Mode of delivery preferences: the role of childbirth fear among nulliparous women

Introduction

The increasing Cesarean Section (CS) rates may be attributed to women's increasing requests for elective CS. High Fear of Childbirth (FOC), especially among nulliparous women, may be significantly associated with CS preference without medical indications. The current study aims to investigate the impact of childbirth fear on the mode of delivery preference among nulliparous women.

Methods

A cross-sectional correlational study was performed in the Maternal and Children Hospital (MCH) from the beginning of October 2022 to the end of February 2023 and incorporated a convenience sample of 342 nulliparous women. The data was collected using a self-reported questionnaire comprising participants' demographic and obstetrics characteristics and the FOC questionnaire. A logistic regression model examined the relationship between CS preference and the other independent variables.

Results

The results indicated that 74.3% of the nulliparous women preferred vaginal delivery, while 25.7% preferred Cesarean Section. Concerning childbirth-related fear, the highest mean scores were related to fear of clinical procedures, fear of harming or distressing the infant, and fear of pain 5.19 ± 1.13, 5.12 ± 1.27, and 5.09 ± 1.22, respectively. High FOC was present among 74.6%, moderate in 17.3%, and severe in 6.7% of the participants. Logistic regression analysis showed maternal age and monthly income were the significant sociodemographic determinants of choosing CS as the preferred delivery mode (p < 0.05). Moreover, the participants who had increased fear of harming or distressing the infant, fear from pain, fear from the body's ability to give birth, fear from not being involved in decision-making, and overall FOC had a higher probability of choosing CS as the preferred delivery mode compared to the participants who had lower fear (p < 0.05).

Discussion

Having high FOC increases the CS preference among nulliparous women. Increased fear of harming or distressing the infant, fear from pain, fear from the body's ability to give birth, and fear from not being involved in decision- making seem to be significant dimensions of childbirth fear associated with CS preference among nulliparous women.

[Classification of caesarean sections by 10 Robson groups in a second level hospital]

Background

In recent years, cesarean section (CS) rates have increased alarmingly. The World Health Organization (WHO) proposes to use the Robson classification system as a global standard, which contributes to a better analysis of CS indications, making it possible to establish strategies to reduce them.

Objective

To analyze the classification of CS by Robson groups from July to September 2020 at the Hospital General de Zona No. 4 (District General Hospital [DGH] No. 4), in Celaya, Guanajuato.

Material and methods

Retrospective study which included 160 records of women undergoing CS. Robson's group classification was used, and descriptive statistics and cluster analysis were performed to better understand the classification groups.

Results

The average age was 27.6 ± 5.6 years. 53.1% had secondary school; 46.9% was a housewife; 46.3% was laborer; 42.8% were cohabitating; 50% had 1 or more births; 42.5% previous CS; 96.9% 1 fetus; 91.9% cephalic presentation; 78.8% 37 weeks of gestational age or more. Robson's group 5 (previous CS) had the highest percentage (42.5%), followed by group 2 (primiparous) with 20.6%, and group 10 (premature) 13.1%. Cluster analysis formed 3 groups, where cluster 1 and 3 contained group 5 of Robson's classification.

Conclusions

DGH No. 4 must carry out the necessary strategies so that women with a previous cesarean section can have a vaginal delivery, without compromising the well-being of the mother-child pair, in addition to interventions to avoid primary CS, because women in group 1 and 2 will potentially belong to group 5, in the next obstetric event.

[Prenatal diagnosis of placenta acretta by ultrasound and its histopathological association]

Background

Anomalous adhesions of the placenta, known as placenta accreta and its variants, are the cause of obstetric hemorrhages that put the pregnant woman at risk. Accretism is strongly associated with a history of uterine surgery (cesarean section, myomectomy, curettage), as well as ultrasonographic signs, such as the presence and size of placental lacunae, loss of the placenta/bladder interface, location on the anterior face of the placenta, and presence of Doppler flow; these markers can be assessed by prenatal ultrasound.

Objective

To analyze the association of prenatal diagnosis of placenta accreta by ultrasound with the histopathological result using the Tovbin index.

Material and methods

Observational, cross-sectional and analytical study. 63 patients who had placenta accreta data by ultrasound measured with the Tovbin index and by means of the histopathological result obtained from the platform of the Mexican Institute for Social Security (IMSS) were included. The association between the two studies with the presence of placenta accreta was analyzed.

Results

63 patients were analyzed; the Tovbin index was positive in 89% of the patients with a diagnosis of placenta accreta confirmed by histopathology. Both the Tovbin index and the histopathology report showed a statistically significant association with a p value of 0.04 for the diagnosis of placenta accreta.

Conclusion

The Tovbin index as an ultrasonographic prenatal diagnosis of placenta accreta has a statistically significant association with histopathology diagnosis.

A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth

Objective

Postpartum women can develop post-traumatic stress disorder (PTSD) in response to complicated, traumatic childbirth; prevalence of these events remains high in the U.S. Currently, there is no recommended treatment approach in routine peripartum care for preventing maternal childbirth-related PTSD (CB-PTSD) and lessening its severity. Here, we provide a systematic review of available clinical trials testing interventions for the prevention and indication of CB-PTSD.

Data Sources

We conducted a systematic review of PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, and Scopus through December 2022 to identify clinical trials involving CB-PTSD prevention and treatment.

Study Eligibility Criteria

Trials were included if they were interventional, evaluated CB-PTSD preventive strategies or treatments, and reported outcomes assessing CB-PTSD symptoms. Duplicate studies, case reports, protocols, active clinical trials, and studies of CB-PTSD following stillbirth were excluded.

Study Appraisal and Synthesis Methods

Two independent coders evaluated trials using a modified Downs and Black methodological quality assessment checklist. Sample characteristics and related intervention information were extracted via an Excel-based form.

Results

A total of 33 studies, including 25 randomized controlled trials (RCTs) and 8 non-RCTs, were included. Trial quality ranged from Poor to Excellent. Trials tested psychological therapies most often delivered as secondary prevention against CB-PTSD onset (n=21); some examined primary (n=3) and tertiary (n=9) therapies. Positive treatment effects were found for early interventions employing conventional trauma-focused therapies, psychological counseling, and mother-infant dyadic focused strategies. Therapies' utility to aid women with severe acute traumatic stress symptoms or reduce incidence of CB-PTSD diagnosis is unclear, as is whether they are effective as tertiary intervention. Educational birth plan-focused interventions during pregnancy may improve maternal health outcomes, but studies remain scarce.

Conclusions

An array of early psychological therapies delivered in response to traumatic childbirth, rather than universally, in the first postpartum days and weeks, may potentially buffer CB-PTSD development. Rather than one treatment being suitable for all, effective therapy should consider individual-specific factors. As additional RCTs generate critical information and guide recommendations for first-line preventive treatments for CB-PTSD, the psychiatric consequences associated with traumatic childbirth could be lessened.

Maternity Access in Rural America: The Role of Family Physicians in Providing Access to Cesarean Sections

INTRODUCTION

As an increasing number of rural hospitals close their maternity care units, many of the approximately 28 million reproductive-age women living in rural America do not have local access to obstetric services. We sought to describe the characteristics and distribution of cesarean section-providing family physicians who may provide critical services in maintaining obstetric access in rural hospitals.

METHODS

Using a cross-sectional study design, we linked data from the 2017 to 2022 American Board of Family Medicine's Continuting Certification Questionnaire on provision of cesarean sections as primary surgeon and practice characteristics to geographic data. Logistic regression determined associations with provision of cesarean sections.

RESULTS

Of 28,526 family physicians, 589 (2.1%) provided cesarean sections as primary surgeon. Those who provided cesarean sections were more likely to be male (odds ratio (OR) = 1.573, 95% confidence limits (CL) 1.246-1.986), and work in rural health clinics (OR = 2.157, CL 1.397-3.330), small rural counties (OR = 4.038, CL 1.887-8.642), and in counties without obstetrician/gynecologists (OR = 2.163, CL 1.440-3.250).

DISCUSSION

Although few in number, family physicians who provide cesarean sections as primary surgeon disproportionately serve rural communities and counties without obstetrician/gynecologists, suggesting that they provide access to obstetric services in these communities. Policies that support family physician training in cesarean sections and facilitate credentialing of trained family physicians could reverse the trend of closing obstetric units in rural communities and reduce disparities in maternal and infant health outcomes.

Simultaneous Cesarean Section and Maternal Cardiac Surgery: Outcomes and Feasibility from a Tertiary Care Hospital in India

INTRODUCTION

Cardiovascular disease is the leading cause of pregnancy-related mortality, and it has gradually increased over time; this rise has been attributed to numerous reasons including the growing number of women with congenital heart disease who are surviving to childbearing age. Valve surgery during pregnancy is a high risk, with a fetal and maternal mortality rate of 35% and 9%, respectively. Prior knowledge about the cardiovascular disease opens up a host of options for the mother even during pregnancy, but presentation in the 3rd trimester puts both the mother and the baby at risk. Simultaneous caesarean section and maternal cardiac surgery is a suitable option for this subset of patients, and with this study we aim to assess its outcomes and feasibility.

METHODS

This is a retrospective study of five pregnant patients who presented with predominant symptoms of heart failure in the 3rd trimester between June 2019 and June 2021. Intraoperative and postoperative intensive care unit charts of all the patients were reviewed.

RESULTS

All five patients underwent simultaneous cesarean section and maternal cardiac surgery successfully with no fetal or maternal mortality and are doing well in the follow-up period.

CONCLUSION

Cesarean section followed by definitive maternal cardiac surgery in the same sitting is a safe and feasible approach in the management of such patients. A well-prepared team is pivotal for a safe delivery with a cardiopulmonary bypass machine on standby. Specialized multidisciplinary care in the antepartum, peripartum, and postpartum period is essential to improve outcomes.

Post-cesarean Delivery Analgesia Using Spinal Anesthesia: Ropivacaine-Fentanyl vs. Ropivacaine-Sufentanil

Background

To improve the quality of intraoperative and postoperative analgesia during spinal anesthesia, intrathecal opioids are used as adjuvant drugs in combination with local anesthetics.

Objectives

This study aimed to compare the intrathecal injection of ropivacaine-fentanyl with ropivacaine-sufentanil in terms of the duration of analgesia after cesarean section (CS).

Methods

This randomized, double-blind clinical trial study was conducted on women referred to Imam Khomeini Hospital of Ahvaz City for elective CS in 2021. A total of 51 patients were randomly divided into 2 groups. The first group (n = 25) received ropivacaine (17.5 mg) + fentanyl (25 μg), while the second group (n = 26) received ropivacaine (17.5 mg) + sufentanil (2.5 μg) for spinal anesthesia. Eventually, several parameters were investigated, including the duration of sensory and motor block, duration of analgesia (based on the Visual Analog Scale (VAS)), hemodynamic parameters, and possible complications.

Results

The duration of surgery (P = 0.059) and the duration of motor block (P = 0.962) were not significantly different between the 2 groups. The mean duration of analgesia (from the time of entering recovery to reaching VAS = 3) was 203.12 ± 72.93 and 207.46 ± 69.59 minutes in the fentanyl and sufentanil groups, respectively (P = 0.658). Systolic and diastolic blood pressure (SBP/DBP) drops in minute 5 were observed more frequently in the sufentanil group than in the fentanyl group (P = 0.027 and P = 0.002, respectively). At the other time points, however, no significant difference was observed between the 2 groups in terms of hemodynamic variables (P > 0.05). Finally, the frequency of pruritus was higher in the sufentanil group than in the fentanyl group (26.9% vs. 4.0%; P = 0.024).

Conclusions

Adding fentanyl or sufentanil to intrathecal ropivacaine provides a similar duration of analgesia. However, fentanyl was associated with better hemodynamic stability and a lower incidence of pruritus.

Post-Cardiac arrest targeted temperature management in a parturient with severe COVID-19 disease

Background and Objective

Targeted temperature management (TTM) may improve neurological outcomes and mortality after cardiac arrest. We present a targeted mild hypothermia treatment in a postpartum patient with COVID-19 after successful cardiopulmonary resuscitation (CPR).

Case presentation

A 23 year old, 26-week pregnant patient with the diagnosis of COVID-19. The patient developed respiratory arrest followed by cardiac arrest and underwent CPR for six minutes. The patient underwent an emergency cesarean section after CPR in intensive care unit. After the resuscitation, 72-hours hypothermia protocol was initiated. We extubated the patient 13 days after the hypothermia procedure. The patient was conscious and cooperative. Respiratory distress worsened in the following days; the patient was re-intubated 18 days after the TTM. The benefit of targeted hypothermia was improved neurologic outcome in our patient. However, severe infectious complications led to multi-organ failure and the patient died on the 45th ICU admission day.

Ropivacaine on Maternal and Neonatal Outcomes After Cesarean Section: A Systematic Review and Meta-analysis

Context

The type of anesthesia in cesarean section can affect the mother and baby. This study aimed to determine the comparative effect of intrathecal hyperbaric bupivacaine vs. hyperbaric ropivacaine on maternal and neonatal outcomes after cesarean section.

Evidence Acquisition

PubMed, Web of Science, Embase, Google Scholar, IranDoc, MagIran, and Scopus databases were searched from 1 September 2022 to 1 November 2022. Eighteen clinical trials with 1542 patients were included in the analysis.

Results

There was no statistically significant difference in hypotension, bradycardia, and Apgar score between the 2 groups (P > 0.05). The risk of nausea (relative risk (RR), 1.526; 95% CI, 1.175 - 1.981; P = 0.001) and vomiting (RR, 1.542; 95% CI, 1.048 - 2.268; P = 0.02) caused by bupivacaine was 0.53% and 0.54% higher than that of ropivacaine. The incidence of shivering (RR, 2.24; 95% CI, 1.480 - 3.39; P = 0.00) was 2.24 times higher in the bupivacaine group than in the ropivacaine group. The average onset time of sensory block (standardized mean difference (SMD), -0.550; 95% CI, -1.054 to -0.045; P = 0.032) and motor block (SMD, -0.812; 95% CI, -1.254 to -0.371; P = 0.000) was significantly lower in the bupivacaine group than in the ropivacaine group.

Conclusions

Despite the fact that ropivacaine and bupivacaine are effective in cesarean section, ropivacaine is more favorable because of less hemodynamic changes, less duration of sensory and motor block, and fewer side effects, which are effective in patient recovery.

Optimizing Cefazolin Prophylaxis in Obstetrical Patients with Reported Beta-Lactam Allergy Undergoing Cesarean Delivery

OBJECTIVE

Evaluate the impact of an allergy history guided algorithm for optimizing peri-operative cefazolin use in patients with reported beta-lactam allergy undergoing cesarean delivery.

METHODS

The Allergy Clarification for Cefazolin Evidence-based Prescribing Tool (ACCEPT) was developed through consensus by allergists, anesthesiologists and infectious diseases specialists, and implemented over a two-month period (December 1, 2018 to January 31, 2019). A segmented regression on monthly cefazolin use was conducted during the baseline (January 1 to November 30, 2018) and intervention (February 1 to December 31, 2019) periods to evaluate the impact of ACCEPT on the monthly use of peri-operative cefazolin in patients with reported beta-lactam allergy undergoing cesarean delivery. The frequency of peri-operative allergic reactions and surgical site infections were collected during both periods.

RESULTS

Of the 3128 eligible women who underwent a cesarean delivery, 282 (9%) reported a beta-lactam allergy. The most common beta-lactam allergens were penicillin (64.3%), amoxicillin (16.0%), and cefaclor (6.0%). The most frequently reported allergic reactions were rash (38.1%), hives (21.4%), and unknown (11.6%). Use of cefazolin increased from 52% (baseline) to 87% during the intervention period. Segmented regression analysis confirmed a statistically significant increase following implementation (incidence rate ratio 1.62, 95% CI 1.19 - 2.21, p=0.002). There was one perioperative allergic reaction in the baseline period and two during the intervention period. Cefazolin use remained high (92%) two years after algorithm implementation.

CONCLUSIONS

Implementation of a simple allergy history guided algorithm in obstetrical patients with reported beta-lactam allergy resulted in a sustained increase in peri-operative cefazolin prophylaxis.

Analgesic Effect of Preoperative Intravenous Administration of Paracetamol on Post-cesarean Pain: A Randomized Clinical Trial

Background

Pain control after every surgery, especially cesarean section, is very important, and physicians strive to discover pain control methods using the least amount of opioids. Paracetamol is a non-opioid analgesic with few complications.

Objectives

The present study aimed to investigate the analgesic effect of preoperative intravenous administration of paracetamol on post-cesarean pain.

Methods

This randomized, double-blind clinical trial was conducted on 240 pregnant women under spinal anesthesia who were candidates for elective cesarean section. The patients' weight, height, age, and body mass index (BMI) were recorded, and patients were randomly divided into 2 equal groups (n = 120). In the first group, 10 mg/kg paracetamol in 100 mL of normal saline (paracetamol group) and, in the second group, 100 mL normal saline (control group) were administered 15 minutes before surgery intravenously. Blood pressure, pulse rate, chills, and nausea were recorded during and 1 hour after surgery; in addition, the visual analogue scale (VAS) and the need for additional analgesics were recorded 1, 2, 4, 6, 12, and 24 hours after surgery.

Results

Mean pain scores were significantly lower in the paracetamol group (4.01 ± 2.22) than in the control group 6 hours (4.83 ± 2.35; P = 0.008) and 24 hours (2.26 ± 1.85 and 2.67 ± 1.80, respectably; P = 0.038) after surgery. Mean meperidine consumption was lower in the paracetamol group than in the control group, but it was not significant. No significant difference was found between the 2 groups in the frequency of chills and nausea (P > 0.05).

Conclusions

Within the limitations of the current study, preoperative intravenous administration of paracetamol significantly reduced post-cesarean pain within 24 hours.

The utero-tonic effects of low dose intravenous ketamine in cesarean section under spinal anesthesia; A randomized double-blind clinical trial

Background

Recently, the prevalence of cesarean section (CS) has been on the rise and the proper uterine tone is an important issue. We investigated the effects of intravenous (IV) ketamine on intraoperative bleeding and the need for oxytocin in CS under spinal anesthesia (SA).

Methods

This study, took place at Alzahra hospital during 2020. Pregnant women candidate for elective CS under SA were divided into two groups of ketamine and placebo. In group K, after umbilical cord clamping, 0.25 mg/kg ketamine and in group P 2ccs normal saline was injected. Mean arterial pressure and heart rate were recorded at baseline, before and 5 minutes after cord clamping and at the end of the surgery. The drop in hemoglobin values, the administrated units of oxytocin and side effects were also recorded.

Results

No significant difference was found in terms of patients' demographic data (P ≥ 0.05). The mean units of administrated oxytocin in group K was 34.61±6.63 and in group P; 48.47±12.15, which was significantly different (P=0.0001). The drop in Hb was less in group K, however not statistically significant (P=0.094). The need for methergine was significantly higher in group P (P=0.0001). The mean HR was significantly higher in group P (P=0.027), however, no significant difference was observed regarding the MAP (P=0.064). The incidence of hallucination (4.8%) and nystagmus (21%) was significantly higher in group K (P= 0.0001), but nausea and vomiting were more significant in group P (P= 0.027).

Conclusion

Prophylactic administration of low-dose ketamine in CS under S.A could significantly reduce the administrated oxytocin units and the need for additional utero-tonics and was associated with less drop in Hb values.

Effect of Intranasal Ketamine on Pain Intensity after Cesarean Section: A Single-Center, Double Blind, Randomized Controlled Trial

Background

Although intravenous or intramuscular opioids are widely used for managing postoperative pain after cesarean section (CS), their side effects are bothering and limit their use. The aim of this study was to determine the effect of intranasal ketamine on pain intensity after CS.

Methods

In a single-center, double-blind, parallel-group, randomized controlled trial, a total of 120 patients who were scheduled for elective CS were randomly assigned into two groups. After birth, 1 mg of midazolam was administered to all patients. In addition, 1 mg/kg intranasal ketamine was administered to patients in the intervention group. For patients in control group, normal saline was administered intranasally as a placebo. The severity of pain and nausea in the two groups was evaluated after 15, 30 and 60 minutes, as well as 2, 6 and 12 hours after the initial administration of the medications.

Results

The trend of changes in pain intensity was decreasing and these changes were statistically significant (time effect; P<0.001). The pain intensity in the placebo group was higher than the intervention and the observed difference was statistically significant, regardless of the time studied (group effect; P<0.001). In addition, it was shown that regardless of the study group, the trend of changes in nausea severity was decreasing and these changes were statistically significant (time effect; P<0.001). Regardless of the time studied, the severity of nausea in the placebo group was higher than the intervention group (group effect; P<0.001).

Conclusions

According to the results of this study, it seems that the using of intranasal ketamine (1 mg/kg), can be considered as an effective, well tolerated and safe method in reducing pain intensity as well as the need for postoperative opioid consumption after CS.

Changes in Maternal Serum Levels of C3 and C4 Complement Components in Different Delivery Methods and Postpartum Hemorrhage

BACKGROUND

Activation of the complement system may play a role in the pathophysiology of human labor. Yet no unanimous conclusion has been drawn.

OBJECTIVE

To compare the differences in maternal complement components C3 and C4 serum levels in cesarean section and the vaginal delivery at term and in the postpartum hemorrhage.

METHODS

One hundred and sixty six women delivered at term were enrolled in this study. Maternal blood samples were obtained from 47 cases of elective cesarean section and 119 cases of the vaginal delivery. Serum complement levels were measured subsequently by immuno-scatter turbidimetry.

RESULTS

The maternal complement levels declined significantly during delivery by both the cesarean section and the vaginal delivery (p＜0.01) in comparison with the baseline. A much larger drop of C3 serum level was found in the postpartum hemorrhage and in the vaginal delivery, and the incidence of the postpartum hemorrhage has a positive correlation with the complement decline rate.

CONCLUSION

The complement system may be involved in the delivery process and represents a predictive value in postpartum hemorrhage.

Comparing the Effect of Intrathecal Injection of Meperidine, Meperidine-Bupivacaine, and Bupivacaine Alone on Pain Severity and Hemodynamic Parameters after Elective Cesarean Section

Background

This study aimed to evaluate the effect of meperidine and bupivacaine on maternal hemodynamic changes prior to anesthesia and compare it with post-intervention.

Methods

In this clinical trial, the rate of postoperative analgesia on 90 healthy women candidates for elective cesarean section with spinal anesthesia was evaluated by meperidine, bupivacaine, and a combination of these two drugs. The study was conducted on 90 patients, including 30 patients receiving injection of meperidine, 30 patients receiving injection of bupivacaine, and 30 patients receiving injection of meperidine plus bupivacaine. Nausea, vomiting, headache, itching, and shortness of breath were also recorded.

Results

The mean systolic and diastolic blood pressure as well as heart rate and mean arterial blood pressure in the meperidine group were significantly lower than those detected before the intervention (P < 0.05). The mean SpO₂ index was significantly decreased in meperidine and meperidine+bupivacaine groups (P < 0.05). The prevalence of nausea, vomiting and itching was higher in meperidine group compared to those in the other two groups (P = 0.032).

Conclusions

In sum, the prevalence of nausea, vomiting, and itching in the meperidine group was higher than those in the other two groups. Due to almost equal performance of meperidine and meperidine plus bupivacaine in analgesia, the stabilization of other hemodynamic indices in the meperidine plus bupivacaine group, and the decline in the prevalence of nausea, vomiting, and itching, this combination may have been a good alternative to meperidine.

Effect of Intravenous Dexmedetomidine on Shivering in Cesarean Section under Intrathecal Anesthesia: Randomized Clinical Trial

Background

Shivering is one of the most common side effects after cesarean section (C-section) under spinal or epidural anesthesia. However, it is often not treated.

Objectives

The aim of this study was to evaluate the effectiveness of intravenous dexmedetomidine (DEX) in the prevention of shivering after intrathecal anesthesia in women undergoing C-sections.

Methods

This double-blind, placebo-controlled clinical trial was conducted on 80 women candidates for elective C-sections under intrathecal anesthesia who were referred to Imam Khomeini Governmental Hospital in Ahvaz, Iran, during 2020 - 2021. Patients were randomly divided into two groups of intravenous DEX (group D; 0.5 µg/kg) and normal saline (control, group C) and received the medications after umbilical cord clamping. All patients were evaluated during and after surgery for hemodynamic changes, the incidence and severity of shivering based on Chu and Tsai, side effects (e.g., nausea, vomiting), and sedation level based on the Ramsey scale.

Results

The incidence of shivering in group C was significantly higher than in group D (P = 0.003). Moreover, the severity of shivering on minutes 20, 30, and 45 in group C was significantly higher than in group D (P < 0.05). The mean sedation score during minutes 10 - 30 in group D was significantly higher than in group C (P < 0.05). Heart rate was not significantly different between the two groups (P < 0.05). Systolic and diastolic blood pressure were higher in group D than in group C (P < 0.05).

Conclusions

The administration of intravenous DEX effectively reduces the incidence and severity of shivering and provides appropriate sedation in patients undergoing C-sections, and it does not cause remarkable side effects.

Excessive gestational weight gain is an independent risk factor for gestational diabetes mellitus in singleton pregnancies: Results from a French cohort study

OBJECTIVE

Increase in prevalence of maternal obesity worldwide raises concern among health professionals. Our purpose was to evaluate the impact of maternal obesity and of excessive gestational weight gain (GWG) on the course of singleton pregnancies in a French maternity ward.

STUDY DESIGN

3599 consecutive women who delivered from April 2013 to May 2015 at Brest University Hospital were included in HPP-IPF cohort study, a study designed to evaluate clinical and biological determinants of postpartum hemorrhage (PPH). Maternal obesity was defined by a pre-pregnancy Body Mass Index (BMI) ≥ 30 kg/m² and excessive GWG was defined according to the Institute of Medicine 2009 guidelines. Obstetric complications(including gestational diabetes mellitus (GDM), gestational hypertension, pre-eclampsia, venous thromboembolism, PPH, cesarean section (C-section) and macrosomia) were collected prospectively in a standardized case report form. For each complication, Odd Ratios (OR) according to pre-pregnancy BMI and GWG were calculated in univariable and multivariable analyses.

RESULTS

Out of the 3162 women analyzed for this report, 583 (18.4%) were overweight, 400 (12.7%) were obese and 36.6% had excessive GWG. In multivariable analysis, after adjustment for confounding factors, obese women were at increased risk of GDM (OR 5.83, 95%CI 4.37-7.79), PPH (OR 1.69, 95%CI 1.19-2.41), C-section (OR 2.50, 95%CI 1.92-3.26) and macrosomia (OR 1.90, 95%CI 1.31-2.76). Similarly, women with excessive GWG were at increased risk of GDM (OR 1.55, 95%CI 1.17-2.06), C-section (OR 1.46, 95%CI 1.16-1.83) and macrosomia (OR 2.09, 95%CI 1.50-2.91).

CONCLUSIONS

Maternal obesity and excessive GWG are independent risk factors for GDM, C-section and macrosomia in singleton pregnancies. Further studies are needed to evaluate if a lifestyle intervention aiming at avoiding excessive GWG could improve clinical outcomes in pregnant women.

Intrapartum versus postpartum insertion of intrauterine device in women delivering by cesarean section

BACKGROUND

The intrauterine device (IUD), being a reversible and effective contraception method, is the most widely used worldwide. This study aims to demonstrate the efficacy of IUD insertion during elective lower segment cesarean section (LSCS) versus its insertion six weeks postpartum.

METHODS

A cohort study was conducted on 200 women planned for elective cesarean delivery and desired IUD as a contraceptive method. They were allocated into two groups; group I, in which IUD was inserted during LSCS, and group II, in which IUD was inserted six weeks or more after LSCS. Both groups were compared regarding failed insertion, post-insertion pain, and uterine perforation. They were followed for one year for the incidence of menorrhagia, vaginal infection, IUD displacement/expulsion, missed threads, or unintended pregnancy.

RESULTS

Women in the second group showed a significantly higher incidence of failed insertion and uterine perforation than women in the first group. On the contrary, women in the first group showed a significantly higher incidence of missed threads than women in the second group. Regarding other consequences, there were no significant differences between both groups concerning menorrhagia, vaginal infection, IUD displacement/expulsion, or unintended pregnancy.

CONCLUSION

IUD insertion during elective LSCS showed a significantly lower incidence of failed insertion and uterine perforation than its insertion six weeks postoperative.

Advanced Maternal Age as an Obstetric Risk Factor: Current Experience in a Hospital from Northwestern Spain

INTRODUCTION

Studies updating the evidence in advanced maternal age as an independent factor of obstetric risk are needed. The aim of this study was to determine the prevalence of ≥ 35-years-old pregnant women who give birth in a Spanish hospital in Northwestern Spain, and to describe the incidence of maternal and perinatal morbidity and mortality.

MATERIAL AND METHODS

Retrospective follow-up observational study including women ≥ 20 years-old who gave birth over one year (n = 1378). Data were collected from medical records, including socio-demographic characteristics, comorbidities, gestational conditions, variables related with the delivery and perinatal outcomes. Multivariable logistic regression analysis was performed to determine the association of advanced maternal age with obstetric and perinatal outcomes.

RESULTS

Forty-two percent of pregnant women were ≥ 35 years old. In the multivariable analysis, advanced maternal age was associated with the likelihood of gestational diabetes (OR = 1.84; 95% CI = 1.10 - 3.07), hypothyroidism (OR = 2.11; 95% CI = 1.17 - 3.80), lower probability of an eutocic delivery (OR = 0.74; 95% CI = 0.56 - 0.98), and a hospital admission > four days (OR = 2.91; 95% CI = 1.95 - 4.35). An association with the rate of C-sections was not found (OR = 1.24; 95% CI = 0.89 - 1.72).

CONCLUSION

A high prevalence of pregnant women of advanced maternal age was confirmed. There was a higher rate of comorbidities and longer hospital admissions in older women but not a higher rate of higher C-sections and other complications.

[Effects of Early Oral Feeding versus Delayed Oral Feeding on Bowel Function, Gastrointestinal Complications and Surgical Recovery after Cesarean Section under Regional Anesthesia: Systematic Review and Meta-Analysis]

PURPOSE

This study aimed to assess combined effects of early oral feeding after Cesarean section (C/S) under regional anesthesia on bowel function, gastrointestinal complications and surgical recovery.

METHODS

A systematic literature search was conducted using KISS, RISS, PubMed, CINAHL, EMBASE, CENTRAL and Google Scholar to identify randomized clinical trials comparing early oral feeding (EOF) with delayed oral feeding (DOF) after C/S. Outcome variables were bowel function and gastrointestinal complications and surgical recovery. Effect size was calculated using weighted mean differences (WMDs) and relative risks (RRs), with 95% confidence intervals (CIs).

RESULTS

Seven studies involving 1,911 patients from 568 studies, 7 studies were included in meta-analysis. EOF was significantly associated with shorter time to recover bowel movement compared with DOF (WMD, -2.50; CI, -3.50~-1.50). EOF was not associated with nausea (RR, 1.15; CI, 0.87~1.53) and vomiting (RR, 0.96; CI, 0.65~1.42), but lower incidence of abdominal distension (RR, 0.70; CI, 0.50~0.98). EOF was significantly associated with shorter time to discontinuation of intravenous fluids (WMD, -8.88; 95% CI, -16.65~-1.11) and removal of urinary catheter (WMD, -15.23; CI, -25.62~-4.85).

CONCLUSION

This meta-analysis provides evidence that EOF after C/S under regional anesthesia not only accelerates return of bowel function and surgical recovery but also reduces gastrointestinal complications. These results suggest that EOF should be offered to women who have undergone C/S to improve the recovery experience and reduce overall medical costs.

Prevalence and risk factors of low back and pelvic pain in women with rectus abdominis diastasis: a multicenter retrospective cohort study

Background

To explore the association between low back pain (LBP) and pelvic pain (PP) and rectus abdominis diastasis (RAD) in postpartum women and identify the characteristics and risk factors.

Methods

Women diagnosed with RAD and a history of labor and delivery, between 2009 and 2018, were identified from six hospitals within the Partners Healthcare System. Univariate and multivariable binary logistic regression analyses were used to identify the risk factors associated with pain.

Results

Age at onset of RAD in the non-cesarean delivery group was earlier than those in cesarean delivery (CD) group (P = 0.017). Women who underwent CD demonstrated 4.5 times greater risk of RAD than those who had no CD exposure. The cumulative composition ratio of LBP at every age stage of the period from 8 years pre-first delivery to 8 years post-first delivery was significantly higher than the other five conditions (RAD, umbilical hernia, PP, depressive disorder [DD], and strain of muscle, fascia, and tendon [SMFT]) (P for trend < 0.001). Women with DD, SMFT, and PP were more likely to have LBP (odds ratio [OR] = 1.91, 95% confidence interval [CI] 1.06 to 3.47, P = 0.032; OR = 4.50, 95% CI 1.64 to 12.36, P = 0.003; OR = 2.14, 95% CI 1.17 to 3.89, P = 0.013; respectively).

Conclusions

In postpartum women with RAD, DD, SMFT, and PP were found to be risk factors contributing to the development of LBP. Race and LBP also played roles in the development of PP.

Arteriovenous Malformation Complicating Cesarean Scar Pregnancy: A Rare Case of Vaginal Bleeding Managed Successfully by Uterine Artery Embolization

Objective: Arteriovenous malformation (AVM) can occur in cesarean scar ectopic pregnancy. The presence of retained product of conception can pose a diagnostic dilemma and clinical presentation could be similar.

Case report: A 27 year old female presented with continuous vaginal bleeding for two and half months following dilatation and evacuation (D&E) done for cesarean scar pregnancy (CSP) of 10 weeks 4days period of gestation. Sonography with color Doppler revealed dilated tortuous vessels around the mass in lower uterine segment suggesting CSP with AVM. Digital subtraction angiography confirmed the diagnosis. Bilateral uterine artery embolization achieved complete devascularisation as confirmed on post intervention angiogram. Patient became symptom free since then.

Conclusion: Uterine artery embolization is an effective mode of treatment of AVM complicating CSP if future fertility is desired.

Comparing the Effects of Low Dose of Ketamine, Tramadol, and Ondansetron in Prevention of Post Spinal Anesthesia Shivering in Cesarean Section

Background

Shivering frequently occurs in cesarean section (CS) under spinal anesthesia (SA), resulting in several complications. To date, pethidine has been considered as the gold standard for post-SA shivering control, but it is contraindicated in breastfeeding women.

Methods

This randomized, double-blind study was conducted at Alzahra hospital in Guilan, Iran, From January 2019 to November 2020. A total of 508 eligible term parturient women were enrolled and randomly divided into four groups of low dose ketamine (K), tramadol (T), ondansetron (O), and placebo (P). The incidence and severity of shivering and patients' complications were recorded and compared among the groups.

Results

The patients were homogenous in terms of demographic variables. Shivering was witnessed in 68 (53.5%), 26 (20.5%), 75 (59.1%), and 82 (64.6%) patients in K, T, O, and P groups, respectively (P = 0.0001). Regarding shivering severity, there was a significant difference among the four groups (P = 0.0001). In addition, a significant difference was seen regarding Apgar scores at the first minute, but not at the fifth minute (P = 0.168).

Conclusions

Considering the high incidence of shivering in placebo group, prophylactic intervention in CS under SA seems to be necessary. Among the studied drugs, tramadol was the most effective one, followed by a low dose of ketamine and ondansetron.

Do Large Uterine Fibroids Impact Pregnancy Outcomes?

Objectives

We sought to assess the prevalence of fibroids complicating pregnancy among Omani women who delivered and were followed-up at Sultan Qaboos University Hospital (SQUH) and correlate the presence of large fibroids (> 5 cm) with maternal and neonatal outcomes.

Methods

This retrospective cohort study was conducted at the Department of Obstetrics and Gynecology, SQUH, from 1 January 2011 to 31 December 2016. Demographic data included maternal age, gravidity, parity, body mass index (BMI), and history of preterm delivery. Ultrasonographic data included the total number of fibroids, number of fibroids > 5 cm in diameter, and location. The main outcomes measured were preterm delivery, preterm premature rupture of membranes (PPROM), malpresentation, intrauterine growth restriction (IUGR), mode of delivery, postpartum hemorrhage, retained placenta, and cesarean myomectomy. Fetal outcomes included birth weight and Apgar score. We used the chi-square test and t-test to calculate significant outcomes.

Results

The total number of deliveries over the study period was 24 800. Among these, 62 women had fibroids complicating pregnancy, giving an overall prevalence of 0.3%. Of the 62 women with documented uterine fibroids, 41 had fibroids > 5 cm in diameter and formed the study group, while the control group included 88 women with no fibroids and normal singleton pregnancies. The mean age, parity, BMI, and history of preterm delivery were comparable. The mean age of the study group was 32.6 years. There was no statistically significant difference in obstetric outcomes between the study and control group in terms of preterm labor (p =0.381), PPROM (p =0.536), malpresentation (p =0.237), IUGR (p =0.059), and retained placenta (p =0.296). Postpartum hemorrhage was significantly higher in the study group (p =0.018), the commonest cause was uterine atony (p =0.007). Women with large fibroids had a significantly increased cesarean section rate (p =0.002), the main indications were obstructed labor and failure to progress (62.5%). Five of the 44 women in the study group (12.8%) underwent cesarean myomectomy. Regarding neonatal outcomes, a statistically significant difference was noted in the Apgar scores.

Conclusions

Fibroids measuring > 5 cm in diameter are more likely to cause obstetric complications and are associated with higher cesarean rates. Pre-conception myomectomy is recommended for women with large fibroids.

Sphenopalatine Ganglion versus Greater Occipital Nerve Blocks in Treating Post-Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Clinical Trial

BACKGROUND

Despite being invasive, with serious complications, epidural blood patch (EBP) is still considered the gold standard therapy for Post Dural Puncture Headache (PDPH). The use of Peripheral nerve blocks for PDPH are studied here.

OBJECTIVES

To investigate the efficacy of sphenopalatine ganglion block (SPGB) and greater occipital nerve block (GONB) to relieve PDPH and its associated symptoms.

STUDY DESIGN

Randomized comparative single-blind trial.

SETTING

A University hospital.

METHODS

Patients who received spinal anesthesia for elective cesarean section, and then developed PDPH during hospitalization or within 5 days after dural puncture were enrolled to receive GONB (n = 47) or SPGB (n = 46) for treatment of PDPH. GONB Group: Patients received bilateral GONB using 3 mL mixture of 2 mL lidocaine 2% plus 1 mL dexamethasone 4 mg on each side of occipital region. SPGB Group: Patients received bilateral SPGB using the same mixture in each nostril. Assessments included Numeric Rating Scale (NRS) for severity of headache at supine and sitting positions, nausea NRS, neck stiffness, need for EBP, and complications.

RESULTS

The supine and sitting headache NRS scores significantly decreased at 30 minutes after blocks and throughout follow-up period in both groups (P < 0.000). Clinically significant drop of NRS to < 4 was reached earlier in GONB group. There was a significant difference between groups after 2 hours in supine and sitting headache NRS scores (P = 0.020 and 0.030, respectively); however, both treatments showed similar effectiveness from the third hour afterwards (P > 0.05). Both techniques were effective in relieving neck stiffness and nausea (P < 0.000), with no adverse effects.

LIMITATIONS

A limitation to this study was the small sample size.

CONCLUSIONS

GONB and SPGB are equally effective in relieving symptoms of PDPH. Both techniques are safe, simple, and less invasive than EBP.

Effects of General Anesthesia Versus Spinal Anesthesia on Serum Cytokine Release After Cesarean Section: A Randomized Clinical Trial

Background

Tissue damage caused by major surgery, such as cesarean section, may lead to a poor host immune response and excessive release of cytokines. These responses may increase the risk of infection, cause postoperative pain, and exert damaging effects on various body organs.

Objectives

Anesthesia methods may affect cytokine production after surgery. This study aimed to compare the serum levels of cytokines in general and spinal anesthesia among women undergoing cesarean section.

Methods

Thirty parturients (ASA class I and II) undergoing cesarean section were randomly assigned into two equal groups of spinal anesthesia and general anesthesia. Blood samples were taken for measuring the levels of interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor-alpha (TNF-α) before induction of anesthesia and 30 minutes after entering the recovery room.

Results

In the general anesthesia group, the postoperative serum levels of IL-6 and TNF-α were significantly higher than the corresponding preoperative levels. Significant differences were found between the two groups in the preoperative and postoperative levels of TNF-α. Changes in the IL-6 and TNF-α concentrations were significantly higher in the general anesthesia group as compared to the spinal anesthesia group. However, there was no significant difference in the IL-6:IL-10 and TNF-α: IL-10 ratios between the two groups.

Conclusions

General anesthesia, as compared to spinal anesthesia, significantly increased the IL-6 and TNF-α levels after cesarean section. Therefore, the spinal anesthesia technique may be a better option for patients undergoing cesarean section.

Factors Associated with the Type of Cesarean Section in Greece and Their Correlation with International Guidelines

BACKGROUND

Cesarean section (CS) rates have been increasing worldwide with different effects on maternal and neonatal health. Factors responsible for the growing trend of CSs, include maternal characteristics, medical insurance and convenient scheduling or financial incentives. Effective interventions and guidelines are required to reduce CS rates.

OBJECTIVE

The aim of this research was to investigate the factors contributing to CS rate increase and their correlation with international guidelines.

METHODS

The performed analysis included the available socio-demographic and medical information retrieved from the medical records and a related questionnaire in both emergency and elective CSs.

RESULTS

Out of the included 633 births, the cesarean delivery rate was 58%. Women with a previous CS showed higher percentages for Elective CS (66.1%) compared to Emergency CSs for the same reasons (8.9%). Furthermore, 23% of the patients underwent an Emergency CS because of failure of labor to progress while 18% of CSs were due to maternal desire.

CONCLUSION

The high rates of CS in Greece demonstrate the lack of use of international obstetric protocols, national strategies, Cesarean Section audits and a significant shortage of midwives. A decrease in iatrogenic and non-iatrogenic factors leading to the primary CS will decrease CS rates.

Comparative Study of Effect of Spinal Anesthesia in Sitting and Lateral Positions on the Onset Time of Sensory Block and Hemodynamic Condition in Cesarean Section: A Randomized Clinical Trial

BACKGROUND

Spinal anesthesia is the method of choice for the cesarean section. Hypotension is a common complication of this method.

OBJECTIVES

This study aimed to compare the effect of spinal anesthesia in the sitting and lateral positions on the onset time of sensory block and hemodynamic condition in cesarean sections.

METHODS

In this clinical trial, 106 elective cesarean section candidates under spinal anesthesia were selected and randomly divided into two groups: spinal anesthesia in the sitting position (group S) and the lateral position (group L). The onset time of the sensory block, quality of sensory and motor block, hemodynamic condition, frequency of hypotension, nausea, and vomiting, and the doses of ephedrine and atropine were compared between both groups. Data were analyzed with SPSS version 16 software at a 95% confidence level.

RESULTS

There was no statistically significant difference between the two groups in terms of age. The frequency of hypotension in L and S groups was 24.5% and 57.7%, respectively (P = 0.001), in minute 6 after spinal anesthesia and 5.7% and 36.5%, respectively (P < 0.001), in minute 8 after spinal anesthesia. The mean time to reach the sensory level of T6 was 1.30 ± 0.43 min versus 4.54 ± 2.12 min (P < 0.001), motor block score in minute 5 was 2.98 ± 0.14 versus 2.82 (P = 0.044), and ephedrine dose was 11.5 mg and 16.92 mg in the L and S groups, respectively (P = 0.010). The maximum sensory-motor block and satisfaction of women with spinal anesthesia were significantly higher in the lateral position than in the sitting position (P < 0.05).

CONCLUSIONS

Cesarean sections under spinal anesthesia in the lateral position than in the sitting position lead to a more rapid sensory and motor block, reduced ephedrine consumption, and enhanced satisfaction of women.

The Essential Role of Family Physicians in Providing Cesarean Sections in Rural Communities

Of family physicians who perform cesarean sections, more than half do so in rural communities and 38.6% provide cesarean sections in counties without any obstetrician/gynecologists. As policymakers in the United States struggle with a widening landscape of 'obstetrical deserts,' efforts to adequately train a family physician workforce prepared to provide cesarean sections could help maintain access to local obstetric services in rural communities and reduce perinatal morbidity and mortality.

Social Inequities Between Prenatal Patients in Family Medicine and Obstetrics and Gynecology with Similar Outcomes

INTRODUCTION

Family Medicine (FM) physicians play a vital role in caring for vulnerable populations across diverse practice settings. The significant decline in FM physicians performing deliveries compounds the estimated shortage of 9000 prenatal care providers expected by 2030.This study investigated the social risk profile, as characterized by social determinants of health, of patients receiving prenatal care from FM versus Obstetrics and Gynecology (OB/Gyn) providers.

METHODS

Retrospective chart review of patients receiving prenatal care between 2015 to 2018 at Penn State Health Hershey Medical Center comparing social determinants of health between FM and OB/Gyn.

RESULTS

A total of 487 patient charts were reviewed with final analysis completed on 215 charts from each cohort. When compared with OB/Gyn, prenatal patients cared for by FM were more likely to be younger (27 vs 29 years old; P < .0001), African American (28% vs 8%; P < .0001), single (52% vs 37%; P < .01), have high school or less education (67% vs 49%; P < .01), use Medicaid (46% vs 23%; P < .0001), and use tobacco during pregnancy (17% vs 8%; P < .01). In addition, FM patients had a lower rate of total Cesarean-sections (C-section), including primary and repeat, when compared with OB/Gyn (23% vs 32%; P = .04).

CONCLUSIONS

Our work demonstrates that when compared with OB/Gyn at our institution, FM physicians provide care to a cohort of patients with an increased burden of social risk without compromise to care as evidenced by a lower C-section rate and similar gestational age at delivery.

Uterine scar rupture at the site of the placenta accreta presenting as a case of sudden death

Uterine rupture during pregnancy is a known complication of placenta accreta. This paper presents a case of sudden maternal death in the 27^th week of gestation due to a ruptured uterine scar at the site of placenta accreta with a short inter-pregnancy period of 6 months with previous two C-sections. Autopsy findings revealed a massive hemoperitoneum and a thinned out anterolateral uterine wall. Internal examination revealed clotted and fluid blood in the peritoneal cavity with rupture of the anterior uterine wall at the site of the placenta accreta in a healed cesarean section scar. Placenta accreta is a rare complication of pregnancy. However, it is becoming more frequent and a significant risk factor with the increasing rate of C-section.

Is Primary Cesarean Section a Cause of Increasing Cesarean Section Rates in Greece?

INTRODUCTION

Cesarean Section is a surgical procedure which can be life saving and necessary in some circumstances. Nonetheless, Cesarean Delivery continues to result in increased complications for subsequent deliveries as well as increased financial costs. This phenomenon raises concerns over the growing rates of Cesarean deliveries among women at low risk for a complicated birth whose first delivery was by Cesarean Section for non-medical reasons.

AIM

The aim of this study was to determine whether PCS is a main factor in the overall percentage of CS in Greece and define the causes of elective and emergency cesarean sections in primary ones.

METHODS

From 365 cesarean deliveries during the research period, a sample of 162 women who underwent a primary cesarean section at a Greek University hospital has consented to participate. Medical and demographic data as well as data from women's medical dossier were used in the day 3 postpartum.

RESULTS

Out of 162 primiparous mothers, 38.9% underwent an emergency cesarean section and 61.1% an elective cesarean section. Furthermore, the results show that women, who had been diagnosed with stress disorders or depression, with abnormal fetal heart rate, pathological NST/Doppler and had developed complications after cesarean section, were more likely to undergo an emergency cesarean delivery.

CONCLUSION

This survey shows the lack of evidence-based guidelines in obstetrician's practice and the lack of perinatal support centers in Greece. Primary CS can be characterized as a key factor in the overall increase of CS, given the vicious cycle of recurrence of a Cesarean delivery.

Magnesium Sulfate and Clonidine; Effects on Hemodynamic Factors and Depth of General Anesthesia in Cesarean Section

Background

Making stable hemodynamic and also durable unawareness is a daily challenge in the setting of general anesthesia in women who undergo surgical delivery of neonate and have limitations to receive opioids derivatives.

Objectives

We aimed to evaluate the effects of magnesium sulfate and clonidine on hemodynamic changes and depth of anesthesia and in mentioned mothers and also in neonatal APGAR index.

Methods

Current randomized, double-blind controlled trial study was conducted among a total of 360 pregnant females (38 - 41 weeks of gestation) who underwent elective cesarean section. Participants were randomly divided into three drug-receiving groups (equal 120 members): magnesium sulfate (30 mg/kg), clonidine (3 µg/kg), and placebo (0.9% NaCl). Patients’ blood pressure, heart rate, cerebral state index (CSI) in specific time zones, and also late 24-hour recall were recorded. The CSI is an electroencephalographic monitoring method helping to assess the depth of anesthesia. Neonatal parameters, including APGAR score and umbilical venous blood sampling, were measured.

Results

Mean patients’ age was 28 ± 4.5. A significant decreasing and stabilizing effect of magnesium sulfate and clonidine on hemodynamic parameters (blood pressure and heart rate) was revealed (P < 0.001). Evidence implied on deeper anesthesia (lower CSI) among drug receivers comparing to placebo (P < 0.001). None of the participants experienced a late 24-hour recall postoperatively. All neonates were healthy, and no decrease was reported in APGAR score at minutes 1 and 5. Umbilical blood gas analysis showed no signs of acidosis and/or hypoxemia.

Conclusions

Adjuvant administration of either magnesium sulfate or clonidine is associated with hemodynamic stability and favorable unawareness in the setting of elective surgical delivery.

Effect of Sequential Compression Device on Hemodynamic Changes After Spinal Anesthesia for Caesarean Section: A Randomized Controlled Trial

Background

The benefit of sequential compression device (SCD) for the prevention of hypotension after spinal anesthesia in cesarean sections has not been determined.

Objectives

In this study, an attempt was made to determine whether SCD can prevent hemodynamic changes following spinal anesthesia for cesarean sections.

Methods

In a prospective clinical trial, 76 parturient women undergoing elective cesarean sections under spinal anesthesia were randomly divided into SCD or control groups. The maternal hemodynamic changes within 75 min after spinal anesthesia, nausea, vomiting, and neonatal Apgar score at 1 and 5 min were compared between the groups.

Results

There were no significant differences between the groups in the patients' characteristics, maximum sensory block, skin incision to delivery time, spinal anesthesia to delivery time (min), and the total duration of surgery. Concerning heart rate changes, RM ANOVA showed a significant difference in the effect of time, groups, and the interaction of the two factors (P < 0.0001, P < 0.0001, and P < 0.0001, respectively). Tukey post hoc test showed that 3 min after spinal anesthesia, diastolic blood pressure was significantly higher in the SCD group than in the control group (P < 0.05). The SCD group had meaningfully lower rates of nausea (P = 0.005) and vomiting (P = 0.001) than the control group. The SCD group also demonstrated a significantly lower mean ephedrine dosage per patient (4.1 mg against 17.1 mg, P = 0.001). However, no significant difference was observed between the groups in terms of neonatal Apgar scores at 1 and 5 minutes.

Conclusions

This study showed that SCD could reduce extensive changes in diastolic blood pressure as an important hemodynamic parameter and the incidence of nausea and vomiting. Thus, SCD can be used in spinal anesthesia care practices for elective cesarean sections.

Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial

OBJECTIVE

Examination of postoperative analgesia with intravenous and oral acetaminophen.

DESIGN

Prospective, three-arm, nonblinded, randomized clinical trial.

SETTING

A single academic medical center.

SUBJECTS

Parturients scheduled for elective cesarean delivery.

METHODS

This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects.

RESULTS

Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group.

CONCLUSIONS

Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.

Respiratory Distress Syndrome in Neonates Delivered at Term-gestation by Elective Cesarean Section at Tertiary Care Hospital in Oman

Objectives

We sought to assess the relationship between respiratory distress syndrome (RDS) in neonates delivered by elective cesarean section at term gestation with and without corticosteroids cover. We also aimed to determine other neonatal complications such as sepsis, hypoglycemia, and hyperbilirubinemia.

Methods

We conducted a retrospective descriptive study from January 2010 to December 2015 on all Omani women who delivered by elective cesarean section at Sultan Qaboos University Hospital between 37+0 and 38+6 weeks gestation.

Results

Among 650 patients included in the study, 20.8% (n = 135) received corticosteroids antenatally and 79.2% did not. RDS was found in 16 out of 650 neonates, making the prevalence of RDS 2.5%. Higher gravidity and parity and a mean gestational age of less than 37.6 weeks, were associated with a significant risk of RDS. Administration of antenatal corticosteroids did not change the respiratory morbidity in the newborns (p = 0.340). A mean birth weight of 2.9 kg was associated with a significant risk of RDS (p = 0.043). All 16 newborns required neonatal intensive care unit admission and ventilator support. The most common ventilatory support used was continuous positive airway pressure (56.2%). The most common secondary complication in neonates diagnosed with RDS was transient tachypnea of the newborn (53.8%).

Conclusions

The prevalence of RDS was low. Giving antenatal corticosteroids for patients with planned elective cesarean at term did not seem to have a beneficial effect on neonatal respiratory morbidity. Further studies with larger sample size including multiple centers is recommended.

Cesarean Section in a Pregnant Woman with COVID-19: First Case in Portugal

We report the first cesarean delivery in a woman with COVID-19 in a level III hospital in Portugal. It refers to a healthy woman with a term pregnancy that tested positive for COVID-19 on the day of labor induction. Given a Bishop score < 4 and the prior history of a cesarean section, the team decided to perform a surgical delivery. Appropriate personal protective equipment and safety circuits were employed, as described in more detail in the case report. Both the mother and the newborn are well. With this report we aimed to share our concerns, clinical management, maternal and neonatal outcomes, and to present our current circuits and adjustments regarding the COVID-19 pandemic in our maternity hospital.

Correction to the article "Cesarean Section in a Pregnant Woman with COVID-19: First Case in Portugal", published on Acta Med Port 2020 Jun;33(6):429-431

Article published with errors:https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/13883On page 430, section “Discussion”, line 5, where it reads: (...) given the conflicting data about pre and postnatal transmission,6,7 a multi-disciplinary team consensus comprising obstetricians, neonatologists and infectious diseases specialists at our institution decided on mother-neonate separation immediately after birth until both were tested negative for SARS-CoV-2.4It should read: (...) given the conflicting data about pre and postnatal transmission,6,7 after thoughtful discussion between a multidisciplinary team and the mother, and respecting her expressed will, a shared decision was made of mother infant separation immediately after birth until both were tested negative for SARS-CoV-2.4 Artigo publicado com erros:https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/13883Na página 430, secção “Discussão”, linha 6, onde se lê: (...) given the conflicting data about pre and postnatal transmission,6,7 a multi-disciplinary team consensus comprising obstetricians, neonatologists and infectious diseases specialists at our institution decided on mother-neonate separation immediately after birth until both were tested negative for SARS-CoV-2.4Deverá ler-se: (...) given the conflicting data about pre and postnatal transmission,6,7 after thoughtful discussion between a multidisciplinary team and the mother, and respecting her expressed will, a shared decision was made of mother infant separation immediately after birth until both were tested negative for SARS-CoV-2.4

Cesarean Section Beyond Cesar's Borders: A Mini Review on the Cultural History of Cesarean Section High Prevalence Rates in the Middle East

Cesarean section rates have risen significantly in some Middle Eastern countries like Iran, Turkey, and Egypt. Therefore, this review aims to investigate the cultural background for the high cesarean section rates in some Middle Eastern countries to provide the obstetricians and policymakers a better perspective on the crisis. Firstly, the dimensions of the current crisis in the Middle East are discussed. Then, three famous medieval authors are investigated; Ferdowsi (Shahnameh; the birth of Rostam, the Persian superhero, through the cesarean section), Abu Rayhan Biruni (The Remaining Signs of Past Centuries), and Ibn Abi al-Hadid. All these medieval sources try to teach how proud is the one who is born through a cesarean section, and thus a person born vaginally is of a lower rank and therefore less respected. Then, the influencing ancient resources dealing with this subject are reviewed: the birth of Asclepius, the Greek god of medicine, by his father Apollo through a section on the mother's corpse, and Talmud of the Jews. In ancient times, a birth through the cesarean section was a pure birth, or a gift from gods and restricted to divinities. Hoping to gain a new and comprehensive understanding of this current crisis in the Middle East, the World Health Organization (WHO) guidelines on reducing the prevalence of cesarean section are subsequently introduced. The C-section prevalence has increased significantly in the Middle East; comprehensive national, regional, and international policies are highly demanded.

Evaluation of the uterine scar stiffness in women with previous Cesarean section by ultrasound elastography: A cohort study

PURPOSE

To evaluate by means of elastography if the quantitative assessment of the cesarean scar elasticity is feasible using as reference the surrounding intact myometrium and to investigate if the cesarean scar stiffness is influenced by the clinical characteristics of the previous cesarean delivery.

METHODS

Prospective study including women with a previous Cesarean Section (CS) ≥ 37 weeks' gestation performed 12-15 months before. By transvaginal ultrasound two regions of interest (ROI) were selected: uterine scar (Region 1) and surrounding myometrium (Region 2). Strain index (SI) for each ROI was calculated and the Strain Ratio (SR) was defined as Region 1 SI/Region 2 SI. The primary outcome was to compare SR among women who were grouped in accordance to presence of previous vaginal delivery, CS during labor, type of suture or pyrexia during post-partum. The secondary outcome of this study was to evaluate the correlation between SR and maternal, neonatal and labor characteristics.

RESULTS

68 women were included. The mean SR was 1.8 ± 0.7 thus indicating an increased stiffness of the uterine scar compared to the surrounding myometrium. No significant differences were found in terms of SR according to presence of previous VD, CS during labor, type of suture or pyrexia during post-partum period. Strain Ratio was not correlated to maternal characteristics nor to labor and neonatal outcome.

CONCLUSIONS

Evaluation of uterine scar stiffness is feasible by using elastography. The stiffness of the uterine scar is higher than that of the surrounding myometrium and is not correlated to maternal and labor characteristics.

RISK OF NEONATAL HOSPITALIZATION ASSOCIATED TO DELIVERY BY CESAREAN SECTION IN A HIGH COMPLEXITY CLINIC IN BOGOTÁ, COLOMBIA, 2018

OBJECTIVE

To evaluate the association between cesarean delivery and hospitalization of the newborn and describe the indications for cesarean according to Robson's groups in the obstetrics service of a highly complex general institution.

METHODS

Cross-sectional study. All births occurred between March and July 2018 in a high complexity general teaching hospital in Bogotá, Colombia were included, by consecutive sampling up to a sample size of 1040 pregnant women. The frequency of caesarean section, indications, neonatal outcomes for each Robson group, and the risk of neonatal hospitalization are described using the crude and adjusted odds ratio (OR) using multivariate analysis.

RESULTS

1,493 births were included, of which 539 (36.3 %) were by cesarean section. Women with a history of uterine scar scheduled for elective caesarean section and those hospitalized for induction provide the majority of caesarean sections. The main indications for cesarean section were suspicion of unsatisfactory fetal status and prolongued labor. Adjusted for birth weight, caesarean section increased the overall risk of neonatal hospitalization (adjusted OR [aOR] = 2,2; IC 99 %: 1,3-3,7).

CONCLUSIONS

There are groups of Robson susceptible of intervention to decrease the rate of caesarean sections due to the suspicion of unsatisfactory fetal status and prolongation of labor. An association was found between cesarean delivery and subsequent neonatal hospitalization. Randomized controlled studies are required to determine the benefit of the strategies to reduce cesarean section rates and evaluate the association found.

The Effect of Intrathecal Meperidine on Maternal and Newborn Outcomes After Cesarean Section: A Systematic Review and Meta-Analysis Study

Context

Spinal anesthesia is the most preferred method for cesarean section. This meta-analysis was performed to determine the effect of minimum and maximum intrathecal doses of meperidine (pethidine) [5 to 40 mg] on the maternal and newborn outcomes after cesarean section.

Evidence Acquisition

The data were collected through the systematic search in the ISI, PubMed, Scopus, Google Scholar, Barakat, MagIran, SID, Irandoc, and EMBASE medical databases. Eighteen clinical trial studies with 1,494 patients were included.

Results

Patients who had received intrathecal meperidine had experienced lower shivering, relative risk [RR] = 0.34 (95% CI = 0.23, 0.48) and longer analgesia, [standard mean difference (SMD)] = 7.67 (95% CI = 1.85, 13.49) after the surgery. Moreover, RR of nausea = 1.37 (95% CI = 1.13, 1.66), vomiting RR = 2.02 (95% CI = 1.28, 3.20), and pruritus RR = 9.26 (95% CI = 4.17, 20.58) was higher in the pethidine group than in the control group. There was no statistically significant difference in the Apgar score at one-minute RR = 0.99 (95% CI = 0.9, 1.09), at five-minute RR = 0.93 (95% CI = 0.87, 1.08), maternal hypotension RR = 1.00 (95% CI = 0.87, 1.15), and maternal sensory and motor blockade durations, SMD = -1.72 (95% CI = -3.78.0.34) and SMD = -4.38 (95% CI = -9.19, 0.44), respectively in the two pethidine and control groups.

Conclusions

Intrathecal meperidine can reduce shivering and increase the duration of postoperative analgesia, though it increases the relative risk of nausea, vomiting, and pruritus. No significant difference was found both in the Apgar score, maternal hypotension, and duration of the motor and sensory block.

Improving Learners' Comfort With Cesarean Sections Through the Use of High-Fidelity, Low-Cost Simulation

INTRODUCTION

Several studies have demonstrated effective simulation-based training for laparoscopic procedures in OB/GYN, but limited simulation curricula exist for abdominal procedures, particularly cesarean sections (CSs).

METHODS

We developed a high-fidelity modification of an existing CS model costing about $25 and incorporated it into a 90-minute teaching simulation event for medical students and OB/GYN residents in a single academic program. The simulation included a structured curriculum, pre-/postsimulation surveys, a surgical instrument review, a mannequin with the CS model containing a fetus in breech position, and live video streaming. Our surveys assessed participants' comfort with the procedure and its related components on a 5-point scale, and we used a paired t test to analyze our data.

RESULTS

Twenty-two learners (eight third-year medical students, one fourth-year medical student, three first-year residents, four second-year residents, one third-year resident, four fourth-year residents, and one unknown level) participated in this simulation. We found a statistically significant improvement in perceived CS instrument knowledge, suturing skills, and satisfaction with the model among all participants. Only third-year medical students had a statistically significant increase in comfort level in performing a CS after the simulation. Video streaming engaged a wider audience, but poor lighting and audio limited its efficacy.

DISCUSSION

Using this simulation model at the end of medical school or early in residency may have the greatest positive effect on resident comfort with CSs. This low-cost and versatile model can be used across educational settings, including OB/GYN interest group activities, intern boot camp, and interprofessional emergency drills.

Effect of Low-Dose Intravenous Ketamine on Prevention of Headache After Spinal Anesthesia in Patients Undergoing Elective Cesarean Section: A Double-Blind Clinical Trial Study

Background

Spinal anesthesia is the most commonly used method for elective cesarean section, which is a popular technique due to its simplicity, reliability, and speed to achieve adequate anesthesia. Headache following dura perforation is the most important delayed complication following spinal and epidural anesthesia.

Objectives

To evaluate the impact of low-dose intravenous ketamine in patients undergoing cesarean section under spinal anesthesia on the prevention of dura perforation headache (PDPH).

Methods

This clinical trial study was performed on 64 pregnant women undergoing cesarean section at Vali-e-Asr Hospital. The patients were divided into two groups. In the case group, 0.15 mg/kg body weight ketamine was injected intravenously and in the control group, normal saline was used as the placebo. The incidence of headache and its severity at one, 4, 12, and 24 hours postoperatively, nausea and its severity were also measured and compared. Independent t-test, Mann-Whitney U and chi-square tests were used. A P value < 0.05 was considered statistically significant.

Results

The data revealed that low dose intravenous ketamine significantly decreased patients’ headaches (P = 0.001), the sensation of pruritus (P = 0.009), and the need for analgesic (P = 0.001). Furthermore, the sensation of postoperative nausea was less in the case group. The patients in the case and control groups had no significant difference in terms of hypertension or bradycardia (P = 0.717 and 0.939, respectively).

Conclusions

The injection of ketamine as a premedication in the cesarean section can reduce the severity of postoperative headache in mothers. Therefore, it is recommended to use ketamine as an anti-headache drug in pregnant women.

The Effect of Adding Low-Dose Naloxone to Intrathecal Morphine on Postoperative Pain and Morphine Related Side Effects after Cesarean Section: A Double-Blind, Randomized, Clinical Trial

BACKGROUND:

Nowadays, spinal anaesthesia is a suitable choice for most elective and emergency cesarean section (C-section) deliveries.

AIM:

This study aimed to determine the effect of adding low-dose naloxone to intrathecal morphine on postoperative pain and morphine related side effects after C-section.

MATERIAL AND METHODS:

In the present double-blind, randomised clinical trial, 70 women aged over 18 years, who were candidates for elective medical C-section under spinal anaesthesia were selected and randomly assigned to either the study group or the control group. For spinal anaesthesia, 10 mg of Bupivacaine plus 100 μg of morphine was administered for all patients. However, patients in the study group received 20 µg of naloxone intrathecally; but the patients in the control group only received normal saline as a placebo. After surgery, patient-controlled analgesia (PCA) pump with paracetamol (Apotel®) was connected to each patient. The intensity of postoperative pain in the patients was evaluated and recorded using Visual Acuity Screening (VAS) at 2, 4, 6 and 24 hours after the surgery. The patients were also examined for postoperative nausea and pruritus.

RESULTS:

Regardless of the groups to which the patients were assigned, a significant difference in pain intensity was observed during the study period (time effect; p < 0.001). Although the intensity of pain was lower in the study group, the difference was not statistically significant (group effect; p = 0.84). Also, there was no group time interaction between pain intensity and the times studied (p = 0.61). The incidence rates of postoperative nausea and pruritus were significantly lower in the study group compared to the control group (p < 0.001).

CONCLUSION:

According to the results of this study, adding low dose naloxone to intrathecal morphine did not significantly change postoperative pain intensity in the patients undergone elective C-section using spinal anaesthesia; however, significantly decreased the severity of postoperative nausea and pruritus.

Anatomical predicting factors of difficult spinal anesthesia in patients undergoing cesarean section: An observational study

Objectives:

Although Spinal anesthesia is the most common and safe anesthetic method for patients undergoing cesarean section, difficult access to it is a frequent problem in operating theaters. The predictive factors for the difficulty of spinal anesthesia in patients undergoing cesarean section were investigated.

Methods:

A total of 110 pregnant women, single-stranded, aged 18-40 years old and ASA class I or II candidates for elective cesarean section with spinal anesthesia were studied. Demographic information, body appearance, ability to bend the back of the patient was recoded. Also the position of the anatomical landmarks of the lumbar spine, the presence or absence of deformity in the spinal column lumbar was recorded for all patients.

Results:

The correlation coefficient of age, weight, body mass index, general body appearance, retention ability, anatomical signs of the spinal column (touching the spinous process) and the interval between the vertebra with the difficulty of spinal anesthesia were statistically significant (p<0.05). Complications after spinal anesthesia had a statistically significant relationship with the difficulty of performing spinal blockade (p: 0.006).

Conclusion:

Increasing age, weight, body mass index, reducing the ability to bend the waist, the non-touching of the spinous process and interstitial space causes the difficulty of performing spinal anesthesia in patients undergoing cesarean section. The results can contribute to determining and designing a spinal blockade scoring system based on the patient’s characteristics and effective factors before the surgery, to facilitate the technique by anesthesiologist.

Incidence and Risk Factors of Early Onset Neonatal AKI

BACKGROUND AND OBJECTIVES

Neonatal AKI is associated with poor short- and long-term outcomes. The objective of this study was to describe the risk factors and outcomes of neonatal AKI in the first postnatal week.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The international retrospective observational cohort study, Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), included neonates admitted to a neonatal intensive care unit who received at least 48 hours of intravenous fluids. Early AKI was defined by an increase in serum creatinine >0.3 mg/dl or urine output <1 ml/kg per hour on postnatal days 2-7, the neonatal modification of Kidney Disease: Improving Global Outcomes criteria. We assessed risk factors for AKI and associations of AKI with death and duration of hospitalization.

RESULTS

Twenty-one percent (449 of 2110) experienced early AKI. Early AKI was associated with higher risk of death (adjusted odds ratio, 2.8; 95% confidence interval, 1.7 to 4.7) and longer duration of hospitalization (parameter estimate: 7.3 days 95% confidence interval, 4.7 to 10.0), adjusting for neonatal and maternal factors along with medication exposures. Factors associated with a higher risk of AKI included: outborn delivery; resuscitation with epinephrine; admission diagnosis of hyperbilirubinemia, inborn errors of metabolism, or surgical need; frequent kidney function surveillance; and admission to a children's hospital. Those factors that were associated with a lower risk included multiple gestations, cesarean section, and exposures to antimicrobials, methylxanthines, diuretics, and vasopressors. Risk factors varied by gestational age strata.

CONCLUSIONS

AKI in the first postnatal week is common and associated with death and longer duration of hospitalization. The AWAKEN study demonstrates a number of specific risk factors that should serve as "red flags" for clinicians at the initiation of the neonatal intensive care unit course.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), NCT02443389.

[Ratio of transfer cesarean section after trial of labor and maternal-fetal adverse outcomes based on Robson classifications]

Objective: To investigate the ratio of transfer cesarean section after trial of labor and maternal-fetal outcomes based on Robson classifications. Methods: The delivery data by cesarean section in Third Affiliated Hospital of Guangzhou Medical University from January 1st, 2009 to December 31st, 2015 (gestational age ≥28 weeks and newborn birth weight >1 000 g) were retrospectively collected. The ratio of transfer cesarean section after trial of labor and maternal-fetal adverse outcomes were analyzed by weighted adverse outcome score in different Robson classifications. Results: (1) The highest ratio of transfer cesarean section after trial of labor was classification 9 (all abnormal lies, including previous cesarean section and breech were excluded) reached 47.31% (431/911) , followed by classification 2 (nulliparous women with a single cephalic pregnancy, ≥37 weeks gestation who had labour induced) accounted for 44.90%(409/911). (2)The tops of weighted adverse outcome score of transfer cesarean section after trial of labor were classification 10 (single cephalic pregnancy at <37 weeks gestation, including women with previous cesarean delivery) 24.55, classification 5 (single cephalic pregnancy multiparous women, with at least one previous cesarean delivery, ≥37weeks gestation) 3.64. Conclusion: Carefully evaluating the delivery mode and emphasizing the intrapartum management in nulliparous women with a single cephalic pregnancy, at ≥37 weeks gestation who had labour induced and trial of labor after cesarean section is essential to reduce the risk of adverse outcomes in transfer cesarean section after trial of labor.