Epidural ropivacaine versus bupivacaine for cesarean sections: a system review and meta-analysis

INTRODUCTION

It is still no consensus on the use of ropivacaine or bupivacaine in epidural anesthesia for cesarean section (CS), because their anesthetic potency and relative complications remains controversial. This system review and meta-analysis aimed to compare the efficacy of epidural ropivacaine and bupivacaine for elective CSs and investigate relative complications for parturients and neonates.

METHODS

We searched PubMed, MEDLINE, Embase, Cochrane Library, Science-Direct, and Google Scholar to June 30, 2023 for randomized controlled trials (RCTs), which compared epidural ropivacaine with bupivacaine for elective CSs. The success rate of epidural anesthesia (EA) was primary outcome. The secondary outcomes included onset times of sensory block, maternal side effects, neonatal Apgar scores and umbilical artery pH.

RESULTS

We analyzed 8 RCTs with 532 parturients. 0.75% ropivacaine is associated with a shorter onset time of sensory block than 0.5% bupivacaine (SMD = -0.43, 95% CI: -0.70 to -0.17; p = .001). 0.5% ropivacaine resulted in a reduced nausea than 0.5% bupivacaine (RR = 0.49, 95% CI: 0.28 to 0.83; p = .008). In addition, there were no significant difference between ropivacaine and bupivacaine groups in terms of success rate of epidural anesthesia, maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH.

CONCLUSIONS

The findings suggest that there were no significant difference between epidural ropivacaine and bupivacaine for elective CSs in terms of the success rate (85.9% vs. 83.5), maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH. But compared with 0.5% bupivacaine, epidural 0.75% ropivacaine was mildly effective for reducing onset time of sensory block and 0.5% ropivacaine reduced the incidence of maternal nausea.

Effect of Reflexology on Pain, Fatigue, Sleep Quality, and Lactation in Postpartum Primiparous Women After Cesarean Delivery: A Randomized Controlled Trial

BACKGROUND

Mothers commonly experience pain, fatigue, sleep disruption, and breastfeeding problems after cesarean delivery. To date, no follow-up study has examined all of these variables to evaluate the utility of reflexology in reducing these problems and supporting breastfeeding.

RESEARCH AIM

This study aimed to determine the effect of foot reflexology performed in the postpartum period on pain, fatigue, sleep quality, and lactation in primiparous women who underwent cesarean delivery.

METHODS

This is a two-arm, parallel-group randomized controlled trial. Data were collected between January 1, 2020, and January 31, 2021, with a sample of 80 women who were randomly assigned to the reflexology (n = 40) and control (n = 40) groups. The reflexology group received 40 minutes of foot reflexology once a week for 8 weeks. The primary outcomes of the study were pain, fatigue, sleep quality, and breastfeeding efficacy.

RESULTS

Pain scores in the reflexology group decreased by 90.9% in week 1, 90.2% in week 2, and 59.8% in week 3 compared to the control group. Pain resolved at week 4 in the reflexology group and week 7 in the control group. The reflexology group showed a 36.9% decrease in fatigue level, a 48.0% increase in energy level, a 70.7% increase in sleep quality, and a 20.2% increase in breastfeeding efficacy compared to the control group (p < 0.05).

CONCLUSIONS

Foot reflexology reduces postpartum symptoms and positively affects breastfeeding and can be used safely in postnatal care practices.

Neonatal and maternal outcomes at early vs. full term following induction of labor; A secondary analysis of the OBLIGE randomized trial

INTRODUCTION

Birth at early term (37+0-38+6 completed gestational weeks [GW] and additional days) is associated with adverse neonatal outcomes compared with waiting to ≥39 GW. Most studies report outcomes after elective cesarean section or a mix of all modes of births; it is unclear whether these adverse outcomes apply to early-term babies born after induction of labor (IOL). We aimed to determine, in women with a non-urgent induction indication (elective/planned >48 h in advance), if IOL at early and late term was associated with adverse neonatal and maternal outcomes compared with IOL at full term.

MATERIAL AND METHODS

An observational cohort study as a secondary analysis of a multicenter randomized controlled trial of 1087 New Zealand women with a planned IOL ≥37+0 GW. Multivariable logistic regression was used to analyze neonatal and maternal outcomes in relation to gestational age; 37+0-38+6 (early term), 39+0-40+6 (full term) and ≥41+0 (late term) GW. Neonatal outcome analyses were adjusted for sex, birthweight, mode of birth and induction indication, and maternal outcome analyses for parity, age, body mass index and induction method. The primary neonatal outcome was admission to neonatal intensive care unit (NICU) for >4 hours; the primary maternal outcome was cesarean section.

RESULTS

Among the 1087 participants, 266 had IOL at early term, 480 at full term, and 341 at late term. Babies born following IOL at early term had increased odds for NICU admission for >4 hours (adjusted odds ratio [aOR] 2.16, 95% confidence intervals (CI) 1.16-4.05), compared with full term. Women having IOL at early term had no difference in emergency cesarean rates but had an increased need for a second induction method (aOR 1.70, 95% CI 1.15-2.51) and spent 4 h longer from start of IOL to birth (Hodges-Lehmann estimator 4.10, 95% CI 1.33-6.95) compared with those with IOL at full term.

CONCLUSIONS

IOL for a non-urgent indication at early term was associated with adverse neonatal and maternal outcomes and no benefits compared with IOL at full term. These findings support international guidelines to avoid IOL before 39 GW unless there is an evidence-based indication for earlier planned birth and will help inform women and clinicians in their decision-making about timing of IOL.

Likelihood of primary cesarean section following induction of labor in singleton cephalic pregnancies at term, compared with expectant management: An Australian population-based, historical cohort study

INTRODUCTION

There has been increased use of both induction of labor (IOL) and cesarean section for women with term pregnancies in many high-income countries, and a trend toward birth at earlier gestational ages. Existing evidence regarding the association between IOL and cesarean section for term pregnancies is mixed and conflicting, and little evidence is available on the differential effect at each week of gestation, stratified by parity.

MATERIAL AND METHODS

To explore the association between IOL and primary cesarean section for singleton cephalic pregnancies at term, compared with two definitions of expectant management (first: at or beyond the week of gestation at birth following IOL; and secondary: only beyond the week of gestation at birth following IOL), we performed analyses of population-based historical cohort data on women who gave birth in one Australian state (Queensland), between July 1, 2012 and June 30, 2018. Women who gave birth before 37+0 or after 41+6 weeks of gestation, had stillbirths, no-labor, multiple births (twins or triplets), non-cephalic presentation at birth, a previous cesarean section, or missing data on included variables were excluded. Four sub-datasets were created for each week at birth (37-40). Unadjusted relative risk, adjusted relative risk using modified Poisson regression, and their 95% confidence intervals were calculated in each sub-dataset. Analyses were stratified by parity (nulliparas vs. parous women with a previous vaginal birth). Sensitivity analyses were conducted by limiting to women with low-risk pregnancies.

RESULTS

A total of 239 094 women were included in the analysis, 36.7% of whom gave birth following IOL. The likelihood of primary cesarean section following IOL in a Queensland population-based cohort was significantly higher at 38 and 39 weeks, compared with expectant management up to 41+6 weeks, for both nulliparas and paras with singleton cephalic pregnancies, regardless of risk status of pregnancy and definition of expectant management. No significant difference was found for nulliparas at 37 and 40 weeks; and for paras at 40 weeks.

CONCLUSIONS

Future studies are suggested to investigate further the association between IOL and other maternal and neonatal outcomes at each week of gestation in different maternal populations, before making any recommendation.

Comparative analysis of low-dose bupivacaine and ropivacaine combined with spinal-epidural anesthesia in cesarean sections for pregnant women with coexisting mental illness

OBJECTIVE

To analyze the application effects of low-dose bupivacaine and ropivacaine combined with epidural anesthesia.

METHODS

The primary outcome measure was the anesthesia effect, assessed by the excellent anesthesia rate. Secondary outcomes included the occurrence of adverse reactions, blood pressure, and serum prolactin levels at different time points. The anesthesia effect, serum prolactin levels, occurrence of adverse reactions, and MAP at various time points [before anesthesia (T0), 5 min after anesthesia (T1), at the start of surgery (T2), at delivery of the fetus (T3), and at closure of the abdomen (T4)] were compared between the two groups.

RESULTS

① Anesthesia effect: The excellent anesthesia rate was 71.88% in the control group and 93.94% in the observation group, with a significantly higher rate in the observation group than in the control group (p = 0.017). ② Serum prolactin levels: The serum prolactin levels in both groups increased significantly after surgery compared to before surgery (p < 0.001); however, there was no statistically significant difference in serum prolactin levels between the two groups before and after surgery (p = 0.651). ③ Occurrence of adverse reactions: The occurrence rate of adverse reactions was 28.13% in the control group and 9.09% in the observation group, with a significantly lower rate in the observation group than in the control group (p = 0.048).

CONCLUSION

In cesarean sections for pregnant women with coexisting mental illness, low-dose ropivacaine demonstrates significantly better anesthesia efficacy, blood pressure stability, and anesthesia safety compared to low-dose bupivacaine. Both low-dose bupivacaine and ropivacaine result in increased prolactin levels postpartum.

Natural childbirth and cesarean section - descriptive analysis of queries in Google search engine

OBJECTIVES

The use of internet-based search engines for health information is very popular and common. The Internet has become an important source of health information and has a considerable impact on patient's decision making process. Knowledge of pregnant women about childbirth comes from health professionals and personal experiences described by friends or family members. There is a growing interest in digital sources used by pregnant women. Analysis of queries related to regarding to natural childbirth and cesarean section in the Google search engine.

MATERIAL AND METHODS

In this infodemiology, descriptive study tool "AlsoAsked" was used. This is a tool for analyzing data appearing in Google search results. "AlsoAsked" search was conducted on April 19, 2023. Search phrases "natural childbirth" and "cesarean section" in polish language were used. Questions that were typed into the Google search engine, ranked according to popularity (volume) and thematic connections have been discussed.

RESULTS

The most frequently asked questions were related to the course and duration of labor as well as the preparation for labor and cesarean section (CS). Comparison between a natural labour and CS in the context of safety and pain received a great deal of attention.

CONCLUSIONS

The most popular questions regarding CS were related to elective CS and indications for it. Some questions concerned the connection between labor and clinical state of a newborn.

Transversus Abdominis Plane Block versus Epidural Anesthesia for Pain Management Post-Caesarean Delivery: A Pilot Study

Background

Effective post-operative analgesia profoundly influences patient recovery and outcomes after caesarean delivery. The Transversus Abdominis Plane (TAP) block represents a potential alternative, potentially offering greater effectiveness than epidural analgesia while causing fewer adverse effects.

Objective

To assess if the abdominal transverse block provides superior postoperative pain relief in patients undergoing caesarean delivery compared to epidural analgesia.

Methods

Participants were divided into parallel groups: an experimental group receiving TAP block (n=25) and a control group receiving epidural analgesia (n=24). All patients received a 10 mg dose of hyoscine at the end of the surgery. Experimental Group received a total of 20 mL of 0.2% ropivacaine. In Epidural group received 0.2% ropivacaine at 4 mL/h for 24 hours. All participants were administered combined with neuroaxial block anesthesia. The patients selected for epidural analgesia received the mentioned dose, while the other group block had the epidural catheter removed after the cesarean section. The primary outcome was post-caesarean pain, evaluated using the Visual Analog Scale (VAS) at four intervals (0, 6, 12, and 24 hours). Also, surgical bleeding and residual motor were evaluated. VAS pain scores between the groups were compared using the Friedman test and Generalized Linear Model (GLM) for non-normally distributed data. The effect size was estimated with Eta Square ([Formula: see text]), considering values ≥0.38 as indicative of large effects. A two-tailed p-value < 0.05 was deemed statistically significant.

Results

Statistically significant differences in pain scores were noted at 0 and 6 hours post-surgery (p<0.01). The TAP block group reported lower pain scores at 0 hours (mean=0.04) and 6 hours (mean=1.16) compared to the epidural group, reflecting a substantial effect size.

Conclusion

The TAP block proves advantageous in mitigating postoperative pain for women post-caesarean delivery, particularly in the initial 6 postpartum hours. This relief promotes early mother-infant bonding and facilitates breastfeeding.

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Application of quality control circle in the management of early ambulation after cesarean section: An observational study

BACKGROUND

The quality control circle (QCC) model has achieved good results in clinical applications in many hospitals in China and has gained popularity. This study aims to explore the application of QCC activities on early ambulation after cesarean section.

METHODS

A QCC management group was established following standardized methods and techniques. The theme of the group was identified as "to enhance the implementation rate of the patient early ambulation after the cesarean section" through a matrix graph. The early ambulation rates after surgery of patients who received cesarean section were compared before and after QCC managements.

RESULTS

Our data suggested that the early ambulation rates after cesarean section increased from 37.5% to 81.25% after applying QCC management. The biggest factor influencing the ambulation activities 24 ± 4 hours after the surgery was patients and family members do not cooperate. In addition, outstanding improvements in terms of nurses' sense of responsibility and self-confidence, communication and teamwork capacity in the problem-solving process were observed after the establishment of QCC.

CONCLUSION

The application of QCC management had not only increase the early ambulation rates after cesarean section but also improved the quality of nursery care in general.

Infant Infections Following Cesarean Delivery on Maternal Request: A Population-Based Cohort Study

OBJECTIVES

Investigations about cesarean delivery (CD) on maternal request (CDMR) and infant infection risk frequently rely on administrative data with poorly defined indications for CD. We sought to determine the association between CDMR and infant infection using an intent-to-treat approach.

METHODS

This was a population-based cohort study of low-risk singleton pregnancies with a term livebirth in Ontario, Canada between April 2012 and March 2018. Subjects with prior CD were excluded. Outcomes included upper and lower respiratory tract infections, gastrointestinal infections, otitis media, and a composite of these 4. Relative risks (RR) and 95% confidence intervals (CI) were calculated for component and composite outcomes up to 1 year following planned CDMR versus planned vaginal deliveries (VD). Sub-group and sensitivity analyses included age at infection (≤28 vs. >28 days), type of care (ambulatory vs. hospitalization), restricting the cohort to nulliparous pregnancies, and including individuals with previous CD. Last, we re-examined outcome risk on an as-treated basis (actual CD vs. actual VD).

RESULTS

Of 422 134 pregnancies, 0.4% (1827) resulted in a planned CDMR. After adjusting for covariates, planned CDMR was not associated with a risk of composite infant infections (aRR 1.02, 95% CI 0.92-1.11). Findings for component infection outcomes, sub-group, and sensitivity analyses were similar. However, the as-treated analysis of the role of delivery mode on infant risk for infection demonstrated that actual CD (planned and unplanned) was associated with an increased risk for infant infections compared to actual VD.

CONCLUSIONS

Planned CDMR is not associated with increased risk for neonatal or infant infections compared with planned VD. Study design must be carefully considered when investigating the impact of CDMR on infant infection outcomes.

Risk factors for placenta accreta spectrum without prior cesarean section: A case-control study in China

OBJECTIVE

To identify the risk factors for placenta accreta spectrum (PAS) disorders in women without prior cesarean section (CS).

METHODS

This retrospective case-control study investigated patients without prior CS who gave birth at Peking University Third Hospital between January 1, 2015 and December 31, 2021. Patients diagnosed with PAS according to the clinical diagnostic criteria of the 2019 International Federation of Gynecology and Obstetrics (FIGO) classification were included as the study group. Patients were matched as the control group according to delivery date and placenta previa, in a 1:2 allocation ratio. Maternal characteristics were compared between the two groups.

RESULTS

The study included 348 patients in the study group and 696 in the control group. The multivariate analysis showed that the independent risk factors of PAS consisted of operative hysteroscopy (once: adjusted odds ratio [aOR] 2.38, 95% CI 1.28-4.24, P = 0.006; twice or more: aOR 5.43, 95% CI 1.04-28.32, P = 0.045), uterine curettage (once: aOR 2.54, 95% CI 1.80-3.58, P < 0.001; twice: aOR 3.01, 95% CI 1.81-5.02, P < 0.001; three or more times: aOR 9.18, 95% CI 4.64-18.18, P < 0.001), multifetal pregnancy (aOR 5.64, 95% CI 3.01-10.57, P < 0.001), adenomyosis (aOR 2.77, 95% CI 1.23-6.22, P = 0.014), in vitro fertilization (aOR 1.51, 95% CI 1.04-2.20, P = 0.030) and pre-eclampsia (aOR 2.72, 95% CI 1.36-5.45, P = 0.005), and the independent protective factor was being multiparous (aOR 0.37, 95% CI 0.25-0.54, P < 0.001).

CONCLUSION

After controlling the effect of placenta previa, we found that patients with PAS without prior CS had unique maternal characteristics. Classification and quantification of the intrauterine surgeries they have undergone is essential for identifying high-risk patients. Early identification of high-risk groups by risk factors has the potential to improve the prognosis considerably.

Undiagnosed Uterine Didelphys in a Multiparous Somali Woman with Two Previous Cesarean Sections

Background

Uterine didelphys (UD) develops from failure of fusion of the paired Müllerian ducts, resulting in two noncommunicating uteri. We present a 31-year-old pregnant woman whose UD anomaly had not been detected during two previous cesarean sections and her presentation to a health-care clinic for her fifth pregnancy.

Case Presentation

She was referred to our obstetrics clinic due to suspicion of abdominal pregnancy and a complaint of severe lower abdominal pain. On ultrasonography, UD was detected with two adjacent uteri, one of which was empty and the other with a fetus of approximately 1100 g at 28 weeks and 1 day of gestational age. Magnetic resonance imaging confirmed the presence of UD. Due to severe lower abdominal pain of the patient and severe oligohydramnios of the fetus, emergency cesarean section was performed, and a 980 g male baby was delivered.

Conclusion

This case exemplifies how difficult life is for women living in an underdeveloped and resource-limited country like Somalia.

Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section

Uterine rupture is a rupture of the body or lower part of the uterus during pregnancy or delivery. Total of 98 cases with incomplete uterine rupture were classified as the incomplete uterine rupture group, 100 cases with a history of cesarean delivery without uterine rupture were classified as the non-ruptured uterus group, and controls were selected using a systematic sampling method. The maternal age ≥35 years were associated with 2.18 times higher odds of having an incomplete uterine rupture. The odd of having an incomplete uterine rupture was 3.744 times higher for a woman with delivery interval ≤36 months. Having pregnancy complication was associated with 3.961 times higher odds of having an incomplete uterine rupture. The neonatal weight was lighter in the incomplete uterine rupture group (P = 0.007). The number of preterm birth and transfer to the NICU were higher in the incomplete uterine rupture group (P ＜ 0.01). The operation time and the length of time in hospital were longer in the group with incomplete uterine rupture (P ＜ 0.01). Age ≥35 years, delivery interval ≤36 month, and pregnancy with complication were independent risk factors of incomplete rupture of the uterus secondary to previous cesarean section.

Acute colonic pseudo-obstruction post-cesarean section is not a benign entity: A case series and review of the literature

Acute colonic pseudo-obstruction (ACPO) is an infrequent occurrence after cesarean section. Anecdotal evidence suggests that the clinical course of ACPO in the obstetric setting is different to that seen in non-pregnant adult patients with ACPO secondary to alternative causes, such as systemic illnesses, the use of certain medications, and after non-abdominal surgery. The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section. Here we describe the clinical course of ACPO in four patients after cesarean section from our institution, followed by a review of the literature and a discussion of the important issues surrounding this condition in the postpartum time period. The findings from our cohort of patients and the reports from the medical literature support a hands-on combined approach from a group of specialists including obstetricians, surgeons, radiologists, and enterostomal therapists. Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively. Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach. Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with ACPO mandate immediate surgical intervention. Appropriate postoperative care is necessary to deal with the complex physiological and psychological consequences of emergency surgery and potential stoma formation so soon after cesarean section.

Maternal and perinatal outcomes in women aged 42 years or older

OBJECTIVE

To describe maternal and fetal outcomes of pregnancies after 42 years and to compare maternal and fetal morbidities according to the conception mode; comparing pregnancies obtained spontaneously and those resulting from assisted reproductive technology (ART).

METHODS

This retrospective cohort study was conducted in a level 3 maternity hospital. This study covered all women, aged 42 years or older, who gave birth between January 1, 2014 and December 31, 2019. Univariate and multivariate analyses with logistic regression models were used to compare maternal and perinatal outcomes depending on conception mode: spontaneous or using ART.

RESULTS

A sample of 532 women, including 335 spontaneous pregnancies (63%) and 147 pregnancies after ART (27.6%) were studied. Conception mode was missing for 50 (9.4%). We found increased rates not only of maternal complications such as maternal overweight and obesity, pre-eclampsia, and gestational diabetes, but also of interventions such as hospitalization during pregnancy, cesarean section, postpartum hemorrhage, and perinatal outcome like preterm birth. There were also more maternal and perinatal negative outcomes among the ART group. After multivariate analysis, pre-eclampsia was predominant in the ART group (odds ratio 0.25, 95% confidence interval 0.07-0.85, P = 0.02).

CONCLUSION

While maternal and fetal risks increase for late pregnancies, there also appears to be a difference depending on the conception mode, with pregnancies resulting from ART having more pregnancy-related complications than those obtained spontaneously.

Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review

BACKGROUND

Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs).

OBJECTIVES

To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature.

SEARCH STRATEGY

The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS.

SELECTION CRITERIA

English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework.

MAIN RESULTS

Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels.

CONCLUSIONS

There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.

Variation in Breastfeeding Initiation and Duration by Mode of Childbirth: A Prospective, Population-Based Study

Introduction: Despite known benefits of breastfeeding, including prevention against infections for infants, in the presence of numerous barriers, less than half of infants in high-income countries breastfeed for 6 months. One potential barrier to breastfeeding is birth by cesarean section (C-Section), which can invoke long-term difficulties. However, our structured literature review found that existing empirical research does not fully elucidate this relationship due to differences in operationalization of C-section and breastfeeding, omission of important confounders, and failure to exclude those who did not initiate breastfeeding (or use time-to-event analyses). In this article, we attempt to overcome these limitations. Methods: We analyzed data from 14,414 mother-infant dyads enrolled in the United Kingdom-based prospective Millennium Cohort Study, beginning in 2001. Using multivariable logistic regression, we examined the association between mode of birth (vaginal, emergency C-section, and elective C-section) and likelihood of breastfeeding initiation. We then applied adjusted Accelerated Failure Time survival models to examine the associations between mode of birth and duration of any and exclusive breastfeeding. Results: Those with planned (but not emergency) C-section were less likely to initiate breastfeeding (odds ratio: 0.84, 95% confidence interval [CI]: 0.71-0.99) relative to vaginal births. However, those with either planned or unplanned C-section discontinued both any and exclusive breastfeeding sooner than vaginal births. This effect was more pronounced for those with planned C-section (time ratio [TR]: 0.75, 95% CI: 0.64-0.89) than unplanned C-section (TR: 0.85, 95% CI: 0.74, 0.97) compared with vaginal births. Conclusions: Through application of rigorous methods, this study provides compelling evidence that breastfeeding duration may be impeded by C-section birth. The findings suggest that additional support for mothers who intend to breastfeed and have a C-section birth may be warranted.

Reproductive outcomes after in vitro fertilization in women with cesarean section scar diverticulum: A retrospective study

PURPOSE

Some studies have suggested that cesarean section diverticulum may affect the pregnancy outcomes of assisted reproductive technology through a variety of mechanisms. This study aims to explore whether previous cesarean section and uterine scar diverticulum affect pregnancy outcomes after in vitro fertilization.

METHODS

This retrospective study included 954 infertile women with only one previous delivery who had in vitro fertilization treatment and underwent fresh embryo transplantation for the first time at our center between 2015 and 2019. We first divided the women into two groups by previous vaginal delivery (n = 557) or cesarean section delivery (n = 397), and the latter group included 88 women with cesarean diverticulum and 309 women without cesarean diverticulum. Baseline characteristics were compared and analyzed, and logistic regression analyses were performed to explore the different pregnancy outcomes among the above groups.

RESULTS

Although the live birth rate, clinical pregnancy rate, and mean embryo implantation rate after in vitro fertilization were significantly reduced in patients with previous cesarean section (live birth rate: 26.45% vs. 43.99%, adjusted OR: 0.602, CI: 0.447-0.810; clinical pregnancy rate: 35.26% vs. 49.91%, adjusted OR: 0.724, CI: 0.544-0.962; mean embryo implantation rate: 0.227 ± 0.378 vs. 0.243 ± 0.397, adjusted OR: 0.860, CI: 0.514-1.439), there were no significant differences in pregnancy outcomes between the women with cesarean diverticulum and without cesarean diverticulum (p > 0.05) or between the two groups at different ages. The live birth and clinical pregnancy rates in the women with residual muscle thickness ≤2.2 mm or prolonged menstruation were reduced, but the difference was not statistically significant (p > 0.05).

CONCLUSION

This study showed reduced pregnancy and live birth rates after in vitro fertilization in patients with previous cesarean section, while uterine scarring did not adversely affect pregnancy and delivery outcomes after in vitro fertiliazation.

Is Appendectomy During Late Stages of Pregnancy Associated with an Increased Cesarean Delivery Rate? - a Retrospective Analysis of One Center During 10 Years

Introduction

About one in 500 pregnant women requires a surgical intervention that is not pregnancy-related. One of the most common surgical interventions during pregnancy is appendectomy. The primary aim of this study was to assess surgical access of appendectomy during pregnancy and pregnancy outcome. Secondary outcomes were clinical symptoms and diagnostics as well as histopathological analysis.

Methods and Material

This is a single-center retrospective data analysis conducted at a tertiary perinatal center. A digital search of the hospital record archive was conducted focusing on pregnant women beyond 24 0/7 weeks of pregnancy encoding appendectomy. Descriptive statistical analysis was performed.

Results

Between January 2013 and January 2023, a total of 20 appendectomies were performed during pregnancy with gestational age beyond 24 0/7 weeks of pregnancy. All of them were performed as lower midline laparotomy. The rate of appendix perforation was 3/20 (15.0%). 19/20 patients (95.0%) delivered via cesarean. In 7/20 patients (35.0%) appendectomy was performed during cesarean delivery due to incidental finding of irritated or abnormal vermiform appendix. In the pathological work-up, only 2/7 (28.6%) of these subjects had inflammation.

Conclusion

In this small monocentric cohort, only open appendectomies were performed. Our data indicate that it is safe to perform open appendectomy during pregnancy if necessary. In this small patient group, there was an increase in simultaneous cesarean deliveries.

Risk of uterine rupture in multiparous women after induction of labor with prostaglandin: A national population-based cohort study

OBJECTIVE

To assess whether, after induction of labor with prostaglandin, multiparous (≥2 para) women have an increased risk of uterine rupture compared with nulliparous or uniparous women.

METHODS

This was a retrospective population-based cohort study including women who underwent induction with prostaglandin in all maternity wards in Sweden between May 1996 and December 2019 (n = 56 784). The study cohort was obtained by using data from the Swedish Medical Birth Register, which contains information from maternity and delivery records. The main outcome measure was uterine rupture.

RESULTS

Overall, multiparous women induced with prostaglandin had an increased risk of uterine rupture compared with nulliparous women (adjusted odds ratio [OR], 3.33 [95% confidence interval (CI), 1.38-8.04]; P < 0.007). Multiparous women with no previous cesarean section (CS) induced with prostaglandin had more than three times higher risk of uterine rupture (crude OR, 3.55 [95% Cl, 1.48-8.53]; P = 0.005) compared with nulliparous women and four times higher risk compared with uniparous women (OR, 4.10 [95% CI, 1.12-15.00]; P < 0.033). Multiparous women with previous CS had a decreased risk of uterine rupture compared with uniparous women with one previous CS (crude OR, 0.41 [95% Cl, 0.21-0.78]; P = 0.007).

CONCLUSION

Our study implies that multiparity in women with no previous CS is a risk factor for uterine rupture when induced with prostaglandin. This should be taken into consideration when deciding on the appropriate method of induction.

Influence of ovarian torsion on reproductive outcomes and mode of delivery

Purpose

To investigate differences in reproductive outcomes among patients before and following ovarian torsion.

Study design

In this retrospective cohort study, we investigated the reproductive outcomes of patients who underwent surgery for ovarian torsion between 1988 and 2015 in a tertiary medical center. Data on deliveries before and after ovarian torsion were compared.

Results

During the study period, 199 women underwent surgery due to ovarian torsion. The majority (91.4%; n = 182) underwent detorsion, and 8.6% (n = 17) underwent unilateral adnexectomy. At the time of the torsion, 27.6% (n = 55) of patients were pregnant. Among women who suffered from ovarian torsion, about half (52%) of the deliveries occurred before the torsion and 48% following the torsion. No significant difference in the live birth rate was noted (p = 0.19). The fertility treatment rate in our cohort was 7.5% before and 5% after the torsion (p = 0.01). In addition, live birth, cesarean delivery, and fertility treatment rates were similar in women who underwent detorsion vs. those who had adnexectomy.

Conclusion

Surgically treated ovarian torsion does not appear to negatively influence fertility and live birth potential.

Impact of anthro-metabolic indices and gestational weight gain on maternal and neonatal outcomes: a prospective observational study

OBJECTIVE

The aim of this study was to examine the relationship of anthro-metabolic indices on maternal and neonatal outcomes.

METHODS

This prospective observational study was conducted on healthy mother-baby pairs between January 1, 2023 and July 1, 2023. Detailed sociodemographic information was collected through an interview with the mother. Clinical, biochemical, obstetric, fetal, and neonatal outcomes were abstracted from hospital medical records. Anthropometric measurements were obtained from the examination of mother-baby pairs.

RESULTS

A total of 336 healthy mothers-children pairs were included. Mothers of newborn ≥4000 g had higher gestational age (p=0.003), body mass index (p=0.003), gestational weight gain (p=0.016), waist circumferences (p=0.002), and hip circumferences (p=0.001). gestational weight gain was associated with the mode of delivery (p=0.023). waist-to-hip ratio (p=0.005), gestational weight gain (p=0.013), and a body shape ındex (p<0.001) were associated with longer length of hospital stay. Age (p<0.001) and inter-pregnancy interval (p=0.004) were higher in pre-pregnancy underweight/obese mothers. Receiver operating characteristic analysis revealed that maternal waist circumferences (AUC: 0.708, p=0.005), maternal weight (AUC: 0.690, p=0.010), and hip circumferences (AUC: 0.680, p=0.015) were sufficient to predict macrosomia (p<0.05).

CONCLUSION

The study demonstrated a significant association between gestational weight gain and cesarean delivery, prolonged hospital stay, and macrosomia. It was also found that maternal body mass index, waist circumferences, and hip circumferences during pregnancy were associated with macrosomia. On the contrary, no significant relationship was found between maternal anthro-metabolic characteristics and maternal-fetal and birth outcomes.

The impact of general anesthesia on the outcomes of preterm infants with gestational age less than 32 weeks delivered via cesarean section

Background

Recent advancements in China's perinatal and neonatal intensive care have significantly reduced neonatal mortality, yet preterm births before 32 weeks remain the primary cause of neonatal fatalities and contribute to long-term disabilities. The prognosis of very preterm infants (VPIs) is significantly affected by factors including the intrauterine environment, delivery method and neonatal intensive care. Cesarean section which often used for preterm births has implications that are not fully understood, particularly concerning the type of anesthesia used. This study examines the impact of general anesthesia (GA) during cesarean delivery on VPI outcomes, aiming to identify strategies for mitigating GA-associated risks.

Methods

This cohort study analyzed 1,029 VPIs born via cesarean section under 32 weeks' gestation at our single-center from 1 January 2018, to 31 December 2022. Detailed medical records, encompassing perioperative information, maternal data and neonatal outcomes were meticulously examined. The primary aim of this investigation was to compare maternal characteristics and neonatal outcomes between VPIs delivered under GA and neuraxial anesthesia (NA). A significance level of p < 0.05 was established.

Results

Of the 1,029 VPIs analyzed, 87.95% (n = 905) were delivered via NA and 12.05% (n = 124) via GA. Mothers with hypertensive pregnancy diseases and emergency operations were more inclined to choose GA. VPIs delivered under GA showed a lower Apgar score at one and 5 minutes (p < 0.01), increased need for tracheal intubation resuscitation (32.2% vs. 12.2%, p < 0.01) and a greater incidence of severe neurological injury (SNI) (14.5% vs. 5%, p < 0.01). Multivariable analysis revealed GA was significantly associated with lower Apgar scores at one (OR 6.321, 95% CI 3.729-10.714; p < 0.01) and 5 minutes (OR 4.535, 95% CI 2.975-6.913; p < 0.01), higher risk of tracheal intubation resuscitation (OR = 3.133, 95% CI = 1.939-5.061; p < 0.01) and SNI (OR = 3.019, 95% CI = 1.615-5.643; p < 0.01). Furthermore, for VPIs delivered under GA, a prolonged interval from skin incision to fetus delivery was associated with a lower 5-min Apgar score (p < 0.01).

Conclusion

This study revealed the significant impact of GA on adverse outcomes among VPIs. In cases when GA is required, proactive measures should be instituted for the care of VPIs such as expediting the interval from skin incision to fetal delivery.

Cesarean Delivery Complicated by Peripartum Infection and Risk of Uterine Rupture During Subsequent Trial of Labor

Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery.

Acute Bowel Obstruction Due to Transmural Migration of Gossypiboma: A Case Report

gossypiboma is used to describe a retained surgical swab in the body after an operation. It remains an unwanted complication of surgical practice that increase morbidity and mortality of the patient and profound medico legal problems. Intra-abdominal gossypiboma can migrate in to the ileum, stomach, colon or bladder without any apparent opening in the wall of these luminal organs. Vigilant sponge counting during procedures and thorough exploration prior to closure of the abdomen, are essential practices to avoid such occurrences. Herein we present a case of gossypiboma in a 26-year old woman that was in the lumen of small bowel and caused acute intestinal obstruction.

Natural history and clinical features of hepatitis C virus infection during childhood: A nationwide, observational survey in Japan

AIM

Few data on spontaneous clearance rates of cases of mother-to-child transmission of hepatitis C viral (HCV) infection are available in Japan. Furthermore, the treatment courses of interferon-based and direct-acting antiviral agent (DAA) therapies for children are also unclear. Our aim was thus to clarify the long-term natural progression of HCV infection and the treatment outcomes of children in Japan.

METHODS

We conducted a combined multicenter, observational survey involving 65 pediatric institutions in Japan. Pediatric HCV infection cases with patients born between 1973 and 2021 were collected over the 11-year period from 2012 to 2022. A total of 563 patients were enrolled, with 190 excluded for having insufficient laboratory data or treatment information, resulting in 373 eligible cases.

RESULTS

Of 328 cases of mother-to-child infection, 34 (10.4%) had spontaneous clearance, with a median time to spontaneous clearance of 3.1 years (range 0.9-7.2 years). Of the total 373 eligible cases, 190 received antiviral therapy (interferon-based therapy, 158; DAA therapy, 32). Sustained virologic response rates after first-line treatment were 75.3% (119/158) and 100% (32/32) for interferon-based therapy and DAA therapy, respectively, with the DAA group showing a shorter time from therapy initiation to viral negativity (2.7 vs. 1.0 months; p = 0.0031).

CONCLUSIONS

Approximately 10% of Japanese children infected by mother-to-child transmission achieve spontaneous resolution of HCV infection. Our findings indicate that DAA therapy is safe and highly effective in Japanese children, achieving higher sustained virologic response rates and shorter time to clearance of the virus compared with interferon-based therapy.

Resource setting impacts neonatal but not maternal survival in bitches treated for dystocia: 243 cases (2015-2020)

OBJECTIVE

To compare maternal and fetal outcomes of dystocia managed surgically and nonsurgically at referral hospitals (RHs) versus community medicine clinics (CMCs), determine the rate of C-section, and evaluate the incidence of hypoglycemia and hypocalcemia in bitches presented with dystocia.

ANIMALS

Bitches presented with dystocia at 2 RHs and 2 CMCs.

METHODS

Information on signalment, presence of hypoglycemia and/or hypocalcemia, diagnostic imaging performed, nonsurgical and surgical interventions performed, maternal and fetal outcomes, and total cost of care was obtained from the electronic medical records of bitches presenting for dystocia between October 2015 and October 2020. Descriptive statistics were performed and outcome compared between RHs and CMCs using a Fisher exact test, with a P < .05 considered significant.

RESULTS

230 bitches were evaluated with 243 separate episodes of dystocia, with 183 (75%) episodes treated at an RH and 60 (25%) at a CMC. There was a low incidence of hypoglycemia (5% [9/178]) and ionized hypocalcemia (1% [2/164]). Seventy-three percent (177/243) of bitches underwent surgical intervention, 25% (61/243) received nonsurgical management, and 2% (5/243) transferred to their primary veterinarian. There was no difference in survival for bitches operated at an RH compared with a CMC. However, bitches operated at an RH were more likely (P = .04) to be discharged with at least 1 live neonate.

CLINICAL RELEVANCE

In bitches diagnosed with dystocia, hypoglycemia and hypocalcemia were rare. The majority of bitches underwent a C-section. The setting where the C-section was performed did not impact maternal survival.

Efficacy of Bakri Intrauterine Balloon in Managing Postpartum Hemorrhage: A Comparative Analysis of Vaginal and Cesarean Deliveries with Placenta Accreta Spectrum Disorders

BACKGROUND The incidence of placenta accreta spectrum disorder (PAS) has been increasing in past decades, and women with PAS are a high-risk maternal population. This study aimed to explore the performance of Bakri intrauterine balloon tamponade (IUBT) in the treatment of postpartum hemorrhage (PPH), among those with and without PAS. MATERIAL AND METHODS The outcomes of 198 women who underwent treatment for PPH using IUBT were retrospectively analyzed. The demographics and maternal outcomes were analyzed for vaginal and cesarean births, with PAS and without PAS. RESULTS Compared to women with vaginal births (n=130), women who underwent cesarean births (n=68) showed a higher proportion of age ≥35 years (χ²=6.85, P=0.013), multiple births (χ²=13.60, P<0.001), preeclampsia (χ²=9.81, P=0.002), use of transabdominal IUBT (χ²=84.12, P<0.001) and pre-IUBT interventions (χ²=41.61, P<0.001), but had less infused volume of physiological saline (t=6.41, P<0.001). Women with PAS (n=105) showed a higher rate of pre-IUBT intervention (χ²=4.96, P=0.029) and transabdominal IUBT placement (χ²=9.37, P=0.002) than non-PAS women (n=93). The 36 women with PAS (n=36) showed a higher rate of preeclampsia (χ²=4.80, P=0.029), pre-IUBT intervention (χ²=5.90, P=0.015), and transabdominal IUBT placement (χ²=14.94, P<0.001) and a shorter duration from delivery to Bakri insertion (χ²=3.31, P=0.002), than non-PAS women (n=32). CONCLUSIONS PAS was a major cause of PPH at 198 vaginal and cesarean births. An accurate and timely pre-IUBT intervention and Bakri IUBT placement was critical for controlling PPH in cesarean births, especially in women with PAS.

Racial disparities in low-risk cesarean birth rates across hospitals

BACKGROUND

We compared low-risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low-risk cesarean rates less than or equal to White women.

METHODS

In this cross-sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low-risk cesarean for Black and White women across hospital categories.

RESULTS

Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low-risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low-risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01-1.44) increase in the odds of having a low-risk cesarean.

DISCUSSION

Black women had higher odds of a low-risk cesarean than White women and were more likely to access care in hospitals with higher low-risk cesarean rates. The existence of hospitals where low-risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low-risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system-level policy efforts to improve equity and reduce cesarean birth rates.

Prenatal Ultrasound Diagnosis of Vasa Previa With Careful Intraoperative Management: A Case Report

Vasa previa is a rare but potentially life-threatening condition to the fetus. Timely antenatal diagnosis and delivery by cesarean section (CS) can lead to a favorable outcome. Here, we report a case of recurrent pregnancy loss (G3A2) with vasa previa, which was diagnosed prenatally by ultrasound. She was admitted at her 31st week with bleeding per vaginum (PV) provisionally diagnosed as antepartum hemorrhage (APH) and managed conservatively as placenta previa. Follow-up ultrasonography (USG) revealed vasa previa at 33 weeks. The fetus was delivered by lower segment cesarean section (LSCS) after careful separation of the membranes and avoiding damage to the vessels as there was velamentous insertion of cord with the lower margin of the placenta in the lower segment. The baby was cared for in the neonatal intensive care unit due to prematurity and discharged after six days. This case report highlights the importance of prenatal ultrasound in diagnosing vasa previa and planning an elective cesarean section with caution intraoperatively for the safe delivery of the baby.

Evaluation of Association Between Adenomyosis and Cesarean Scar Defect

PURPOSE

This study aims to investigate and compare quantitative factors of the cesarean scar defect (CSD) in symptomatic patients with and without uterine adenomyosis.

METHOD

This study was conducted as a case-control study. Patients who met the inclusion criteria were divided into two groups: with adenomyosis (case) and without adenomyosis (control). The demographic data, medical history, and sonohysterography findings were extracted from the patient's documents and archived images.

RESULT

During 2 years, 310 symptomatic women with a history of previous cesarean section underwent sonohysterography. Among them, 204 patients met the inclusion criteria. The most common chief complaints were post-menstrual bleeding (34.3%) and prolonged bleeding (27%). Cesarean scar depth and width significantly differed between these two groups, and patients with underlying adenomyosis had significantly larger defects (P-value of .009 and .005, respectively). Mean RMT/AMT ratio was 31.83% in the case group and 42.88% in the control group. In our study, RMT/AMT ratios were significantly lower in the case group (P-value of .001). In addition, we performed analysis on a subgroup of patients with one prior cesarean section. Similar results were achieved with a lower RMT/AMT ratio in case group (mean of 31.20% in case group and 46.47% in control group; P-value of .000).

CONCLUSION

Our study showed a strong association between the presence of adenomyosis and larger clinically more significant CSDs. To establish a causative relationship, we suggest a prospective cohort study to follow up the patients and compare the evolution of CSD in patients with and without adenomyosis.

Is enhanced recovery after surgery essential?

BACKGROUND

The enhanced recovery after surgery (ERAS) method is designed for the patient to recover quickly, have less pain and have a more comfortable period after the surgery; that includes preoperative, intra and postoperative processes. ERAS has been started to be applied in cesarean section surgeries as the patients need to recover quickly. In the literature, there is no study about the results of ERAS in cesarean section about pain scores and complications.

OBJECTIVES

It is aimed to compare the results of cesarean section patients using the ERAS method completely in patients who have had cesarean section without meeting some of the postoperative conditions of the ERAS criteria.

STUDY DESIGN

It is a prospective study designed as postoperative metoclopramide, enema and routine opioids in group 1, enema and metoclopramide in group 2, metoclopramide only in group 3 and nothing in group 4. Postoperative pain scoring was done by using visual analog scale (VAS). Analysis of variance tests and t tests were used for results.

RESULTS

There was no difference between groups according to age, parity, and birth weight. As a result, although there was no difference between the groups in terms of discharge time and complications, the VAS score used in pain scoring was found to be significantly lower in group 3 compared to the other groups (p: 0.000). Only metoclopramide group (group 3) had lowest VAS score.

CONCLUSION

It has been revealed that the ERAS procedure does not need to be so detailed in the postoperative period, and the addition of metoclopramide may be sufficient. Since pain can be a subjective factor, other randomized studies are needed in terms of other criteria.

Breast Milk Excretion of Dinalbuphine Sebacate Injection Administered After Cesarean Section

Ensuring the safety of analgesics during lactation is crucial for women of childbearing potential. Available data regarding the transfer of nalbuphine for postoperative acute pain via breast milk are limited to the postmarketing experience. This lactation study aimed to assess nalbuphine and dinalbuphine sebacate concentrations in breast milk from lactating women with postoperative pain treated with dinalbuphine sebacate extended-release injection (150 mg dinalbuphine sebacate/2 mL Naldebain). Breast milk was collected throughout the 5-day posthospitalization interval from 20 mothers injected with one dose of extended-release dinalbuphine sebacate intramuscularly. Maternal safety was assessed during the study period. Nalbuphine was detectable in 71% of milk samples collected from all mothers, whereas dinalbuphine sebacate was undetectable or below the quantitation limit (0.1 ng/mL). The mean nalbuphine concentration in milk was approximately 10.55 ng/mL, with the peak concentration reaching up to 12.7 ng/mL. The mean relative infant dose was 0.39% (coefficient of variation, 65%). The mean pain intensity at rest was reduced to mild pain from Day 2 morning to discharge. Overall, the maternal safety profile was tolerable. The breast milk of women who receive one dose of dinalbuphine sebacate injection postpartum contains low nalbuphine concentration. In addition, dinalbuphine sebacate injection potentially reduces maternal pain intensity during the first postpartum week and offers low toxicity risk among breastfed infants.

Rectus Abdominis Endometriosis Following Cesarean Section: A Case Report

Endometriosis involves the growth of endometrial-like tissue outside the uterine cavity, with its manifestation in the rectus abdominis muscle being exceptionally rare and primarily observed in women with a history of abdominal surgeries. In this report, we present the case of a 42-year-old female with a medical history of two cesarean sections who presented with cyclical abdominal pain and a palpable mass in the right lower quadrant. An MRI scan of the pelvis revealed a lesion on the right lower quadrant of the abdominal wall, proximate to the previous Pfannenstiel incision. A percutaneous US-guided biopsy of the abdominal lesion was performed, and histopathology demonstrated the presence of endometrial glands and stroma, confirming the diagnosis of rectus abdominis endometriosis. She was submitted to a local wide excision with adequate margins of normal surrounding tissue and has remained free of recurrence for two years.

The effect of progressive relaxation exercises and transcutaneous electrical neural stimulation administered to women delivering via cesarean delivery on pain, breastfeeding success, and comfort levels: A randomized controlled study

OBJECTIVE

This study aimed to determine the effect of progressive relaxation exercises (PRE) and transcutaneous electrical nerve stimulation administered to women delivering via cesarean delivery on acute pain, breastfeeding success, and comfort levels.

METHODS

This is a single-blind, randomized controlled study. This study was carried out in the obstetrics and gynecology clinic of a university hospital affiliated with the Ministry of Health in Turkey between August 20, 2018 and April 15, 2019. A total of 120 participants were randomly assigned to one of four groups, which included a transcutaneous electrical neural stimulation (TENS) group, a PRE group, a combined intervention group, and a control group. Data were collected with a Data Collection Form, The Visual Analogue Scale, The LATCH Breastfeeding Diagnostic Tool, and The Postpartum Comfort Scale.

RESULTS

According to the findings of the study, it was determined that pain significantly decreased and comfort increased after having a cesarean delivery in all three intervention groups compared to the control group (p < 0.05). Regarding the breastfeeding success, while there was no statistically significant change in this behavior in the TENS group, it was significantly better in the PRE group and the combined intervention group, where TENS and PRE were administered together (p < 0.05).

CONCLUSIONS

According to our study results, we recommend that TENS and PRE should be employed together after a cesarean delivery as safe non-pharmacological methods in pain management, eliminating breastfeeding problems, and increasing comfort.

Intrapartum use of sildenafil citrate to prevent fetal compromise and emergency operative birth in term pregnancies in the United Kingdom and Australia: A preliminary cost-effectiveness analysis

OBJECTIVE

To compare cost-effectiveness of oral sildenafil citrate, administered after onset of labor, with standard care to health system funders in the UK and Australia.

METHODS

We conducted a modeled cost-effectiveness analysis, measuring costs and quality adjusted life years (QALYs), using a decision-analytic model covering onset of labor to 1 month post-birth. The relative risk of emergency cesarean section and operative vaginal birth was taken from a Phase 2 placebo controlled double blinded randomized control trial.

RESULTS

Both options of care resulted in the same QALYs gained over the model time period (0.08). Sildenafil citrate was cost-saving compared with standard care, saving £92 per birth in the UK (AU$303 per birth in Australia). Sensitivity analyses did not identify any areas of uncertainty that stopped sildenafil citrate being cost saving compared with standard care. Threshold analysis revealed that sildenafil citrate would be cost saving up to a per birth drug or administration cost of £152.32 in the UK (AU$333.61 in Australia).

CONCLUSION

Oral sildenafil citrate may be cost saving compared with standard care; however, the effects on neonatal outcomes still need to be demonstrated in large randomized trials.

Inspecting mother-to-infant microbiota transmission: disturbance of strain inheritance by cesarian section

Introduction

The initial acquisition and subsequent development of the microbiota in early life is crucial to future health. Cesarean-section (CS) birth is considered to affect early microbial transmission from mother to infant.

Methods

In this study, we collected fecal samples from 34 CS infants and their mothers from West China Second Hospital, Sichuan University to assess the microbiota developmental trajectory of mothers and infants. We explored mother-infant gut microbiome transmission via comparison with corresponding Finnish data.

Results

Metagenomic analysis of gut microbiota profiles indicated that the communities of mothers and infants were distinct. The composition of the infant gut microbiome was highly variable but also followed predictable patterns in the early stages of life. Maternal communities were stable and mainly dominated by species from Bacteroidacea spp. We used PStrain to analyze and visualize strain transmission in each mother-infant pair. Excluding missing data, we included 32 mother-infant pairs for analysis of strain transmission. Most CS deliveries (65.6%, 21/32) did not demonstrate transmission of strains from mother to infant. To further explore the mother-infant strain transmission, we analyzed metagenomics data from Finnish mother-infant pairs. A total of 32 mother-infant pairs were included in the analysis, including 28 vaginal delivery (VD) infants and four CS infants. Strain transmission was observed in 30 infants, including 28 VD infants and two CS infants. All VD infants received transmitted stains from their mothers. Finally, a total of 193 strain transmission events were observed, comprising 131 strains and 45 species.

Discussion

Taken together, our data suggested that delivery mode was an important factor influencing the mother-infant strain transmission.

Cesarean sections and sociodemographic disparities in Ecuador: A nationwide study from hospital registries between 2015 and 2022

OBJECTIVE

This study aimed to analyze sociodemographic factors associated with cesarean sections (c-sections) in Ecuador.

METHODS

Data were extracted from the Ecuadorian National Institute of Statistics and Censuses (INEC). Multivariate binary and multinomial logistic regression analyses were performed to assess sociodemographic factors associated with c-sections overall and with each type of c-section (elective or emergency c-section).

RESULTS

This study included 1 118 842 in-hospital deliveries during 2015-2022 in Ecuador, of which 41.3% were c-sections. This exceeds the recommended levels of medical justified c-sections. Those who were older than 20-29 years showed a higher probability for c-sections overall. Regarding ethnicity, Montubios had 57% higher probability for c-sectioned with an adjusted odds ratio (aOR) of 1.57 and a 95% confidence interval (CI) of 1.45-1.71; while indigenous, black, and white individuals exhibited 73%, 29%, and 21% lower probabilities, respectively. However, this varied according to specific type of c-sections: black individuals had 11% higher probability of elective c-section but 44% lower probability of emergency c-section. Deliveries in private healthcare facilities exhibited significantly higher probabilities of c-sections overall (aOR 15.38, 95% CI 15.20-15.56). Higher probability of emergency c-section was also observed during 2020-2022.

CONCLUSION

Cesarean sections in Ecuador still exceed the recommended levels of medically justified c-sections, highlighting the importance of adopting an approach to childbirth that reduces unnecessary interventions. These results suggest an important role of sociodemographic factors, which aligns with the reported need for multicomponent and locally tailored strategies for addressing c-section overuse. The increase in c-sections during the COVID-19 pandemic (2020-2022) might suggest the influence of external health crises on maternal healthcare.

The impact of a trial of labor after cesarean versus elective repeat cesarean delivery: A meta-analysis

BACKGROUND

The increasing global incidence of cesarean section has prompted efforts to reduce cesarean delivery rates. A trial of labor after cesarean (TOLAC) has emerged as an alternative to elective repeat cesarean delivery (ERCD) for women with a prior cesarean delivery. However, the available evidence on the comparative outcomes of these 2 options remains inconsistent, primarily due to varying advantages and risks associated with each. Our meta-analysis aims to compare the maternal-neonatal results in TOLAC and ERCD in women with prior cesarean deliveries.

METHODS

A comprehensive search was performed in PubMed, Embase, Cochrane library databases up to September,2022 to identity studies evaluating perinatal outcomes in women who underwent TOLAC compared to ERCD following a previous cesarean delivery. The included studies were subjected to meta-analysis using RevMan 5.3 software to assess the overall findings.

RESULTS

A total of 13 articles were included in this meta-analysis. Statistically significant differences were identified in the rate of uterine rupture (OR = 2.01,95%CI = 1.48-2.74, P < .00001) and APGAR score < 7 at 5 minutes (OR = 2.17,95%CI = 1.69-2.77, P < .00001) between the TOLAC and ERCD groups. However, no significant differences were observed in the rates of hysterectomy, maternal blood transfusion, postpartum infection, postpartum hemorrhage and neonatal intensive care unit (P ≥ .05) admission between the 2 groups.

CONCLUSIONS

Our analysis revealed that TOLAC is associated with a higher risk of uterine rupture and lower incidence APGAR score < 7 at 5 minutes compared to ERCD. It is vital to consider predictive factors when determining the appropriate mode of delivery in order to ensure optimal pregnancy outcomes. Efforts should be made to identify the underlying causes of adverse outcomes and implement safety precautions to select suitable participants and create safe environments for TOLAC.

Expression of ADAM17 and its clinical value for patients with pernicious placenta previa: A retrospective study of 148 PPP patients underwent cesarean section

To explore the expression and the diagnostic value of ADAM17 in pernicious placenta previa (PPP) combined placental accreta. A total of 148 PPP patients were enrolled and divided into 2 groups: 62 patients with placenta accrete (PPP with PA group) and 86 patients without placenta accrete (PPP without PA group). In the same period, 74 pregnant women without PPP who had undergone cesarean section were selected as controls. The levels of ADAM17 were detected by qt-PCR. Diagnostic efficiency of ADAM17 were evaluated by receiver operating characteristics curve. ADAM17 was higher expression in PPP patients. Multivariate analysis showed that ADAM17 was related to gravida times (HR = 2.43 95% CI, 1.25-3.31), history of cesarean delivery (HR = 3.44, 95% CI = 2.24-4.28), history of abortions (HR = 2.22, 95% CI = 1.57-3.06) for PPP with PA patients and gravida times (HR = 2.01, 95% CI = 1.45-2.86), history of cesarean delivery (HR = 1.89, 95% CI = 1.33-2.48) for PPP patients without PA. Diagnostic efficiency of ADAM17 indicated that the sensitivity and specificity of ADAM17 detection for PPP with PA were 74.41% and 67.21% and for PPP without PA were 89.29% and 85.52%. Area under curve were 0.7876 (0.7090-0.8661) for PPP with PA and 0.9443 (0.9136-0.9750) for PPP without PA. Insummary, ADAM17 was higher expression in patients with PPP. ADAM17 was associated with gravida times, history of cesarean delivery, history of abortions. It also indicated a better diagnostic efficiency for patients with PPP. Further larger sample, multicenter studies should be conducted to confirm the conclusion from our study.

Maternal postures for fetal malposition in late pregnancy for improving the health of mothers and their infants

BACKGROUND

The optimal relationship of the fetus to the mother's birth canal is when the fetus is in the longitudinal lie, cephalic presentation with well-flexed head (vertex presentation), and in the occipito-anterior position. Fetal malposition is described as occipito-posterior (OP) when the back of the fetal head lies posteriorly in the mother's pelvis, and occipito-transverse (OT) when the back of the fetal head lies transversely in the mother's pelvis. The fetal head will often be deflexed and may extend further to a mento-anterior or mento-transverse position, where the chin is anterior or transverse to the maternal pelvis. Fetal malposition is associated with both maternal and fetal complications, including prolonged labour, fetal distress, maternal exhaustion, need for caesarean section, operative vaginal birth, and increased risk of perineal trauma and anal sphincter injuries. This review considered positional interventions in late pregnancy to correct fetal malposition. A separate Cochrane review addresses maternal postural position for fetal malposition during labour.

OBJECTIVES

To assess the effects of maternal posture for fetal malposition in women in late pregnancy.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (24 October 2022), and reference lists of retrieved studies.

SELECTION CRITERIA

Our selection criteria were randomised controlled trials and cluster-randomised controlled trials that included women in late pregnancy with a malposition of the fetus including OP and OT, mento-anterior and mento-transverse, or with uncertain fetal position, randomly allocated to use of specified maternal positioning in late pregnancy, compared with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed potential studies for inclusion in the review. We used standardised methodology for assessment of risk of bias and trustworthiness developed by the Cochrane Pregnancy and Childbirth Group.

MAIN RESULTS

We reviewed three full-text reports; we excluded one due to lack of a comparison group and listed two as awaiting classification. We needed further information from the report authors for both potentially suitable studies to account for substantial imbalances between the numbers allocated to each group in one, or identical numbers for all groups in the other. The failure to resolve these issues may have been due to the long interval since publication of the studies (2004 and 1983).

AUTHORS' CONCLUSIONS

We did not identify evidence for guiding practice with respect to positional interventions for fetal malposition in late pregnancy. More studies are needed to understand the effect of positional interventions in late pregnancy. Future research on positional interventions for fetal malposition in late pregnancy should include follow-up to determine whether short-term correction of fetal position translates to improved pregnancy outcomes. This might include interventions commenced in late pregnancy and repeated as needed until the onset of labour. The latter would be included in the review on maternal positions during labour.

Gastrointestinal Disorders and Atopic Dermatitis in Infants in the First Year of Life According to ROME IV Criteria-A Possible Association with the Mode of Delivery and Early Life Nutrition

Background: Functional gastrointestinal disorders are very common condition. The aim of this study is to evaluate the implications of the mode of pregnancy termination and early infant feeding on the incidence of gastrointestinal disorders and atopic dermatitis at birth and 3, 6, and 12 months of age. Methods: This study included 82 pregnant women and their newborns born at term. All newborns were examined at birth and 3, 6, and 12 months of age according to the ROME IV criteria. Results: In children born after cesarean section, the incidence of regurgitation was significantly higher. In children fed mostly or exclusively with formula, dry skin with allergic features was observed more often compared to breastfed children, but this relation was statistically significant only at the age of 12 months. The use of antibiotic therapy increased the risk of allergic skin lesions by almost seven times at 3 months of life. Gastrointestinal disorders in the form of regurgitation, colic, and constipation occur within the period of up to 12 months of the child's life and may be related to the mode of the termination of pregnancy via cesarean section and the use of artificial feeding or antibiotic therapy. The occurrence of atopic dermatitis in infants at 12 months of life is correlated with the mode of the termination of pregnancy after cesarean section. Conclusions: One of the risk factors for the occurrence of atopic dermatitis and gastrointestinal disorders in the period up to 12 months of the child's life may be a cesarean section and the use of formula feeding or antibiotic therapy.

Trend of incompleteness of the Robson Classification variables in the Live Birth Information (SINASC) in the state of Paraná, Brazil, 2014-2020

OBJECTIVE

To assess the incompleteness of the Robson Classification variables in the Live Birth Information System (Sistema de Informação sobre Nascidos Vivos - SINASC), in the state of Paraná, and its trend, 2014-2020.

METHODS

This was a time-series study that analyzed six variables, according to health macro-regions. Incompleteness was classified (percentage of "ignored" and "blank fields") as follows: excellent (< 1.0%); good (1.0-2.9%); regular (3.0-6.9%); poor (≥ 7.0%). Prais-Winsten regression was used to estimate trends.

RESULTS

A total of 1,089,116 births were evaluated. The variable "cesarean section before the onset of labor" was classified as poor in 2014 (39.4%) and 2015 (44.3%) in the state and in all macro-regions, but with a decreasing trend in incompleteness. The variables "gestational age" in the North and Northwest macro-regions, and "parity" and "number of fetuses" in the Northwest macro-region showed an increasing trend.

CONCLUSION

Most of the variables evaluated showed low percentages of incompleteness with a decreasing trend, but there is a need to improve the completion of some variables.

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

PURPOSE

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

DESIGN

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

The relationship between incidence of cesarean section and physical activity during pregnancy among pregnant women of diverse age groups: Dose-response meta-analysis

BACKGROUND

There is a lack of evidence related to physical activity and risk of cesarean section (CS) by age and/or weight in pregnant women.

OBJECTIVES

To evaluate the effect of physical activity on the incidence of CS and explore the relationship of age and body mass index (BMI) with incidence of CS.

SEARCH STRATEGY

A systematic search was conducted in CNKI, WANGFANG, Web of Science, and PubMed from inception to 31 August 2021.

SELECTION CRITERIA

Experimental studies were included if the participants were pregnant, if intervention included physical activity and controls received routine prenatal care only, and if primary outcome was CS.

DATA COLLECTION AND ANALYSIS

Meta-analysis included a heterogeneity test, data combination, subgroup analysis, forest plot, sensitivity analysis, and dose-response regression analysis.

MAIN RESULTS

Sixty-two studies were included. Physical activity during pregnancy decreased the incidence of CS (relative risk [RR] 0.81, 95% confidence interval [CI] 0.74-0.88, P < 0.001). The incidence of CS was lower among the overweight/obese group (RR 0.78, 95% CI 0.65-0.93) compared with the normal weight group (RR 0.82, 95% CI 0.74-0.90). The incidence of CS was lowest among the young age group (RR 0.61, 95% CI 0.46-0.80) compared with the middle age group (RR 0.74, 95% CI 0.64-0.85) and the older age group (RR 0.90, 95% CI 0.82-1.00). The critical value, when age becomes a risk factor for CS, was 31.7 years in the intervention group and 28.5 years in the control group.

CONCLUSIONS

Physical activity during pregnancy can reduce the incidence of CS, especially among obese people, and prolong the gestational age span.

A multidisciplinary approach to management of a non-traumatic subdural hematoma in the third trimester of pregnancy: A case report and review of literature

Key Message

Although non-traumatic SDHs are uncommon during and immediately following pregnancy, management of these cases should be carried out by a multidisciplinary team, including obstetricians, pediatricians, neurosurgeons, and anesthesiologists.

Abstract

Intracranial hemorrhage represents an uncommon but serious complication of pregnancy. Non-traumatic subdural hematomas (SDH) are uncommon during the prenatal period with limited literature about etiology and management. In this case report, the authors report on a patient with non-traumatic SDH in the third trimester of pregnancy. The patient is a 40-year-old G6P5L5 female at gestational age of 34 weeks and 5 days presenting with frontal headache, nausea, vomiting, and blurry vision. CT scan revealed an acute on chronic right subdural hematoma with midline shift and multiple herniations. An emergency cesarean section and right burr hole SDH evacuation were performed. Etiology of the SDH remains unknown. Although non-traumatic SDHs are uncommon during and immediately following pregnancy, health care providers should always consider this possibility if a patient presents with typical symptoms and signs. Management of these cases should be carried out by a multidisciplinary team, including obstetricians, pediatricians, neurosurgeons, and anesthesiologists to optimize maternal and fetal outcomes.

Successful Fetal Reduction in Early Second Trimester: Series of Three Cases Conceived With Infertility Treatment

This case series explores three instances of a successful fetal reduction in early second-trimester pregnancies conceived through infertility treatments. The patients, all admitted to a central Indian tertiary care hospital, underwent assisted reproductive technologies such as in vitro fertilization (IVF) or intrauterine insemination (IUI). Faced with triplet pregnancies, fetal reduction was made to mitigate risks and enhance maternal and fetal well-being. The reduction procedures, conducted either transvaginally or transabdominally under continuous ultrasound guidance, resulted in the cessation of targeted fetal heart activity and motility. Post-reduction, pregnancies progressed without major complications, culminating in successful deliveries via lower segment cesarean section (LSCS) in the third trimester. This case series underscores the importance of selective fetal reduction in managing pregnancies arising from infertility treatments, emphasizing its role in minimizing risks associated with multiple gestations. Using continuous ultrasound guidance during the reduction procedures proved effective in ensuring precision and safety. These cases contribute valuable insights to the evolving field of reproductive medicine, offering clinicians a nuanced understanding of successful interventions to optimize outcomes in complex pregnancies.

Voices of Women With Emergency Cesarean Section Experience: A Qualitative Approach

The midwifery psychoeducation, relationship with the midwives, feelings from the surgery, and delivery expectations are major factors that affect the birth experiences of mothers following an emergency cesarean section. This study aimed to give voice to mothers to express the feelings they had before, during, and after an emergency cesarean section and primarily to express whether their expectations were met after the surgery. The research was conducted on mothers who gave birth through an emergency cesarean section in a public hospital by completing specific questionnaires. This study was carried out with 15 mothers. The data was collected through a semi-structured questionnaire form, including socio-demographic characteristics. From the research, four main themes and 11 sub-themes emerged. The main themes described are "midwifery psychoeducation," "relationship with the midwives," "feelings from the C-section," and "delivery expectations." The majority of women did not attend parenting preparation classes either because they did not consider it necessary or because they were unaware of their existence. The presence of a midwife remains valuable during the perinatal period for most mothers. However, feelings vary between fear, shock, terror, disappointment, pain, and in some cases happiness. In the majority of cases, emergency cesarean section did not meet the expectations of mothers, who described it as a violent and sudden experience. The results highlight the need to strengthen midwives in order to promote psychosocial education, support during childbirth, and counseling for traumatic experiences.

Isthmocele, not cesarean section per se, reduces in vitro fertilization success: a systematic review and meta-analysis of over 10,000 embryo transfer cycles

IMPORTANCE

Previous reviews have shown that a history of cesarean section (CS) is associated with a worse in vitro fertilization (IVF) prognosis. To date, whether the decline in the IVF chances of success should be attributed to the CS procedure itself or to the presence of isthmocele remains to be clarified.

OBJECTIVE

To summarize the available evidence regarding the impact of isthmocele on IVF outcomes.

DATA SOURCES

Electronic databases and clinical registers were searched until May 30, 2023.

STUDY SELECTION AND SYNTHESIS

Observational studies were included if they assessed the effect of isthmocele on IVF outcomes. Comparators were women with isthmocele and women without isthmocele with a previous CS or vaginal delivery. Study quality was assessed using the modified Newcastle-Ottawa Scale.

MAIN OUTCOMES

The primary outcome was the live birth rate (LBR). The effect measures were expressed as adjusted odds ratios (aORs) and unadjusted odds ratios (uORs) with 95% confidence intervals (95% CIs). The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation working group methodology.

RESULTS

Eight studies (n = 10,873 patients) were included in the analysis. Women with isthmocele showed a lower LBR than both women with a previous CS without isthmocele (aOR, 0.62; 95% CI, 0.53-0.72) and those with a history of vaginal delivery (aOR, 0.55; 95% CI, 0.42-0.71). The LBRs in women with a previous CS without isthmocele and those with a history of vaginal delivery were similar (aOR, 0.74; 95% CI, 0.47-1.15). Subgroup analysis suggested a negative effect of the intracavitary fluid (ICF) in women with isthmocele on the LBR (uOR, 0.36; 95% CI, 0.18-0.75), whereas the LBRs in women without ICF and those without isthmocele were similar (uOR, 0.94; 95% CI, 0.61-1.45).

CONCLUSION AND RELEVANCE

We found moderate quality of evidence (Grading of Recommendations Assessment, Development and Evaluation grade 3/4) supporting a negative impact of isthmocele, but not of CS per se, on the LBR in women undergoing IVF. The adverse effect of isthmocele on IVF outcomes appears to be worsened by ICF accumulation before embryo transfer.

CLINICAL TRIAL REGISTRATION NUMBER

CRD42023418266.