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Fischer RL, Schenker D, Gosschalk J. Cesarean section prior to 28 weeks' gestation: which type of uterine incision is optimal? J Matern Fetal Neonatal Med 2024; 37:2358385. [PMID: 38887786 DOI: 10.1080/14767058.2024.2358385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/17/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVE The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy. METHODS This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery. RESULTS There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 - 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03. CONCLUSION In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.
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Affiliation(s)
- Richard L Fischer
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cooper University Hospital, Camden, NJ, USA
| | - Danielle Schenker
- Department of Obstetrics and Gynecology, Cooper University Hospital, Camden, NJ, USA
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Gialdini C, Chamillard M, Diaz V, Pasquale J, Thangaratinam S, Abalos E, Torloni MR, Betran AP. Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. EClinicalMedicine 2024; 72:102632. [PMID: 38812964 PMCID: PMC11134562 DOI: 10.1016/j.eclinm.2024.102632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/29/2024] [Accepted: 04/19/2024] [Indexed: 05/31/2024] Open
Abstract
Background Caesarean section (CS) is the most performed major surgery worldwide. Surgical techniques used for CS vary widely and there is no internationally accepted standardization. We conducted an overview of systematic reviews (SR) of randomized controlled trials (RCT) to summarize the evidence on surgical techniques or procedures related to CS. Methods Searches were conducted from database inception to 31 January 2024 in Cochrane Database of Systematic Reviews, PubMed, EMBASE, Lilacs and CINAHL without date or language restrictions. AMSTAR 2 and GRADE were used to assess the methodological quality of the SRs and the certainty of evidence at outcome level, respectively. We classified each procedure-outcome pair into one of eight categories according to effect estimates and certainty of evidence. The overview was registered at PROSPERO (CRD 42023208306). Findings The analysis included 38 SRs (16 Cochrane and 22 non-Cochrane) published between 2004-2024 involving 628 RCT with a total of 190,349 participants. Most reviews were of low or critically low quality (AMSTAR 2). The SRs presented 345 procedure-outcome comparisons (237 procedure versus procedure, 108 procedure versus no treatment/placebo). There was insufficient or inconclusive evidence for 256 comparisons, clear evidence of benefit for 40, possible benefit for 17, no difference of effect for 13, clear evidence of harm for 14, and possible harm for 5. We found no SRs for 7 pre-defined procedures. Skin cleansing with chlorhexidine, Joel-Cohen-based abdominal incision, uterine incision with blunt dissection and cephalad-caudal expansion, cord traction for placental extraction, manual cervical dilatation in pre-labour CS, changing gloves, chromic catgut suture for uterine closure, non-closure of the peritoneum, closure of subcutaneous tissue, and negative pressure wound therapy are procedures associated with benefits for relevant outcomes. Interpretation Current evidence suggests that several CS surgical procedures improve outcomes but also reveals a lack of or inconclusive evidence for many commonly used procedures. There is an urgent need for evidence-based guidelines standardizing techniques for CS, and trials to fill existing knowledge gaps. Funding UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).
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Affiliation(s)
- Celina Gialdini
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
- Facultat de Ciències de la Salut Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | | | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Julia Pasquale
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | - Maria Regina Torloni
- Evidence Based Healthcare Post-Graduate Program, Department of Medicine, São Paulo Federal University, São Paulo, Brazil
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Stone AL, Pham A, Osmundson SS, Pedowitz A, Kingsley PJ, Marnett LJ, Patel S, Wickersham N, Sorabella LL, Bruehl S. Interactions Between Endocannabinoid and Endogenous Opioid Systems Prospectively Influence Postoperative Opioid Use in Pregnant Patients Undergoing Cesarean Delivery. THE JOURNAL OF PAIN 2024:104548. [PMID: 38663651 DOI: 10.1016/j.jpain.2024.104548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/09/2024] [Accepted: 04/16/2024] [Indexed: 05/08/2024]
Abstract
Both endocannabinoid (EC) and endogenous opioid systems are involved in nociceptive processing and may work together synergistically based on preclinical models. This study evaluated the interactive effects of preoperative beta-endorphin concentrations (a key analgesic endogenous opioid) in cerebrospinal fluid (CSF) and ECs (CSF and plasma 2-arachidonoylglycerol [2-AG] and plasma anandamide [AEA]) on postoperative opioid use and pain intensity in a prospective cohort of n = 112 pregnant patients undergoing scheduled cesarean delivery. Maternal blood and CSF samples were collected preoperatively for beta-endorphin and EC assays. Patients completed measures of outpatient opioid use (number of tablets used and days of use) and average pain intensity at 2 weeks postoperatively. Results of general linear model analyses controlling for maternal age, BMI at time of delivery, and race revealed significant multiplicative interactions between EC and beta-endorphin concentrations on number of opioid tablets used (based on pill count), days of opioid use, and total milligram morphine equivalents used in the 2 week follow-up period. Elevated preoperative plasma and CSF 2-AG predicted reduced outpatient opioid analgesic use particularly for patients low in CSF beta-endorphin. Similar analyses for pain intensity at 2-week follow-up indicated a significant interaction (p<.02) characterized by higher preoperative beta-endorphin concentrations being associated with lower subsequent pain only for individuals with low preoperative plasma AEA concentrations. Further exploration of interactions between EC and endogenous opioid inhibitory systems as they influence responses to opioid analgesics in other clinical pain populations may help guide development of precision pain management approaches. PERSPECTIVE: In the postoperative setting of patients undergoing cesarean delivery, elevated endocannabinoids were linked to reduced outpatient opioid analgesic use in individuals who had low endogenous opioid concentrations in cerebrospinal fluid. Further exploration of interactions between these two inhibitory systems as they impact on responses to pain management interventions appears warranted.
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Affiliation(s)
- Amanda L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amelie Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Sarah S Osmundson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Pedowitz
- University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Philip J Kingsley
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA; A.B. Hancock Memorial Laboratory for Cancer Research, Vanderbilt University, Nashville, TN
| | - Larry J Marnett
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA
| | - Sachin Patel
- Department of Psychiatry, Northwestern University School of Medicine, Chicago, IL, USA
| | - Nancy Wickersham
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L Sorabella
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Miao J, Luo Y, Wang C, Li H, Yu H. Meta-analysis comparing different ultrasound detection methods to accurately assess wound healing and scar formation after caesarean section. Int Wound J 2024; 21:e14837. [PMID: 38629613 PMCID: PMC11022302 DOI: 10.1111/iwj.14837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 04/19/2024] Open
Abstract
The accurate assessment of wound healing post-caesarean section, especially in twin pregnancies, remains a pivotal concern in obstetrics, given its implications for maternal health and recovery. Traditional methods, including conventional abdominal ultrasonography (CU), have been challenged by the advent of transvaginal ultrasonography (TU), offering potentially enhanced sensitivity and specificity. This meta-analysis directly compares the efficacy of TU and CU in evaluating wound healing and scar formation, crucial for optimizing postoperative care. Results indicate that TU is associated with significantly better outcomes in wound healing, demonstrated by lower REEDA scores (SMD = -20.56, 95% CI: [-27.34.20, -13.77], p < 0.01), and in scar formation reduction, evidenced by lower Manchester Scar Scale scores (SMD = -25.18, 95% CI: [-29.98, -20.39], p < 0.01). These findings underscore the potential of integrating TU into routine post-caesarean evaluation protocols to enhance care quality and patient recovery.
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Affiliation(s)
- Jing‐Jing Miao
- Department of UltrasoundHenan Chest HospitalZhengzhouChina
| | - Ying‐Ying Luo
- Department of UltrasoundThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Chen‐Yu Wang
- Department of UltrasoundThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Hui‐Xia Li
- Department of UltrasoundThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Hong‐Xia Yu
- Department of UltrasoundThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
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Khamvongsa P, Gotluru C, Stavros S, Borges J, Bonnice S. Horizontal mattress uterine closure compared to single layered lock suture in cesarean section - A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol X 2023; 20:100234. [PMID: 37701631 PMCID: PMC10493498 DOI: 10.1016/j.eurox.2023.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/27/2023] [Accepted: 09/02/2023] [Indexed: 09/14/2023] Open
Abstract
Objective The objective of this study is to compare the outcomes of standard cesarean section uterine closure, single-layered running lock sutures, versus using primary horizontal mattress sutures (the K uterine closure technique). Method This study used a retrospective cohort chart review of patients undergoing elective primary and repeat cesarean section between January 2016 and August 2020 at a South Florida hospital. From 613 included patients, 176 received the K uterine closure technique completed by a triple board-certified physician. Remaining 437 patients received single-layered lock uterine closure completed by other physicians in the same hospital. Clinical, demographic, and post-operative outcomes were collected using patients' operative, post-operative, and progress notes. Results Using the data gathered, the experimental group demonstrated a greater difference between pre- and post-cesarean section hemoglobin (p < 0.027) and hematocrit (p < 0.014) compared to single-layered lock closure methods. There was a significantly lower estimated blood loss (p < 0.001), however, there was no significant difference in the average quantitative blood loss (p < 0.374). There was also a significant reduction in the length of total and postoperative hospital stay (p < 0.001), but the total operation time was significantly increased (p < 0.016). No significant difference was found in the percentage of patients using opioids as pain management during hospital stay (p < 0.431). There was no need for blood transfusion nor an increase in infectious morbidity using this method. Conclusions Using the K uterine closure technique for post-cesarean section uterine closure was a reasonable alternative for closure of hysterotomy. It led to decreased duration of hospital stay and no significant difference in quantitative blood loss. The greater difference in hemoglobin and hematocrit for the K uterine closure technique group could be explained due to the significantly greater total operation time. Although the single-layered running lock suture closure is what has been more historically performed by obstetricians for cesarean sections, this data supports the viability and efficacy of the K uterine closure technique as an equally safe, non-inferior alternative. The value of this technique for uterine closure can be confirmed with future prospective studies and potential research in reduction of uterine scar defects. Synopsis Primary horizontal mattress closure at cesarean section provides a safe alternative to single-layered lock closure and may reduce blood loss, hospital stay, and opioid use.
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Affiliation(s)
- Peter Khamvongsa
- Obstetrics and Gynecology Department, Baptist Health System, Miami, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, USA
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Chitra Gotluru
- Herbert Wertheim College of Medicine, Florida International University, Miami, USA
- University of California Davis, Obstetrics and Gynecology, Sacramento, CA, USA
| | - Sarah Stavros
- Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Jordana Borges
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Sabrina Bonnice
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
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Sarwahi V, Hasan S, Rao H, Visahan K, Grunfeld M, Dzaugis P, Wendolowski S, Vora R, Galina J, Lo Y, Moguilevitch M, Thornhill B, Amaral T, DiMauro JP. Does a dedicated "Scoliosis Team" and surgical standardization improve outcomes in adolescent idiopathic scoliosis surgery and is it reproducible? Spine Deform 2023; 11:1409-1418. [PMID: 37507585 DOI: 10.1007/s43390-023-00728-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE The objective of this study was to determine if standardization improves adolescent idiopathic scoliosis (AIS) surgery outcomes and whether it is transferrable between institutions. METHODS A retrospective review was conducted of AIS patients operated between 2009 and 2021 at two institutions (IA and IB). Each institution consisted of a non-standardized (NST) and standardized group (ST). In 2015, surgeons changed institutions (IA- > IB). Reproducibility was determined between institutions. Median and interquartile ranges (IQR), Kruskal-Wallis, and χ2 tests were used. RESULTS 500 consecutive AIS patients were included. Age (p = 0.06), body mass index (p = 0.74), preoperative Cobb angle (p = 0.53), and levels fused (p = 0.94) were similar between institutions. IA-ST and IB-ST had lower blood loss (p < 0.001) and shorter surgical time (p < 0.001). IB-ST had significantly shorter hospital stay (p < 0.001) and transfusion rate (p = 0.007) than IB-NST. Standardized protocols in IB-ST reduced costs by 18.7%, significantly lowering hospital costs from $74,794.05 in IB-NST to $60,778.60 for IB-ST (p < 0.001). Annual analysis of surgical time revealed while implementation of standardized protocols decreased operative time within IA, when surgeons transitioned to IB, and upon standardization, IB operative time values decreased once again, and continued to decrease annually. Additions to standardized protocol in IB temporarily affected the operative time, before stabilizing. CONCLUSION Surgeon-led standardized AIS approach and streamlined surgical steps improve outcomes and efficiency, is transferrable between institutions, and adjusts to additional protocol changes.
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Affiliation(s)
- Vishal Sarwahi
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA.
| | - Sayyida Hasan
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Himanshu Rao
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Keshin Visahan
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | | | - Peter Dzaugis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Stephen Wendolowski
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Rushabh Vora
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Jesse Galina
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Yungtai Lo
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | - Terry Amaral
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Jon-Paul DiMauro
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
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Gudu W, Sisay ZT, Wondafrash M, Sium AF. Cesarean delivery surgical techniques in Africa: A survey study from Ethiopia. PLoS One 2023; 18:e0292382. [PMID: 37812627 PMCID: PMC10561831 DOI: 10.1371/journal.pone.0292382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To describe the surgical techniques of Caesarean delivery (CD) practiced by Ethiopian Obstetricians and Gynecologists. METHODS A descriptive survey study was conducted in Ethiopia from March 1, 2021 to April 30, 2021. Members of the Ethiopian Society of Obstetrician and Gynecologists were randomly selected and their Cesarean delivery surgical techniques were explored. Data were analyzed using IBM SPSS statistics 22. Simple descriptive analysis were employed and frequencies and percentage were calculated to present the data. RESULTS A total of 258 obstetricians and Gynecologists practicing in Ethiopia were approached with a response rate of 97.3% (251/258). Double layer closure of uterine incision (98.4%) and subcuticular closure of skin wound (96.4%) are practiced by most of the participants. There was a large difference in practice of blunt versus sharp fascia extension (43.3 vs 55.8%), cephalo-caudad versus lateral uterine incision extension (58 vs.39%), and closure versus non-closure of pelvic and parietal peritoneum (57.4 vs 42.6, and 39.8 versus 60.2%). CONCLUSIONS Blunt and sharp fascia extension, cephalo-caudad and lateral uterine incision extension, closure and non-closure of the pelvic and parietal peritoneum are practiced by similar numbers of Ethiopian Obstetricians and Gynecologists. This demonstrates a wide variation exists in the techniques of Cesarean Delivery across Ethiopia.
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Affiliation(s)
- Wondimu Gudu
- Department of obstetrics and Gynecology, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Zekarias Taye Sisay
- Department of obstetrics and Gynecology, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mekitie Wondafrash
- St. Paul Institute for Reproductive Health and Rights, Addis Ababa, Ethiopia
| | - Abraham Fessehaye Sium
- Department of obstetrics and Gynecology, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Andzane D, Miskova A, Krone A, Rezeberga D. Impact of Intraoperative Factors on the Development of Postpartum Septic Complications. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1637. [PMID: 37763756 PMCID: PMC10536124 DOI: 10.3390/medicina59091637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Triclosan-coated sutures (antibacterial sutures) can reduce the risk of postoperative surgical site infection. This study aimed to investigate the effect of intraoperative factors, including antibacterial sutures, on the risk of postpartum septic complications. Materials and Methods: The prospective study included patients who underwent caesarean section. The exclusion criterion was chorioamnionitis. The investigation group patient's (n = 67) uterus and fascial sheath of the abdominal wall were sutured with triclosan-coated polyglactin 910 sutures during surgery. The control group consisted of 98 patients using uncoated polyglactin 910 sutures only. The patients were contacted by phone after the 30th postoperative day. Results: No significant difference was found between the investigation group and the control group in the development of postpartum endometritis (11.7% in the investigation group vs. 8.4% in the control group, p = 0.401), wound infection (6.3% vs. 3.6%, p = 0.444) or patients experienced any septic complication (15.9% vs. 12%, p = 0.506). Postpartum endometritis was more common in patients who underwent instrumental uterine examination during the surgery (23.8% vs. 18%, p = 0.043). A moderately strong correlation was found for haemoglobin level on the third-fourth postoperative day with the development of postpartum septic complications, p < 0.001, Pearson coefficient -0.319. Post-caesarean delivery septic complications were not statistically more common in patients with blood loss greater than 1 L. The incidence of post-caesarean endometritis was 13.4%, and wound infection was 4.8% in this study's hospital, having five to six thousand deliveries per year. Conclusions: Using antibacterial sutures during caesarean section does not affect the incidence of postpartum septic complications. Instrumental uterine examination during caesarean section increases the risk of post-caesarean endometritis and is, therefore, not recommended. Haemoglobin level on the 3rd-4th postoperative day, rather than the estimated blood loss during surgery, affects the development of postpartum septic complications.
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Affiliation(s)
- Diana Andzane
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
- Gynaecology Clinic, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, Miera Street 45, LV-1013 Riga, Latvia
- Department of Clinical Skills and Medical Technologies, Rīga Stradiņš University, Anninmuizas Bulvaris 26a, LV-1067 Riga, Latvia
| | - Anna Miskova
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, Miera Street 45, LV-1013 Riga, Latvia
- Department of Clinical Skills and Medical Technologies, Rīga Stradiņš University, Anninmuizas Bulvaris 26a, LV-1067 Riga, Latvia
| | - Antra Krone
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
| | - Dace Rezeberga
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
- Gynaecology Clinic, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, Miera Street 45, LV-1013 Riga, Latvia
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Gross ME, Godecker A, Hughes A, Sampene K. Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations. BMC Pregnancy Childbirth 2023; 23:651. [PMID: 37684606 PMCID: PMC10492279 DOI: 10.1186/s12884-023-05922-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE Aspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice. METHODS We implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race. RESULTS Pre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80-100% of the time. CONCLUSION It is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.
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Affiliation(s)
- Maya E Gross
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Amy Godecker
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ainsley Hughes
- Department of Obstetrics and Gynecology, George Washington School of Medicine, Washington, DC, USA
| | - Katherine Sampene
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Pham A, Osmundson SS, Pedowitz A, Wickersham N, Sorabella LL, Bruehl S. Prospective evaluation of cerebrospinal fluid levels of β-Endorphin as a predictor of opioid use after scheduled cesarean delivery. RESEARCH SQUARE 2023:rs.3.rs-3125641. [PMID: 37502834 PMCID: PMC10371117 DOI: 10.21203/rs.3.rs-3125641/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background Prior laboratory work indicates that lower endogenous opioid function is associated with greater analgesic and subjective responses to opioid analgesics. We evaluated whether lower preoperative cerebrospinal uid (CSF) levels of the analgesic endogenous opioid β-Endorphin (BE) were associated with increased opioid use after cesarean delivery (CD). Methods We enrolled 136 pregnant women without opioid use or chronic pain who were undergoing CD under regional anesthesia. Preoperatively, participants completed validated pain measures and biospecimens were collected to assess BE levels in plasma and CSF. Postoperatively, pain measures at 48 hours and 2 weeks postpartum were assessed. We evaluated the association between CSF BE levels and total opioid use (in morphine milligram equivalents; MMEs) using linear regression controlling for confounding factors (primary analysis). In secondary analyses, we examined: 1) associations between plasma BE levels and total opioid use, and 2) associations between CSF and plasma BE levels and secondary outcomes (inpatient versus outpatient opioid use, pain intensity). Results Participants completed surveys with 100% response rate. The majority were non-Hispanic white (65%), college educated (58%), had private insurance (71%), and had a prior cesarean delivery (69%). Psychiatric diagnoses (depression or anxiety) were common, both currently (22%) and in the past (26%).The median total opioid use across the inpatient and 2-week postpartum follow-up period was 89.1 milligram morphine equivalents (IQR 25-138). Preoperative cerebrospinal uid β-Endorphin levels were not associated with total opioid use (beta = -0.05, SE 0.45, p = 0.64). Similar findings were noted for plasma β-Endorphin levels. cerebrospinal uid β-Endorphin levels were only weakly correlated with plasma β-Endorphin levels (r = 0.30, p < .01). Preoperative cerebrospinal uid and plasma β-Endorphin levels were both positively associated with postpartum pain measures (cerebrospinal uid: at 48 hours, beta = 0.19, SE 0.16, p < 0.05; Plasma: at 48-hours, beta = 0.02, SE 0.03, p = 0.02, and at 2-weeks, beta = 0.27, SE 0.03, p < 0.01). Conclusions Lower preoperative cerebrospinal uid levels of β-Endorphin are not associated with increased opioid analgesic use after scheduled cesarean delivery. It is possible that unassessed variability in baseline opioid receptor sensitivity may have confounded ability to test associations between β-Endorphin levels and opioid use outcomes.
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Affiliation(s)
| | | | - Alex Pedowitz
- University of Miami Leonard M. Miller School of Medicine
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11
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Sailakshmi M, Misra S, Hs S, Acharya S, Moharana AK, Ts D. Clinical Equivalence of Monoglyde® and Monocryl® Absorbable Poliglecaprone-25 Sutures: A Single-Blind, Randomized Study. Cureus 2023; 15:e38938. [PMID: 37309337 PMCID: PMC10257932 DOI: 10.7759/cureus.38938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVES Poliglecaprone-25 is a synthetic monofilament suture commonly used for post-cesarean subcuticular skin closure. The present study was designed to assess the effect of subcuticular skin closure using Monoglyde® vs. Monocryl® poliglecaprone-25 absorbable sutures on the risk of wound composite outcomes in the first 30 days post-partum [surgical site infection (SSI), wound dehiscence, hematoma or seroma]. STUDY DESIGN This is a prospective, single-blind, randomized (1:1), multicentric, two-arm study performed between September 2020 and December 2021 at two different centers across India. Women (18-40 years) with a singleton pregnancy requiring cesarean delivery were randomized to Monoglyde® (n=62) or Monocryl® (n=62) suture groups. The primary endpoint is the incidence of wound composite outcomes in the first 30 days post-partum (SSI, wound dehiscence, seroma, or hematoma). In addition, the secondary outcomes, incidence of wound composite outcome at all visits (till four months), suture extrusion and loosening, suture removal and evaluation of microbial deposits on sutures (in case not absorbed or infection), operative time, intraoperative suture handling, postoperative pain, return to normal day-to-day activities, modified Hollander cosmesis score, subject satisfaction score, and adverse events were noted. RESULTS Non-significant difference between the groups regarding demographic characteristics and primary endpoint; the incidence of wound composite outcome was observed. Moreover, no significant difference in suture extrusion and loosening, suture removal and evaluation of microbial deposits on sutures, operative time, intraoperative suture handling, pain, return to normal day-to-day activities, modified Hollander cosmesis, and subject satisfaction score were registered between the groups. CONCLUSIONS This study establishes the clinical equivalence of Monoglyde® and Monocryl® poliglecaprone-25 sutures, and both sutures can be used for subcuticular skin closure following cesarean delivery with minimal risk for wound complications.
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Affiliation(s)
- Mpa Sailakshmi
- Obstetrics and Gynecology, RajaRajeswari Medical College and Hospital, Bengaluru, IND
| | - Sukanta Misra
- Obstetrics and Gynecology, Ramakrishna Mission Seva Pratishthan Vivekananda Institute of Medical Sciences, Kolkata, IND
| | - Sathyashree Hs
- Obstetrics and Gynecology, RajaRajeswari Medical College and Hospital, Bengaluru, IND
| | - Soukhin Acharya
- Obstetrics and Gynecology, Ramakrishna Mission Seva Pratishthan Vivekananda Institute of Medical Sciences, Kolkata, IND
| | | | - Deepak Ts
- Clinical Affairs, Healthium Medtech, Bengaluru, IND
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12
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Hamel MS, Tuuli M. Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery. Obstet Gynecol Clin North Am 2023; 50:327-338. [PMID: 37149313 DOI: 10.1016/j.ogc.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.
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13
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Wu YC, Zou T, Zhang JC, Yang LY, Yao Q. Is a classical incision the only way to perform a near-term conjoined twins' cesarean section? Thoracopagus conjoined twin delivery by a low-segment transverse incision. Am J Obstet Gynecol MFM 2023; 5:100880. [PMID: 36787838 DOI: 10.1016/j.ajogmf.2023.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/10/2023] [Accepted: 01/14/2023] [Indexed: 02/14/2023]
Abstract
Conjoined twin pregnancies are rare, usually occurring in cases of monochorionic monoamniotic twin pregnancies. The most common type of conjoined twins, thoracopagus (42%), is difficult to deliver via a low-segment transverse incision hysterotomy after 35 weeks of gestation. Therefore, conjoined twin cesarean deliveries are typically performed using the classical incision method. However, this often leads to an increased risk of postoperative maternal morbidity and uterine rupture during a subsequent pregnancy. Because of the low survival rate of conjoined twins, subsequent pregnancies are often desired. Hence, minimizing trauma to the uterus is a primary concern. A technique for delivering conjoined twins at 35 weeks of gestation by cesarean delivery with a low-segment transverse incision hysterotomy is proposed here. A video is included to explain and demonstrate these procedures. This method can minimize uterine trauma and maximize the chances of a successful subsequent pregnancy.
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Affiliation(s)
- Yi-Cheng Wu
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China; and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Tong Zou
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China; and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Jin-Cheng Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China; and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Ling-Yun Yang
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China; and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qiang Yao
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China; and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
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14
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Lauterbach R, Ben David C, Bachar G, Justman N, Matanes E, Ginsberg Y, Vitner D, Beloosesky R, Weiner Z, Zipori Y. Continuous versus disrupted subcutaneous tissue closure in cesarean section: A retrospective cohort study. Int J Gynaecol Obstet 2023; 160:113-119. [PMID: 35766992 DOI: 10.1002/ijgo.14322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/01/2022] [Accepted: 05/10/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To compare rates of surgical-site infections following continuous, as compared with interrupted, subcutaneous tissue closure technique during cesarean delivery (CD). METHODS A retrospective cohort study during 2008-2018. The study group included women who underwent either elective or emergent CD with continuous subcutaneous tissue closure, while the control group comprised those with interrupted subcutaneous tissue closure. We excluded women with suspected infectious morbidity before CD. The primary outcome was surgical-site infection (SSI) rate. RESULTS The final analysis included 6281 women. We performed continuous subcutaneous tissue closure in 37.4% (1867/4988) of scheduled CD, and 45.8% (592/1293) of emergent CD. The rate of SSI was significantly lower following continuous than interrupted subcutaneous tissue closure, in both elective CD (2.7% versus 4.5%, respectively, P = 0.031) and emergent CD (3.2% versus 5.4%, respectively, P = 0.036) in nulliparous and multiparous women. Similarly, secondary outcomes such as re-admission rates, postoperative maternal fever, and need for antibiotic treatment were significantly lower following continuous subcutaneous closure. CONCLUSIONS Continuous subcutaneous closure technique during CD yields a lower rate of surgical-site complications compared with the interrupted technique.
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Affiliation(s)
- Roy Lauterbach
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Chen Ben David
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Emad Matanes
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Ruth & Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Ruth & Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
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15
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Garcia R, Barnes S, Boukidjian R, Goss LK, Spencer M, Septimus EJ, Wright MO, Munro S, Reese SM, Fakih MG, Edmiston CE, Levesque M. Recommendations for change in infection prevention programs and practice. Am J Infect Control 2022; 50:1281-1295. [PMID: 35525498 PMCID: PMC9065600 DOI: 10.1016/j.ajic.2022.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 01/25/2023]
Abstract
Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.
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Affiliation(s)
- Robert Garcia
- Department of Healthcare Epidemiology, State University of New York at Stony Brook, Stony Brook, NY,Address correspondence to Robert Garcia, BS, MT(ASCP), CIC, FAPIC, Department of Healthcare Epidemiology, State University of New York at Stony Brook, 100 Nicolls Rd, Stony Brook, NY, 11580
| | - Sue Barnes
- Infection Preventionist (Retired), San Mateo, CA
| | | | - Linda Kaye Goss
- Department of Infection Prevention, The Queen's Health System, Honolulu, HI
| | | | | | | | - Shannon Munro
- Department of Veterans Affairs Medical Center, Research and Development, Salem, VA
| | - Sara M. Reese
- Quality and Patient Safety Department, SCL Health System Broomfield, CO
| | - Mohamad G. Fakih
- Clinical & Network Services, Ascension Healthcare and Wayne State University School of Medicine, Grosse Pointe Woods, MI
| | | | - Martin Levesque
- System Infection Prevention and Control, Henry Ford Health, Detroit, MI
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16
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Pergialiotis V, Panagiotopoulos M, Vogiatzi L, Bellos I, Antsaklis P, Theodora M, Ntomali E, Daskalakis G. Spontaneous versus manual placental delivery during cesarean delivery: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2022; 35:10535-10544. [PMID: 36259483 DOI: 10.1080/14767058.2022.2134769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Standardized techniques have been established for cesarean delivery to reduce cesarean delivery complication rates. Current recommendations suggest against manual removal of the placenta. The purpose of the present meta-analysis is to evaluate published data and provide a summary of the evidence. METHODS For the purposes of this systematic review, we searched Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar, and Clinicaltrials.gov databases from inception till June 2021 for relevant randomized controlled trials. Effect sizes were calculated in R. RESULTS Overall, 19 studies were included that involved 5797 parturient. We did not detect significant differences in the mean intraoperative blood loss among the two techniques (MD = 149.18 ml, 95% CI = -32.55, 330.92). Similarly, intraoperative duration was comparable among the two groups (MD = -0.89 min, 95% CI = -2.34, 0.57). The risk of intraoperative hemorrhage was comparable among the two groups (OR = 1.75, 95% CI = 0.48, 6.36), although the provided result is based on underpowered sample size. Consequently, the need of transfusion was not increased (OR = 1.31, 95% CI = 0.71, 2.44). Neither postpartum endometritis (OR = 1.50, 95% CI = 0.94, 2.40) nor infectious morbidity (OR = 1.82, 95% CI = 0.94, 3.52) increased with manual placental extraction. CONCLUSION The findings of our study suggest that cephalad-caudad blunt expansion of the uterine incision may be safe; however, more data are needed to evaluate its impact on post-partum infectious morbidity as well as its safety in cases at increased risk of perioperative bleeding.
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Affiliation(s)
- Vasilios Pergialiotis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michalis Panagiotopoulos
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Lito Vogiatzi
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Bellos
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Antsaklis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Theodora
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ekaterini Ntomali
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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17
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Antoine C, Timor-Tritsch IE, Agoha C, Alexander J. A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum. Am J Obstet Gynecol MFM 2022; 4:100744. [PMID: 36113718 DOI: 10.1016/j.ajogmf.2022.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/19/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation. OBJECTIVE This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential. STUDY DESIGN Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants. RESULTS The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques. CONCLUSION The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha).
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
| | - Chikadibia Agoha
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
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18
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Antoine C, Alexander JS, Yaghoubian YC, Harary JM. Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae. J Perinat Med 2022; 50:1045-1052. [PMID: 35538677 DOI: 10.1515/jpm-2021-0485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/07/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the diversity of uterine closure techniques (UCTs) among providers in one institution and evaluate concurrent consideration of adverse outcomes for patient counseling, provisional care, and prevention. METHODS Forty-four obstetricians at NYU Langone Health were emailed a survey of their uterine closure technique, patient counseling, and practice experience. Results were stratified by years of practice: ≤5, 5-20, and 20-40 years. RESULTS Thirty-nine obstetricians (88.6%) completed the survey. Among those, a blunt uterine opening was preferred by 29 (74.4%), and a mid-lower segment location was favored by 34 (87.2%). At uterine closure, the endometrium was included by 20 (51.3%), with half a centimeter or more incorporated in the myometrial closure, whereas 15 (38.5%) did not factor in the endometrium's presence. Closure duration varied from 1 to 20 min, with 21 (53.9%) lasting 1-5 min and 12 (30.8%) lasting 5-10 min. All physicians were familiar with the potential post-cesarean complications and counseled their patients accordingly; 25 (64.1%) at the first post-op visit while 14 (35.9%) did so before the next conception. Practitioners with fewer years in practice endorsed the safety of up to five consecutive cesarean births, while those with more experience approved up to ten. Thirty-two obstetricians (82.1%) stated that the risk of abnormal placentation is exclusively associated with the number of cesarean sections, whereas five (12.8%) senior obstetricians asserted that individual surgical techniques are most impactful. CONCLUSIONS The survey illustrates that various UCTs are performed irrespective of potential adverse sequelae and without consideration for subsequent patient counseling and care. Ongoing research must study the impact of UCT on scar healing to formulate preventive strategies for post-cesarean complications.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Yasaman C Yaghoubian
- Department of Obstetrics and Gynecology, North Shore University Hospital/Long Island Jewish Medical, New York, NY, USA
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19
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Bruno AM, Blue NR. Challenges in Interpreting Obstetrics and Gynecology Literature. Clin Obstet Gynecol 2022; 65:225-235. [PMID: 35318984 PMCID: PMC9050836 DOI: 10.1097/grf.0000000000000707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The field of obstetrics and gynecology is constantly replenished with the newest research findings. In an era of rapidly available study publications, there are a number of challenges to interpreting the obstetrics and gynecology literature. Common pitfalls include the over reliance on the dichotomized P-value, lack of transparency, bias in study reporting, limitations of resources, absence of standardized practices and outcomes in study design, and the rare concerns for data integrity. We review these predominant challenges and their potential solutions, in interpreting the obstetrics and gynecology literature.
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Affiliation(s)
- Ann M. Bruno
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
| | - Nathan R. Blue
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
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20
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Quibel T, Winer N, Bussières L, Vayssière C, Deruelle P, Defrance M, Rozenberg P, Bouyer J, Dupuis N, Renaudin B, Dugave L, Banaszkiewicz N, Garabedian C, Ville Y. Impact of COVID-19-Related Lockdown on Delivery and Perinatal Outcomes: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11030756. [PMID: 35160207 PMCID: PMC8837050 DOI: 10.3390/jcm11030756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 02/05/2023] Open
Abstract
Objective: The magnitude and direction of effects on pregnancy outcomes of the lockdown imposed during COVID-19 have been uncertain and debated. Therefore, we aimed to quantify delivery and perinatal outcomes during the first nationwide lockdown due to the COVID-19 pandemic compared with the same durations of time for the pre- and post-lockdown periods. Study design: This was a retrospective cohort study of six university hospital maternity units distributed across France, each of which serves as the obstetric care referral unit within its respective perinatal network. Maternal and perinatal outcomes were compared between the lockdown period and same-duration (i.e., 55-day) periods before and after the 2020 lockdown (pre-lockdown: 22 January–16 March; lockdown: 17 March–10 May; post-lockdown: 11 May–4 July). We compared the overall rates of Caesarean delivery (CD), pre-labor CD, labor induction, operative vaginal delivery, severe postpartum hemorrhage (≥1 L), severe perineal tear, maternal transfusion, and neonatal mortality and morbidity (1- and 5-min Apgar scores < 7), hypoxia and anoxia (umbilical arterial pH < 7.20 or <7.10, respectively), and admission to a neonatal intensive care unit before discharge. Adjusted odds ratios were estimated using logistic regression, controlling for region of birth, maternal age category, multiparity, multiple pregnancies, diabetes, and hypertensive disorders. Results: The study sample consisted of 11,929 women who delivered consecutively at one of the six maternity units studied (4093 pre-lockdown, 3829 during lockdown, and 4007 post-lockdown) and their 12,179 neonates (4169 pre-lockdown, 3905 during lockdown, and 4105 post-lockdown). The maternal and obstetric characteristics of the women delivering during the lockdown period were alike those delivering pre- and post-lockdown on maternal age, parity, body mass index, rate of complication by hypertensive disorders or insulin-treated diabetes, and gestational age at delivery. Overall CD rates were similar during the three periods (23.6%, 24.8%, and 24.3% pre-lockdown, lockdown, and post-lockdown, respectively) and no outcome differed significantly during lockdown compared to pre- and post-lockdown. These findings were consistent across maternity units. Conclusion: The maternal and perinatal outcomes are reassuring regarding the performance of the health-care system during the COVID-19 lockdown studied. Such information is crucial, because additional COVID-19-related lockdowns might still be needed. They are also instructive regarding potential future pandemics.
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Affiliation(s)
- Thibaud Quibel
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, 78300 Poissy, France; (M.D.); (P.R.)
- UVSQ, Inserm, Team U1018, Clinical Epidemiology, Centre de Recherche en Épidé-miologie et Santé des Populations (CESP), Paris Saclay University, 78180 Montigny-le-Bretonneux, France;
- Correspondence: ; Tel.: +33-01-39275131; Fax: +33-01-39274479
| | - Norbert Winer
- Obstetrics and Gynecology Department, Centre Hospitalier Universitaire de Nantes, 44035 Nantes, France; (N.W.); (N.B.)
- UMR PhAN 1280 NUN INRAE F-44000 University Nantes, 44035 Nantes, France
| | - Laurence Bussières
- Obstetrics, and Fetal Medicine and Surgery Department, Hôpital Necker-Enfants Maladies, AP-HP, 75007 Paris, France; (L.B.); (B.R.); (Y.V.)
- EHU 7328 PACT, Université de Paris, 75006 Paris, France
| | - Christophe Vayssière
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, 31059 Toulouse, France; (C.V.); (N.D.)
- UMR1295 CERPOP (Centre for Epidemiology and Population Health Research), Team SPHERE (Study of Perinatal, Paedriatric and Adolescent Health: Epidemiological Research and Evaluation), Toulouse III University, 31062 Toulouse, France
| | - Philippe Deruelle
- Department of Obstetrics and Gynecology, University Hospital of Strasbourg, Avenue Moliere, 67000 Strasbourg, France;
| | - Manon Defrance
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, 78300 Poissy, France; (M.D.); (P.R.)
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, 78300 Poissy, France; (M.D.); (P.R.)
- UVSQ, Inserm, Team U1018, Clinical Epidemiology, Centre de Recherche en Épidé-miologie et Santé des Populations (CESP), Paris Saclay University, 78180 Montigny-le-Bretonneux, France;
| | - Jean Bouyer
- UVSQ, Inserm, Team U1018, Clinical Epidemiology, Centre de Recherche en Épidé-miologie et Santé des Populations (CESP), Paris Saclay University, 78180 Montigny-le-Bretonneux, France;
| | - Ninon Dupuis
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, CHU Toulouse, 31059 Toulouse, France; (C.V.); (N.D.)
| | - Benoit Renaudin
- Obstetrics, and Fetal Medicine and Surgery Department, Hôpital Necker-Enfants Maladies, AP-HP, 75007 Paris, France; (L.B.); (B.R.); (Y.V.)
| | - Louise Dugave
- CHU Lille, Department of Obstetrics, 59000 Lille, France; (L.D.); (C.G.)
| | - Nathalie Banaszkiewicz
- Obstetrics and Gynecology Department, Centre Hospitalier Universitaire de Nantes, 44035 Nantes, France; (N.W.); (N.B.)
| | - Charles Garabedian
- CHU Lille, Department of Obstetrics, 59000 Lille, France; (L.D.); (C.G.)
- University Lille, ULR 2694 METRICS, 59000 Lille, France
| | - Yves Ville
- Obstetrics, and Fetal Medicine and Surgery Department, Hôpital Necker-Enfants Maladies, AP-HP, 75007 Paris, France; (L.B.); (B.R.); (Y.V.)
- EHU 7328 PACT, Université de Paris, 75006 Paris, France
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