Surgical complications after caesarean section: A population-based cohort study

Re-exploration following caesarean birth: a prospective national case-control study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system

BACKGROUND

Re-exploration following caesarean birth and the associated maternal morbidity has not been investigated in the UK. Our aims were to determine the national incidence and identify the associated risk factors.

METHODS

We conducted a prospective observational case-control study across 194 UK consultant-led maternity units in women whose caesarean birth was complicated by a re-exploration. Independent factors for re-exploration were analysed using multivariable multi-level mixed effects logistic regression.

RESULTS

Over the study period (1 June 2021 and 31 May 2022) 238,423 caesarean births were recorded across the UK of which 187 women underwent re-exploration, giving an incidence of one re-exploration per 1282 caesarean births (95%CI 1:1099-1:1471). Haemorrhage (124/187, 66.3%) and sepsis (31/187, 16.6%) were the most common findings at re-exploration. Median (IQR [range]) time interval to re-exploration following the caesarean birth was 1 (0-4 [0-28]) day. Mechanical ventilation was required in 34 (18.6%) women, cardiac arrest was reported in 5 (2.7%) and 3 (1.6%) women died. Independent preceding factors associated with a re-exploration included: receipt of blood transfusion (adjusted OR (95%CI) 8.25 (2.66-25.61)); use of a general anaesthetic (adjusted OR (95%CI) 3.33 (1.61-6.88)); pre-eclampsia (adjusted OR (95%CI) 3.27 (1.55-6.91)); black ethnicity (adjusted OR (95%CI) 3.14 (1.39-7.11)); postpartum haemorrhage (adjusted OR (95%CI) 2.82 (1.81-4.37)); use of anticoagulants or antiplatelet drugs pre-caesarean birth (adjusted OR (95%CI) 2.26 (1.35-3.81)); and emergency caesarean birth (adjusted OR (95%CI) 1.89 (1.01-3.57)).

CONCLUSION

Re-exploration following caesarean birth in the UK is uncommon but is associated with significant maternal morbidity and mortality. These study findings will help guide informed consent and encourage appropriate surveillance of high-risk women postpartum.

Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial

BACKGROUND

Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown.

OBJECTIVE

This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine.

STUDY DESIGN

This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test.

RESULTS

Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar.

CONCLUSION

Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.

L, Agiwal V, Angaali N, A. Y. N, D. S, Haggerty C, Reddy PS. Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

BACKGROUND

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

MAIN OBJECTIVES

To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India.

METHODS

A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity.

RESULTS

The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%).

CONCLUSION

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report

Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.

Ethical Development of Artificial Amniotic Sac and Placenta Technology: A Roadmap

In this paper we present an initial roadmap for the ethical development and eventual implementation of artificial amniotic sac and placenta technology in clinical practice. We consider four elements of attention: (1) framing and societal dialogue; (2) value sensitive design, (3) research ethics and (4) ethical and legal research resulting in the development of an adequate moral and legal framework. Attention to all elements is a necessary requirement for ethically responsible development of this technology. The first element concerns the importance of framing and societal dialogue. This should involve all relevant stakeholders as well as the general public. We also identify the need to consider carefully the use of terminology and how this influences the understanding of the technology. Second, we elaborate on value sensitive design: the technology should be designed based upon the principles and values that emerge in the first step: societal dialogue. Third, research ethics deserves attention: for proceeding with first-in-human research with the technology, the process of recruiting and counseling eventual study participants and assuring their informed consent deserves careful attention. Fourth, ethical and legal research should concern the status of the subject in the AAPT. An eventual robust moral and legal framework for developing and implementing the technology in a research setting should combine all previous elements. With this roadmap, we emphasize the importance of stakeholder engagement throughout the process of developing and implementing the technology; this will contribute to ethically and responsibly innovating health care.