and NW groups. Incidence of shivering in perioperative time was significantly lower in AW and WF groups compared with the NW group (p < 0.04). Thermal comfort was higher in both AW and WF groups compared with NW group (p = 0.02 and p = 0.008, respectively). There were no significant differences among groups for the other evaluated parameters. Conclusion: Combined modalities of active warming are effective in preventing perioperative hypothermia. The routine uses of combined AW are suggested in the setting of cesarean delivery.

Prevention and management of perioperative hypothermia in adult elective surgical patients: A systematic review

BACKGROUND

Body temperature is tightly regulated with hormonal and cellular metabolism for normal functioning; however perioperative hypothermia is common secondary to anesthesia and surgical exposure.Prevention and maintaining body temperature should be started 1-2hrs before induction of anesthesia, to do this both active and passive warming system are effective to prevent complications associated with perioperative hypothermia.

METHODS

The aim of this systematic review is to develop a clear clinical practice protocol in prevention and management of perioperative hypothermia for elective adult surgical patients.The study is conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline 2020. After formulating clear criteria for the evidences to be included an appropriate method of searching was conducted by using the Pub Med, Google scholar and Cochrane library using the following MeSH terms: (inadvertent hypothermia AND anesthesia, hypothermia AND perioperative management and thermoregulation AND anesthesia) were used to draw evidences.After a reasonable amount of evidences were collected, appraisal and evaluation of study quality was based on WHO 2011 level of evidence and degree of recommendation. Final conclusions and recommendations are done by balancing the benefits and downsides of alternative management strategies for perioperative management of hypothermia.This systematic review registered with research registry unique identifying number (UIN) of "reviewregistry1253" in addition the overall AMSTAR 2 quality of this systematic review is moderate level.

DISCUSSION

Preserving a patient's body temperature during anesthesia and surgery is to minimize heat loss by reducing radiation and convection from the skin, evaporation from exposed surgical areas, and cooling caused by the introduction of cold intravenous fluids.

CONCLUSION

Hypothermia is least monitored complication during anesthesia and surgery results cardiac abnormalities, impaired wound healing, increased surgical site infections, shivering and delayed postoperative recovery, and coagulopathies.

Forced-air warming and continuous core temperature monitoring with zero-heat-flux thermometry during cesarean section: a retrospective observational cohort study

Background

Over 30% of parturients undergoing spinal anesthesia for cesarean section become intraoperatively hypothermic. This study assessed the magnitude of hypothermic insult in parturients and newborns using continuous, high-resolution thermometry and evaluated the efficiency of intraoperative forced-air warming for prevention of hypothermia.

Methods

One hundred and eleven parturients admitted for elective or emergency cesarean section under spinal anesthesia with newborn bonding over a 5-month period were included in this retrospective observational cohort study. Patients were divided into two groups: the passive insulation group, who received no active warming, and the active warming group, who received convective warming through an underbody blanket. Core body temperature was continuously monitored by zero-heat-flux thermometry and automatically recorded by data-loggers. The primary outcome was the incidence of hypothermia in the operating and recovery room. Neonatal outcomes were also analyzed.

Results

The patients in the passive insulation group had significantly lower temperatures in the operating room compared to the actively warmed group (36.4°C vs. 36.6°C, p = 0.005), including temperature at skin closure (36.5°C vs. 36.7°C, p = 0.017). The temperature of the newborns after discharge from the postanesthetic care unit was lower in the passive insulation group (36.7°C vs. 37.0°C, p = 0.002); thirteen (15%) of the newborns were hypothermic, compared to three (4%) in the active warming group (p < 0.01).

Conclusion

Forced-air warming decreases perioperative hypothermia in parturients undergoing cesarean section but does not entirely prevent hypothermia in newborns while bonding. Therefore, it can be effectively used for cesarean section, but special attention should be given to neonates.

"The magnitude and associated factors of intraoperative shivering after cesarean section delivery under Spinal anesthesia'': A cross sectional study

Background

Shivering is an involuntary, spontaneous, and repetitive contraction of the skeletal muscle and increases patients’ discomfort, oxygen-consuming, wound infection; increased surgical bleeding, and morbid cardiac events. The aim of this study was to determine the magnitude and associated factors of intraoperative shivering after cesarean section delivery

Methodology

An institution-based cross-sectional study was conducted. A total of 326 willing patients were included in the study after obtaining ethical consent and we have used consecutive sampling techniques. Axillary temperature was recorded preoperatively and in the intra-operative period every 5 min. Descriptive statistics, cross-tabs, and binary logistic regression analysis were performed to identify the association shivering and independent variables. The strength of the association was presented using an adjusted odds ratio with a 95% confidence interval and a p-value<0.05 was considered as statistically significant.

Results

The overall incidence of intraoperative shivering after cesarean section delivery under spinal anesthesia was 51.8% (95% CI: 46.3, 57.1). The majority of the patients who developed shivering were after 20 min of spinal anesthesia. In this study body temperature, mean arterial pressure of the patient, and duration of surgery were significantly associated with shivering.

Conclusion

In this study duration of surgery, hypothermia and hypotension were the independent associated risk factors for intraoperative shivering.

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The incidence of post spinal anesthesia shivering after cesarean section delivery was 51.8% in the study area.

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More than 45% patients were developed Grade III shivering.

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Hypothermia, hypotension and duration of surgery were affected shivering.

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Most patients were developed shivering after 20 min of spinal anesthesia.

Enhanced Recovery after Surgery: Cesarean Delivery

This review summarizes the importance of enhanced recovery after surgery (ERAS) implementation for cesarean deliveries (CDs) and explores ERAS elements shared with the non-obstetric surgical population. The Society for Obstetric Anesthesia and Perinatology (SOAP) consensus statement on ERAS for CD is used as a template for the discussion. Suggested areas for research to improve our understanding of ERAS in the obstetric population are delineated. Strategies and examples of anesthesia-specific protocol elements are included.

Effect of Epidural Dexmedetomidine as an Adjuvant to Local Anesthetics for Labor Analgesia: A Meta-Analysis of Randomized Controlled Trials

Background

This study aims to determine the analgesic effect and safety of dexmedetomidine as an adjuvant to epidural local anesthetics during labor.

Methods

Randomized controlled trials comparing epidural blocks with or without dexmedetomidine for labor analgesia were comprehensively searched. Review manager 5.4 was used to analyze the extracted data.

Results

Compared with placebo and opioids, dexmedetomidine relieved labor pain of 15 min (P=0.002), 30 min (P=0.01), and 120 min (P=0.02) after block and at the moment of fetal disengagement (P=0.0002), decreased mean arterial pressure of 120 min (P=0.01), heart rate of 30 min (P=0.003), 60 min (P < 0.00001), and 120 min (P < 0.00001) after block, blood loss (P=0.02), and the incidence of nausea/vomiting (P=0.006), and increased the incidence of maternal bradycardia (P=0.04). However, sensitivity analysis only found that the incidence of nausea/vomiting was significantly different. Compared with placebo, dexmedetomidine relieved labor pain of 30 min after block (P < 0.00001) and did not increase the incidences of side effects, but only two studies were enrolled. Compared with opioids, dexmedetomidine decreased the incidence of nausea/vomiting (P=0.002), increased the incidence of maternal bradycardia (P=0.04), and had a similar effect on labor pain relief; however, sensitivity analysis found that significant difference existed only at the incidence of nausea/vomiting. Other outcomes from meta-analysis or subgroup analysis were not different.

Conclusions

Epidural dexmedetomidine has the potential to offer a better analgesic effect than placebo, similar labor pain control to opioids, and has no definite adverse effects on the parturient or fetus, but more high-quality studies are needed to confirm these conclusions.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery

The routine use of surgical safety checklists can reduce perioperative complications. Generic surgical safety checklists are insufficient for cesarean delivery because each cesarean delivery involves 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations. To address the added complexity of care coordination and communication inherent in cesarean delivery, the Society for Maternal-Fetal Medicine presents sample standard surgical safety checklists for cesarean delivery that include elements of care for both the mother and newborn. In addition, we present an alternative checklist for time-critical emergency cesarean deliveries in which there is no time to safely perform the standard checklist and a sample preoperative checklist for use before moving the patient to the operating room. We also recommend steps for implementation of the checklists at individual facilities.

Maternal and fetal hypothermia: more preventive compliance is required for a mother and her fetus while undergoing cesarean delivery; a quality improvement review

OBJECTIVE

Cesarean delivery is common, involves two patients, has numerous multi-disciplinary health care providers involved in the delivery management, but has variable levels of anesthesia and health services implementation for decreasing maternal hypothermia and the maternal and neonatal morbidity (and mortality). Limited implementation for either of the ERAS-CD or the ERAC guidelines, for inadvertent or preventive maternal hypothermia, is likely to be occurring on labor delivery floors. This Quality Improvement (QI) review focuses on cesarean delivery and maternal hypothermia.

METHODS

This quality and safety initiative used SQUIRE 2.0 methodology and concurrent PubMed searches to identify systematic review, meta-analysis, topic directed studies, additional published cohorts in the topic area not included in SR/MA, limited case reports that had specific clinical outcomes related to maternal hypothermia and fetal effects.

RESULTS

Two quality and safety improvement guidelines have defined the hypothermia activity element differently, with ERAS-CD recommending to prevent hypothermia, while ERAC recommending to maintain normothermia. The peer-reviewed literature indicates that the knowledge associated with surgical hypothermia outcome is known but it is not implemented for maternal cesarean delivery care. Increased maternal-effect recognition, surveillance, triage, and evidenced-based protocol management is required for the maternal - neonatal dyad undergoing cesarean delivery for the clinical reduction/prevention of neonatal hypothermia that has proven evidence-based maternal morbidity and neonatal morbidity/mortality.

CONCLUSION

TEAM-based anesthesia, obstetrical, neonatology-pediatrics and nursing research collaboration is required through quality-safety-ERAS-ERAC directed processes. Healthcare system recognition and financial support is required for maternal-fetal-neonatal hypothermia prevention protocols implementation.

Association between preoperative toe perfusion index and maternal core temperature decrease during cesarean delivery under spinal anesthesia: a prospective cohort study

Background

The main mechanism of body temperature decrease during cesarean delivery under spinal anesthesia is core-to-peripheral redistribution of body heat, attributable to vasodilation. Perfusion index (PI) obtained with a pulse oximeter helps to assess peripheral perfusion dynamics by detecting the change in peripheral vascular tone. This study aimed to examine whether preoperative toe PI could predict the decrease in core temperature induced by spinal anesthesia during cesarean delivery.

Methods

Parturients undergoing scheduled cesarean delivery under combined spinal-epidural anesthesia from September 2019 to March 2020 were enrolled in this single-center prospective cohort study. All parturients received 0.5% hyperbaric bupivacaine (10 mg) with fentanyl (15 μg) intrathecally. A pulse oximeter probe was placed on the left second toe for continuous PI measurement. The 3 M™ Bair Hugger™ Temperature Monitoring System placed over the right temporal region was used to record core temperature over time. We evaluated the association between the maximum core temperature decrease, which is the primary outcome, and the preoperative toe PI at operating room (OR) admission using a segmented regression model (SRM) and a generalized additive model (GAM). The maximum core temperature decrease was defined as the difference between core temperature at OR admission and minimum intraoperative core temperature.

Results

Forty-eight patients were evaluated. In the SRM, the slope for the association between the maximum core temperature decrease and the preoperative toe PI changed from 0.031 to 0.124 after PI = 2.4%. Likewise, with the GAM, there was a small core temperature decrease when preoperative toe PI was greater than 2.0 to 3.0%.

Conclusions

Low preoperative toe PI was associated with maternal core temperature decrease during cesarean delivery under spinal anesthesia. Preoperative toe PI is a simple, non-invasive, and effective tool for the early prediction of perioperative core temperature decrease during cesarean delivery.

Trial registration

UMIN Clinical Trials Registry (registry number: UMIN000037965).

The relationship between core temperature and perioperative shivering during caesarean section under intrathecal anesthesia with bupivacaine and ropivacaine: a randomized controlled study

Purpose

To assess the incidence rate of perioperative shivering for cesarean section and explore the associations between the occurrence of shivering and hypothermia, core temperature change, local anesthetic.

Methods

This is a prospective, randomized, controlled, double-blinded study of 100 patients consenting for caesarean section under intrathecal anesthesia. Parturients with ASA I or II accepted elective caesarean section with combined spinal-epidural anesthesia (SA). 2–2.5 ml of 0.5% bupivacaine or 0.5% ropivacaine was intrathecally injected in group B and group R, respectively.

Results

The intraoperative shivering incidence in group B was significantly higher than that in group R (66.7 vs. 20.5%, Pvalue < 0.001), and shivering intensity in group B was significantly greater than group R (score: 1.4 vs. 0.3, Pvalue < 0.001). The core temperature in both groups gradually decreased with the time after SA. Hypothermia (core temperature < 36.0 ℃) 5–30 min after SA was not associated with shivering. However, changes of temperature at 25 and 30 min after SA, and bupivacaine were statistically associated with shivering, with the odds of 10.77 (95% CI: 1.36–85.21, P value = 0.02), 8.88 (95% CI: 1.29–60.97, P value = 0.03), and 7.78 (95% CI: 2.94–20.59, P value < 0.01), respectively.

Conclusions

In our study, for cesarean section, the occurrence of shivering was associated with the local anesthetics and the change of core temperature after SA, while not the hypothermia.

Peripartum considerations in sickle cell disease

PURPOSE OF REVIEW

Pregnancy exacerbates sickle cell disease (SCD) and is associated with increased frequency and severity of complications resulting in high levels of maternal and fetal morbidity and mortality. We review recent recommendations for managing SCD in pregnancy.

RECENT FINDINGS

An updated pathobiological model of SCD now attributes the clinical picture to a vicious cycle of four major cellular disturbances. Management decisions should be guided by an understanding of this upgraded model. Red cell transfusions are a key therapeutic intervention used in managing several acute and chronic complications. Transfusion however has significant drawbacks. The American Society of Hematology recently published transfusion guidelines to support care providers.

SUMMARY

Patients should be managed by a multidisciplinary and experienced team. The perioperative episode is a recognized period of disease exacerbation and informed anesthetic management can contribute to improved patient outcomes.

Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Effect of amino acid infusion during cesarean delivery on newborn temperature: a randomized controlled trial

BACKGROUND

The effect of maternal amino acid (AA) infusion before and during cesarean delivery on neonatal temperature remains unknown. We hypothesized that thermogenic effects of AA metabolism would help maintain body temperature of newborn babies and their mothers.

METHODS

Seventy-six parturients scheduled for elective singleton term cesarean delivery were equally randomized to receive intravenous 200 ml of AA or placebo approximately 1 h before subarachnoid block (infusion rate:100 ml/h). The primary outcome was the newborn rectal temperature at 0, 5 and 10 min after birth. The secondary outcomes included the maternal rectal temperature at six time-points: T0 = before starting study solution infusion, T1 = 30 min after starting infusion, T2 = one hour after starting infusion, T3 = during spinal block, T4 = half an hour after spinal block, T5 = at the time of birth and T6 = at the end of infusion, as well as maternal thermal discomfort and shivering episodes.

RESULTS

There were no differences in newborn temperature between the two groups at any of the time-points (intervention-time-interaction effect, P = 0.206). The newborn temperature (mean [95%CI] °C) at birth was 37.5 [37.43-37.66] in the AA and 37.4 [37.34-37.55] in the placebo group. It showed a significant (P < 0.001) downward trend at 5 and 10 min after birth (time effect) in both groups. One neonate in the AA and five in the placebo group were hypothermic (temperature < 36.5 °C) (P = 0.20). There was a significant difference in the maternal temperature at all time points between the two groups (Intervention-time interaction effect, P < 0.001). However, after adjustment for multiplicity, the difference was significant only at T6 (P = 0.001). The mean difference [95%CI] in temperature decline from baseline (T0) till the end of infusion (T6) between the two groups was - 0.39 [- 0.55;- 0.22] °C (P < 0.0001). Six mothers receiving placebo and none receiving AA developed hypothermia (temperature < 36 °C) (P = 0.025). Maternal thermal discomfort and shivering episodes were unaffected by AA therapy.

CONCLUSIONS

Under the conditions of this study, maternal AA infusion before and during spinal anesthesia for cesarean delivery did not influence the neonatal temperature within 10 min after birth. In addition, the maternal temperature was only maintained at two hours of AA infusion.

TRIAL REGISTRATION

ClinicalTrials.government, Identifier NCT02575170 . Registered on 10th April, 2015 - Retrospectively registered.

Effect of Preoperative Oral Carbohydrate Loading on Body Temperature During Combined Spinal-Epidural Anesthesia for Elective Cesarean Delivery

BACKGROUND

Intraoperative hypothermia is a common complication after neuraxial block in cesarean delivery. At least 1 animal study has found that carbohydrate loading can maintain the body temperature of rats during general anesthesia, but it is unclear whether carbohydrate loading is beneficial for body temperature maintenance in parturient women during combined spinal-epidural anesthesia (CSEA) for elective cesarean delivery.

METHODS

Women undergoing elective cesarean delivery were randomized into a control group (group C), an oral carbohydrate group (group OC), or an oral placebo group (group OP), with 40 women in each group. Core body temperature (Tc) and body surface temperature (Ts) before and after cesarean delivery, changes in Tc (ΔTc) and Ts (ΔTs), and the incidence of side effects (eg, intraoperative shivering) were compared among the groups.

RESULTS

The postoperative Tc (core body temperature after cesarean delivery [Tc2]) of group OC (36.48 [0.48]°C) was higher than those of group C (35.95 [0.55]°C; P < .001), and group OP (36.03 [0.49]°C; P = .001). The ΔTc (0.30 [0.39]°C) in group OC was significantly smaller than those in group C (0.73 [0.40]°C; P = .001) and group OP (0.63 [0.46]°C; P = .0048).

CONCLUSIONS

Oral carbohydrate loading 2 hours before surgery facilitated body temperature maintenance during CSEA for elective cesarean delivery.

Maternal temperature in emergency caesarean section (MATES): an observational multicentre study

BACKGROUND

Temperature regulation in women undergoing emergency caesarean section is a complex topic about which there is a paucity of evidence-based recommendations. The adverse effects of inadvertent peri-operative hypothermia are well described. Hyperthermia is also associated with adverse neonatal outcomes, an increased risk of obstetric intervention and increased treatment for suspected sepsis. We conducted a multi-centre observational cohort study to identify the prevalence of hypothermia and hyperthermia during emergency caesarean section. S: Participants undergoing emergency caesarean section were recruited across 14 sites in the UK. The primary end point was maternal temperature in the recovery room. Temperature was measured using a zero heat-flux temperature monitoring device.

RESULTS

Two hundred and sixty-five participants were recruited over a 12-month period. The prevalence of hypothermia (<36.0°C) was 10.7% and the prevalence of hyperthermia (>37.5°C) was 14.7% on admission to recovery. The prevalence of hypothermia, normothermia, and hyperthermia differed among type of anaesthesia: 71.4% of the hypothermic group had received a spinal anaesthetic whereas 76.9% of the hyperthermic group had received epidural top-up anaesthesia. There was a significant decrease in maternal temperature between the time of delivery and admission to the recovery room of 0.20°C (95% CI 0.15 to 0.25, P<0.001).

CONCLUSIONS

Both hypothermia and hyperthermia are prevalent findings in mothers who undergo emergency caesarean section. Therefore, accurate temperature measurement is essential to ensure that an appropriate intra-operative temperature management strategy is employed.

The effect of combination of warm intravenous fluid infusion and forced air warming versus forced air warming alone on maternal temperature and shivering during cesarian delivery under spinal anesthesia

Objective

Administration of warm intravenous (IV) fluid infusion and use of forced air warmers is the most easy and physiologically viable method for maintaining normothermia during surgery and postsurgical periods This study was conducted to assess the effect of combination of active warming (AW) methods namely warm IV fluid infusion and forced air warming versus forced air warming only (WA) on maternal temperature during elective C-delivery under spinal anesthesia.

Materials and Methods

A total of 100 patients scheduled for elective c-section were grouped into those who received both warmed IV fluid infusion and forced air warmer (Combination of active warming WI= 50) and those who received only forced air warmer (WA = 50). Core body temperature and shivering incidence were recorded using a tympanic thermometer from prespinal till the end of surgery every 10 min and in postanesthesia care unit (PACU) at 0, 15, and 30 min.

Results

Core temperature showed statistically significant difference in 15, 35, 45, and 55 min between air warmer and warm infusion groups and in PACU at 0, 15, and 30 min, it was statistically significant (P = 0.000) among WI group (mean temperature = 36.79°C) when compared to WA group (mean temperature = 35.96°C). There was a lower incidence of shivering in WI compared to WA group, which is statistically significant.

Conclusion

Combination of warm Intravenous fluid infusion and Forced air warming is better than forced air warming alone. In maintaining near normal maternal core body temperature during elective cesarean section following spinal anesthesia. Combined warming method also reduces shivering incidence.

Improving intraoperative temperature management in elective repeat cesarean deliveries: a retrospective observational cohort study

Background

Inadvertent perioperative hypothermia (< 36 °C) occurs frequently during elective cesarean delivery and most institutions do employ perioperative active warming. The purpose of this retrospective observational cohort study was to determine if the addition of preoperative forced air warming in conjunction with intraoperative underbody forced air warming improved core temperature and reducing inadvertent perioperative hypothermia during elective repeat elective cesarean delivery with neuraxial anesthesia.

Methods

We evaluated the addition of perioperative active warming to standard passive warming methods (preheated intravenous/irrigation fluids and cotton blankets) in 120 parturients scheduled for repeat elective cesarean delivery (passive warming, n = 60 vs. active + passive warming, n = 60) in a retrospective observational cohort study. The primary outcomes of interest were core temperature at the end of the procedure and a decrease in inadvertent perioperative hypothermia (< 36 °C). Secondary outcomes were surgical site infections and adverse markers of neonatal outcome.

Results

The mean temperature at the end of surgery after instituting the active warming protocol was 36.0 ± 0.5 °C (mean ± SD, 95% CI 35.9–36.1) vs. 35.4 ± 0.5 °C (mean ± SD, 95% CI 35.3–35.5) compared to passive warming techniques (p <  0.001) and the incidence of inadvertent perioperative hypothermia at the end of the procedure was less in the active warming group - 68% versus 92% in the control group (p <  0.001). There was no difference in surgical site infections or neonatal outcomes.

Conclusions

Perioperative active warming in combination with passive warming techniques was associated with a higher maternal temperature and lower incidence of inadvertent perioperative hypothermia with no detectable differences in surgical site infections or indicators of adverse neonatal outcomes.

Effects of combined warmed preoperative forced-air and warmed perioperative intravenous fluids on maternal temperature during cesarean section: a prospective, randomized, controlled clinical trial

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 allocated 135 women undergoing elective cesarean deliveries to either the intervention group (preoperative forced-air and intravenous fluid warming, n = 69) or the control group (no active warming, n = 66). The primary outcome measure was the core temperature change between groups from baseline to the end of the surgical procedure. Secondary outcomes included thermal comfort scores, the incidences of shivering and hypothermia (< 36 °C), 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.

Risk factors for shivering during caesarean section under spinal anaesthesia. A prospective observational study

BACKGROUND

Shivering during caesarean section (CS) under spinal anaesthesia is a common phenomenon. It could not only alter patient's physiology by increasing oxygen consumption but also affect the parturient's experience of childbirth. Shivering is thought to be associated with intraoperative hypothermia, but the risk factors and exact mechanism remain unclear.

METHODS

We conducted a prospective, observational study to examine the potential risk factors for intraoperative shivering, including anxiety levels. Two hundred patients undergoing elective CS under spinal anaesthesia were recruited. Parturient anxiety levels were evaluated using the State-Trait Anxiety Inventory (STAI) questionnaire. Age, weight, height, BMI, anxiety level, number of previous deliveries, sensory block level, level of education, temperature difference during surgery and American Society of Anesthesiologists score were investigated as potential risk factors. Stepwise logistic regression was used to assess the predictors for shivering.

RESULTS

Data from 155 parturients were analysed. Shivering incidence was 21.9% (34 parturients). The statistical model predicted 8.5% of a shivering incidence variability (R-square Nagelkerke = 0.085). Out of all measured variables, only the number of previous deliveries [(W) = 4.295 Exp(B) = 0.562 P < .05] and STAI-X1 [(W) = 4.127 Exp(B) = 1.052 P < .05] were significant. In our model, the risk of shivering decreased by 44% with every previous delivery and increased by 5.2% with each 1-point increase in STAI-X1.

CONCLUSION

We failed to prove a strong correlation between the measured variables and shivering. Our findings, however, support the hypothesis, that to a limited extent, anxiety promotes shivering during CS.

Management of Shivering in Post-Spinal Anesthesia Using Warming Blankets and Warm Fluid Therapy

Hypothermia is a common and serious complication of spinal surgery and it is associated with many harmful perioperative outcomes. The aim of this study was to compare the effectiveness of warming blankets and warm fluid therapy to manage shivering. A quasi-experiment with a non-equivalent control group was applied as the research design. There were 60 patients involved in the study. The instrument of this study was a warmer fluid modification, a warming blanket and a cotton blanket. The data was analyzed using an applied paired t-test and independent t-test. After 60 minutes of the intervention, the mean and SD of body temperature of the patients receiving warm fluids was 36.71 ± 0.18, a warming blanket was 36.12 ± 0.35, and the control group was 35.76 ± 0.22. The p values were 0,000. Warm fluid therapy and warming blankets are significant in terms of increasing the body temperature of post-spinal anesthesia patients. Warm fluids are more effective than warming blanket. Warming blankets and warm fluid therapy can be used as a way to increase the body temperature of patients with hypothermia.

Comparison of nalbuphine, ondansetron and placebo for the prevention of shivering after spinal anaesthesia for urgent caesarean delivery: a randomised double-blind controlled clinical trial

BACKGROUND

Shivering is a common complication of caesarean delivery with neuraxial anaesthesia. The effective prevention and treatment of shivering, especially before delivery, is important and difficult. We tested the hypothesis that prophylactic nalbuphine and ondansetron can prevent post-spinal anaesthesia shivering in parturients undergoing urgent caesarean delivery.

METHODS

Sixty parturients scheduled for urgent caesarean delivery before spinal anaesthesia were selected and divided randomly into three groups. After peripheral venous catheterisation, parturients were given intravenous nalbuphine 0.08 mg/kg (group N), ondansetron 8 mg (group O), or normal saline (group C).

RESULTS

The incidence of shivering and of severe (grade ≥3) shivering was significantly lower in group N (15% and 15%, respectively) than in group C (80% and 65%) before delivery (P <0.001 and P=0.003); and significantly less shivering was observed in group N than in group C in the first 30 min after anaesthesia (P=0.001). Up to 60 min after anaesthesia, the incidence of grade ≥3 shivering remained lowest in group N (P=0.003). According to the data during the period from anaesthesia until delivery, the number needed-to-treat for nalbuphine was 1.54 (95%CI 1.13 to 2.41). No significant differences were found between groups O and N or groups O and C at any time. The incidence of dizziness in group N was significantly higher than that of groups O or C (P=0.009).

CONCLUSION

Nalbuphine 0.08 mg/kg can prevent post-spinal anaesthesia shivering in parturients undergoing urgent caesarean delivery but causes transient dizziness, while ondansetron 8 mg had no significant effect.

The Mediating Role of Burnout in the Relationship between Perceived Patient-safe, Friendly Working Environment and Perceived Unsafe Performance in an Obstetric Unit

Medical errors in obstetric departments are commonly reported and may involve both mother and neonate. The complexity of obstetric care, the interactions between various disciplines, and the inherent limitations of human performance make it critically important for these departments to provide patient-safe and friendly working environments that are open to learning and participative safety. Obstetric care involves stressful work, and health care professionals are prone to develop burnout, this being associated with unsafe practices and lower probability for reporting safety concerns. This study aims to test the mediating role of burnout in the relationship of patient-safe and friendly working environment with unsafe performance. The full population of professionals working in an obstetrics department in Malta was invited to participate in a cross-sectional study, with 73.6% (n = 184) of its members responding. The research tool was adapted from the Sexton et al.'s Safety Attitudes Questionnaire - Labor and Delivery version and surveyed participants on their working environment, burnout, and perceived unsafe performance. Analysis was done using Structural Equation Modeling. Results supported the relationship between the lack of a perceived patient-safe and friendly working environment and unsafe performance that is mediated by burnout. Creating a working environment that ensures patient safety practices, that allows communication, and is open to learning may protect employees from burnout. In so doing, they are more likely to perceive that they are practicing safely. This study contributes to patient safety literature by relating working environment, burnout, and perceived unsafe practice with the intention of raising awareness of health managers' roles in ensuring optimal clinical working environment for health care employees.

Dexmedetomidine versus sufentanil with high- or low-concentration ropivacaine for labor epidural analgesia: A randomized trial

AIM

To study analgesic effects of dexmedetomidine or sufentanil, both combined with ropivacaine, in epidural analgesia during labor.

METHODS

We recruited 160 primigravidae with full-term pregnancy who received epidural anesthesia during labor and randomized them into four groups to receive epidural administration of ropivacaine combined with sufentanil (RS₁ and RS₂ groups) or with dexmedetomidine (RD₁ and RD₂ groups). Systolic blood pressure, diastolic blood pressure and heart rate before anesthesia (T₁ ), 15 min after anesthesia induction (T₂ ), on delivery (T₃ ) and 2 h postpartum (T₄ ), together with visual analogue scale scores, Bromage scores, Ramsay scores, adverse reactions during analgesia and urinary retention at 6 and 24 h postpartum were recorded; the pH, PCO₂ and PO₂ of umbilical cord arterial blood and Apgar scores at 1, 5 and 10 min after childbirth were assessed.

RESULTS

RS₁ group had significantly lower systolic blood pressure, diastolic blood pressure and heart rate than RD₁ group at T₂ and T₃ (all P < 0.05), but not at T1. At T₂ and T₃ , the other three groups were lower than RS₂ group in visual analogue scale and Ramsay scores (all P < 0.05). After childbirth, RD₂ group had significantly higher PO₂ result than other three groups (P < 0.05). At 6 h postpartum, RD₂ group had significantly fewer cases of urinary retention than RD₁ and RS₁ groups (both P < 0.05).

CONCLUSION

A relatively low concentration of ropivacaine, combined with dexmedetomidine, is better in analgesia during labor.

The Effect of Forced-Air Warmer, Ondansetron or their Combination on Shivering in Pregnant Women Coming for Elective Cesarean Section under Spinal Anesthesia: A Prospective, Randomized Controlled Comparative Study

Context:

Perioperative shivering can occur in up to 85% of patients undergoing cesarean section under spinal anesthesia. It has many detrimental effects and disrupts early mother-child bonding. Therefore, it should ideally be prevented by either pharmacologic or nonpharmacological means.

Aims:

The primary aim of this study was to evaluate the efficacy of intraoperative forced-air warming, ondansetron or their combination in preventing perioperative shivering in patients undergoing elective cesarean section under spinal anesthesia.

Settings and Design:

A prospective randomized controlled comparative study done at the tertiary care center.

Subjects and Methods:

A total of 120 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to three groups. Group O received ondansetron 4 mg intravenously (i.v.) after giving block with no forced air warming. Group W received forced-air warming intraoperatively. Group C received ondansetron 4 mg i.v. after giving block plus intraoperative forced-air warming. Core temperature (tympanic membrane) and the arm skin temperature were measured and shivering was graded simultaneously.

Statistical Analysis Used:

Parametric data were analyzed using one-way ANOVA and Student's paired t-test where ever appropriate. Nonparametric data were analyzed using the Kruskal–Wallis and the Chi-square test. Values of P < 0.05 were considered statistically significant.

Results:

Shivering incidence was higher in Group O and Group W being 17.5% and 20%, respectively, and least in Group C being 5%. The incidence of Grade ≥3 shivering requiring rescue drug was lower in Group C (2.5%) compared to that of the Groups W (5%) and O (10%) but was not statistically significant (P = 0.21).

Conclusions:

Combined use of ondansetron and forced- air warmer was more effective in reducing the incidence of shivering in pregnant women during elective cesarean section than when used individually.

The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial

Background and objectives

Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia.

Methods

In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37 °C. Spinal anesthesia was performed at L3–L4 interspace with 10 mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section.

Results

There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p = 0.004). Core temperature was 36.8 ± 0.5 °C at baseline and decreased to 36.3 ± 0.5 °C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9 ± 0.4 °C and decreased to 35.8 ± 0.7 °C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups.

Conclusions

Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2)

The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.

[The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial]

BACKGROUND AND OBJECTIVES

Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia.

METHODS

In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37°C. Spinal anesthesia was performed at L3-L4 interspace with 10mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section.

RESULTS

There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p=0.004). Core temperature was 36.8±0.5°C at baseline and decreased to 36.3±0.5°C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9±0.4°C and decreased to 35.8±0.7°C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups.

CONCLUSIONS

Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

Enhanced recovery after cesarean delivery

Enhanced recovery after surgery is a concept initially developed for patients undergoing colorectal surgery but has been adopted by other surgical specialties with similar positive outcomes. The adoption of enhanced recovery after surgery in the obstetric patient population is rapidly gaining popularity. This review highlights perioperative interventions that should be considered in an enhanced recovery after surgery protocol for women undergoing cesarean delivery.