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Gabbai D, Lavie A, Yogev Y, Attali E. The association between indications for cesarean delivery and surgery time. Int J Gynaecol Obstet 2024; 164:693-698. [PMID: 37545296 DOI: 10.1002/ijgo.15026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE We aimed to determine risk factors for prolonged surgery time of cesarean delivery (CD). METHODS We conducted a retrospective cohort study in a single tertiary university-affiliated medical center (2011-2022). The study group consisted of all women who underwent CD that lasted >90 min (representing the 95th percentile of CD length in our cohort). Data were compared with CDs with an operation time of <90 min. Demographic, obstetric, and surgical characteristics, as well as indications for surgery and urgency (in labor vs. elective surgery), were compared. RESULTS Overall, during the study period, 31 660 CDs were performed in our center. Of them, 1397 (4.4%) lasted >90 min. After applying a multivariate analysis, abnormal placentation (relative risk [RR] 1.5 [95% confidence interval (CI), 1.3-1.8]), previous uterine scar (RR, 2.15 [95% CI, 1.5-3.0]), general anesthesia (RR, 3.5 [95% CI, 2.9-4.4]) and preterm delivery (RR, 2.06 [95% CI, 1.78-2.4]) were found to be associated with prolonged surgical time. CD due to malpresentation (RR, 0.57 [95% CI, 0.46-0.7]), multiple gestations (RR, 0.72 [95% CI, 0.6-0.9]), and patient request (RR, 0.56 [95% CI, 0.38-0.84]) were found to be protective factors. CONCLUSION The main risk factors associated with additional surgery time in CD are general anesthesia, abnormal placentation, previous uterine scar, and preterm delivery.
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Affiliation(s)
- Daniel Gabbai
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Lavie
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmanuel Attali
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Bank TC, Macones G, Sciscione A. The "30-minute rule" for expedited delivery: fact or fiction? Am J Obstet Gynecol 2023; 228:S1110-S1116. [PMID: 36934051 DOI: 10.1016/j.ajog.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 03/18/2023]
Abstract
Initially developed from hospital feasibility data from the 1980s, the "30-minute rule" has perpetuated the belief that the decision-to-incision time in an emergency cesarean delivery should be <30 minutes to preserve favorable neonatal outcomes. Through a review of the history, available data on delivery timing and associated outcomes, and consideration of feasibility across several hospital systems, the use and applicability of this "rule" are explored, and its reconsideration is called for. Moreover, we have advocated for balanced consideration of maternal safety with rapidity of delivery, encouraged process-based approaches, and proposed standardization of terminology regarding delivery urgency. Furthermore, a standardized 4-tier classification system for delivery urgency, from class I, for a perceived threat to maternal or fetal life, to class IV, a scheduled delivery, and a call for further research with a standardized structure to facilitate comparison have been proposed.
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Affiliation(s)
| | - George Macones
- Department of Obstetrics and Gynecology, The University of Texas at Austin, Austin, TX
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3
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Xodo S, de Heus R, Berghella V, Londero AP. Acute tocolysis for intrapartum nonreassuring fetal status: how often does it prevent cesarean delivery? A systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol MFM 2022; 4:100639. [PMID: 35429665 DOI: 10.1016/j.ajogmf.2022.100639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of intrapartum acute tocolysis for nonreassuring fetal heart rate tracing in decreasing the incidence of cesarean delivery. Secondary outcomes included modes of delivery other than cesarean delivery, successful acute tocolysis, time-to-delivery interval, and short-term perinatal outcomes. DATA SOURCES Searches were performed in MEDLINE/PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and Reviews, ClinicalTrials.gov, and the International Clinical Trials Registry Platform from the inception of each database until February 2022. STUDY ELIGIBILITY CRITERIA Selection criteria included randomized controlled trials of laboring patients with singleton gestations randomized to receive intrapartum acute tocolysis for nonreassuring fetal heart rate tracing, as defined by the original trial. METHODS All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated in the original trials. A frequentist network-meta-analysis was performed. RESULTS Four randomized clinical trials were eligible, including 605 patients with nonreassuring fetal heart rate tracing and singleton gestations at gestational ages >32 weeks. The cesarean delivery rate was similar among patients managed with different types of acute tocolysis. Acute tocolysis, compared with emergency delivery, was associated with improved neonatal acid-base status (notably decreasing the prevalence of base deficit >12 mmol/L [beta-2 agonists odds ratio, 0.61; 95% confidence interval, 0.37-0.99] and the rate of neonatal intensive care unit admission [beta-2 agonists odds ratio, 0.42; 95% confidence interval, 0.22-0.78]) and with an increase in the time-to-delivery interval (beta-2 agonists mean difference, 17.62 minutes; 95% confidence interval, 15.66-19.58); there was no reduction of cesarean delivery rate, showing an increased rate with atosiban and beta-2 agonists. CONCLUSION The cesarean delivery rate was not reduced by acute tocolysis when used for nonreassuring fetal heart rate tracing during labor. Acute tocolysis is associated with improved short-term fetal outcomes and safely increases the time-to-delivery interval.
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Affiliation(s)
- Serena Xodo
- Department of Gynecology and Obstetrics, School of Medicine, University of Udine, Udine, Italy (Dr Xodo).
| | - Roel de Heus
- Department of Obstetrics and Gynecology, St Antonius Hospital, Utrecht, The Netherlands (Dr Heus)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
| | - Ambrogio P Londero
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, Genova, Italy (Dr Londero)
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4
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Wong L, Kwan AHW, Lau SL, Sin WTA, Leung TY. Umbilical cord prolapse: revisiting its definition and management. Am J Obstet Gynecol 2021; 225:357-366. [PMID: 34181893 DOI: 10.1016/j.ajog.2021.06.077] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 01/26/2023]
Abstract
Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality, ranging from 23% to 27% in low-income countries to 6% to 10% in high-income countries. In this review, we specifically addressed 3 issues. First, its definition is not consistent in the current literature, and "occult cord prolapse" is a misnomer because the cord is still above the cervix. We proposed that cord prolapse, cord presentation, and compound cord presentation should be classified according to the positional relationship among the cord, the fetal presenting part, and the cervix. All of them may occur with either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed by cord presentation, and lastly by compound cord presentation, which replaces the misnomer "occult cord prolapse." Second, the mainstay of treatment of cord prolapse is urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is imminent. The urgency depends on the fetal heart rate pattern, which can be bradycardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia, because a recent study showed that cord arterial pH declines significantly with the bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval, 0.0003-0.0180), and this may indicate an irreversible pathology such as vasospasm or persistent cord compression. However, cord arterial pH does not correlate with either deceleration-to-delivery interval or decision-to-delivery interval, indicating that intermittent cord compression causing decelerations is reversible and less risk. Third, while cesarean delivery is being arranged, different maneuvers should be adopted to relieve cord compression by elevating the fetal presenting part and to prevent further cord prolapse beyond the vagina. A recent study showed that the knee-chest position provides the greatest elevation effect, followed by filling of the maternal urinary bladder with 500 mL of fluid, and then the Trendelenburg position (15°) and other maneuvers. However, each maneuver has its own advantages and limitations; thus, they should be applied wisely and with great caution, depending on the actual clinical situation. Therefore, we have proposed an algorithm to guide this acute management.
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Affiliation(s)
- Lo Wong
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Angel Hoi Wan Kwan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - So Ling Lau
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Wing To Angela Sin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
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5
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Brandt JA, Morgenstern B, Thangarajah F, GrÜttner B, Ludwig S, Eichler C, Ratiu J, Mallmann P, Ratiu D. Evaluating the Decision-to-Delivery Interval in Emergency Cesarean Sections and its Impact on Neonatal Outcome. In Vivo 2021; 34:3341-3347. [PMID: 33144441 DOI: 10.21873/invivo.12172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM In Germany, performance of an emergency Cesarean section (ECS) is recommended within an interval of ≤20 min from decision to delivery (DDI). The aim of the study was to assess the duration of DDI in ECS as well as its impact on neonatal outcome. PATIENTS AND METHODS Data from 437 patients at a single, tertiary care hospital were retrospectively analysed regarding influence on the duration of DDI. Subsequently the impact of DDI on neonatal outcome and incidence of adverse neonatal outcome was analysed. RESULTS DDI of ECS performed outside core working hours was significantly prolonged (p<0.001). Shorter DDI showed a statistically worse arterial cord blood pH (p=0.001, r=0.162) and base excess (p=0.05; r=0.094). Duration of DDI had no significant impact on the incidence of adverse neonatal outcome (p=0.123). CONCLUSION Awareness of influence on DDI might contribute to expediting DDI, but duration of DDI showed no impact on the incidence of adverse neonatal outcome. Data were not adequate to suggest a recommendation for DDI time standards.
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Affiliation(s)
- Janna-Alica Brandt
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Bernd Morgenstern
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Fabinshy Thangarajah
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Berthold GrÜttner
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Sebastian Ludwig
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Christian Eichler
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Jessika Ratiu
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Dominik Ratiu
- Department of Obstetrics and Gynecology, Medical Faculty, University Hospital Cologne, Cologne, Germany
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6
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Ashwal E, Bergel Bson R, Aviram A, Hadar E, Yogev Y, Hiersch L. Risk factors for postpartum hemorrhage following cesarean delivery. J Matern Fetal Neonatal Med 2021; 35:3626-3630. [PMID: 33508987 DOI: 10.1080/14767058.2020.1834533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify risk factors for postpartum hemorrhage (PPH) following cesarean delivery (CD). METHODS A retrospective study of all women who underwent CD in a university-affiliated tertiary hospital (2014-15). PPH was defined as any of the following: clinical PPH (≥1000 ml estimated blood loss), hemoglobin (Hb) drop ≥3 g/dl (the difference between pre-CD Hb level within a 24 h prior to the delivery) and post-CD (nadir level during the first 72 h after CD)) or the need for blood products transfusion. The characteristics of women with PPH following CD were compared to a control group of those with CD without PPH. RESULTS Of the 15,564 deliveries during the study period, 3208 (20.6%) women met inclusion criteria, of them, 307 (9.6%) had PPH and 2901 (90.4%) served as controls. Women in the PPH group were younger (32.6 ± 5.3 vs. 33.5 ± 5.4, p = .006) and more often nulliparous (45.9% vs. 33.3%, p<.001) compared to the controls. However, there were no differences between the groups regarding the rate of multiple gestations, maternal diabetes mellitus, hypertensive disorders, polyhydramnios, and macrosomia. The rates of induction of labor (16.3% vs. 8.6%, p<.001) and urgent CD (47.9% vs. 32.0%, p<.001) were higher in the PPH group compared to the controls. In multivariate logistic regression, predictors for PPH following CD were (odds ratio, 95% confidence interval) urgent CS (1.57, 1.78-2.11, p = .002), CD duration (1.02, 1.01-1.03, p<.001), and the number of previous CDs (0.74, 0.62-0.90, p = .003). CONCLUSIONS In women undergoing cesarean section, urgent CD, the duration of the surgery, and the number of the previous CD are associated with the risk of PPH and should be taken into consideration during the postpartum assessment.
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Affiliation(s)
- Eran Ashwal
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Riki Bergel Bson
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Rabin Medical Center, Helen Schneider Hospital for Women, Petah Tikva, Israel
| | - Amir Aviram
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Eran Hadar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Rabin Medical Center, Helen Schneider Hospital for Women, Petah Tikva, Israel
| | - Yariv Yogev
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Rabin Medical Center, Helen Schneider Hospital for Women, Petah Tikva, Israel
| | - Liran Hiersch
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Wong L, Tse WT, Lai CY, Hui ASY, Chaemsaithong P, Sahota DS, Poon LC, Leung TY. Bradycardia‐to‐delivery interval and fetal outcomes in umbilical cord prolapse. Acta Obstet Gynecol Scand 2020; 100:170-177. [DOI: 10.1111/aogs.13985] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Lo Wong
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Wing T. Tse
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Chit Y. Lai
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Annie S. Y. Hui
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Piya Chaemsaithong
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Daljit S. Sahota
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Liona C. Poon
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
| | - Tak Y. Leung
- Department of Obstetrics and Gynecology The Chinese University of Hong Kong Hong Kong Hong Kong
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Real-time data analysis using a machine learning model significantly improves prediction of successful vaginal deliveries. Am J Obstet Gynecol 2020; 223:437.e1-437.e15. [PMID: 32434000 DOI: 10.1016/j.ajog.2020.05.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/28/2020] [Accepted: 05/12/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The process of childbirth is one of the most crucial events in the future health and development of the offspring. The vulnerability of parturients and fetuses during the delivery process led to the development of intrapartum monitoring methods and to the emergence of alternative methods of delivery. However, current monitoring methods fail to accurately discriminate between cases in which intervention is unnecessary, partly contributing to the high rates of cesarean deliveries worldwide. Machine learning methods are applied in various medical fields to create personalized prediction models. These methods are used to analyze abundant, complex data with intricate associations to aid in decision making. Initial attempts to predict vaginal delivery vs cesarean deliveries using machine learning tools did not utilize the vast amount of data recorded during labor. The data recorded during labor represent the dynamic process of labor and therefore may be invaluable for dynamic prediction of vaginal delivery. OBJECTIVE We aimed to create a personalized machine learning-based prediction model to predict successful vaginal deliveries using real-time data acquired during the first stage of labor. STUDY DESIGN Electronic medical records of labor occurring during a 12-year period in a tertiary referral center were explored and labeled. Four different models were created using input from multiple maternal and fetal parameters. Initial risk assessments for vaginal delivery were calculated using data available at the time of admission to the delivery unit, followed by models incorporating cervical examination data and fetal heart rate data, and finally, a model that integrates additional data available during the first stage of labor was created. RESULTS A total of 94,480 cases in which a trial of labor was attempted were identified. Based on approximately 180 million data points from the first stage of labor, machine learning models were developed to predict successful vaginal deliveries. A model using data available at the time of admission to the delivery unit yielded an area under the curve of 0.817 (95% confidence interval, 0.811-0.823). Models that used real-time data increased prediction accuracy. A model that includes real-time cervical examination data had an initial area under the curve of 0.819 (95% confidence interval, 0.813-0.825) at first examination, which increased to an area under the curve of 0.917 (95% confidence interval, 0.913-0.921) by the end of the first stage. Adding the real-time fetal heart monitor data provided an area under the curve of 0.824 (95% confidence interval, 0.818-0.830) at first examination, which increased to an area under the curve of 0.928 (95% confidence interval, 0.924-0.932) by the end of the first stage. Finally, adding additional real-time data increased the area under the curve initially to 0.833 (95% confidence interval, 0.827-0.838) at the first cervical examination and up to 0.932 (95% confidence interval, 0.928-0.935) by the end of the first stage. CONCLUSION Real-time data acquired throughout the process of labor significantly increased the prediction accuracy for vaginal delivery using machine learning models. These models enable translation and quantification of the data gathered in the delivery unit into a clinical tool that yields a reliable personalized risk score and helps avoid unnecessary interventions.
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A multidisciplinary approach to improving process and outcomes in unscheduled cesarean deliveries. Am J Obstet Gynecol MFM 2019; 2:100070. [PMID: 33345984 DOI: 10.1016/j.ajogmf.2019.100070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Effective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes. OBJECTIVE To evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes. MATERIALS AND METHODS This was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score <6, and umbilical cord arterial pH <7.2. Descriptive statistics were calculated. Continuous variables were tested for normality and compared using the Student t test or Mann-Whitney U test as appropriate. Categorical variables were characterized by proportions and compared by the χ2 or Fisher exact test as appropriate. RESULTS There were 121 and 119 subjects in the pre-and postimplementation groups respectively, collected from corresponding 3-month periods. There were no significant differences in demographics, comorbidities, or indications for cesarean delivery between groups. Overall median decision to incision interval did not differ between the pre- and postimplementation groups. There was a significant decrease in median decision to incision interval (63 versus 50 minutes, P = .02) in cesarean deliveries performed for nonfetal indications. This was driven by a shorter median decision to operating room interval (32.5 versus 23 minutes, P = .01). The incidences of operative complications (35% [19/55] versus 11% [6/53], P < .01) and cord pH <7.2 (36% [20/55] versus 17% [9/53], P = .02) were also decreased in cesarean deliveries performed for nonfetal indications. The incidences of general anesthesia, maternal transfusion, and 5-minute Apgar score <6 did not differ. Outcomes did not differ between the pre- and postimplementation groups in cesarean deliveries performed for fetal indications. CONCLUSION Implementation of a multidisciplinary process improvement protocol that standardizes language, roles, and processes for unscheduled cesarean deliveries was associated with a reduced decision to incision interval and improved maternal and neonatal outcomes in cesarean deliveries performed for nonfetal indications. Standardized process implementation on labor and delivery has the potential to improve patient outcomes.
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10
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Antoine C, Pimentel RN, Reece EA, Oh C. Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies. J Matern Fetal Neonatal Med 2019; 34:2513-2521. [PMID: 31581865 DOI: 10.1080/14767058.2019.1670158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Abnormal placentation can result in massive hemorrhage, which is the leading cause of severe maternal morbidities and mortality in its management. Over the past 50 years, the incidence of placenta previa (PP), abnormal implantation of the placenta, and cesarean scar pregnancy have continued to rise. This coincides with the well-documented parallel rise in the rate of cesarean deliveries, the performance of multiple repeat cesarean deliveries and the adoption of newer uterine closure techniques. However, no studies have examined the role of uterine closure techniques in abnormal placentation in women with a history of a prior cesarean delivery. OBJECTIVE To assess the practicality of one specific uterine closure technique at cesarean delivery and to evaluate the relationship between previous cesarean delivery and subsequent development of abnormal implantation of the placenta, as well as neonatal and other perioperative outcomes after receiving an endometrium-free uterine closure technique. METHODS This retrospective observational study considered cesarean deliveries (n = 727) and subsequent vaginal births after cesarean delivery (n = 109) among total deliveries (n = 4496) performed in private practice at NYU Langone Health from 1985 to 2015. All cesarean deliveries were performed using the endometrium-free uterine closure technique. The primary outcome was the incidence of abnormal implantation of the placenta in subsequent pregnancies. The secondary outcomes were neonatal and maternal complications, specifically postoperative hemoglobin and hematocrit concentration losses. The association between independent variables and outcomes were evaluated using mixed-effect regression models. RESULTS In contrast to published data, independent of the number of repeat cesarean deliveries, the presence of 26 (3.1%) PPs and of 366 (43.8%) anterior placentas, there were no patients with abnormal implantation of the placenta in a cesarean scar, neither prenatally nor at delivery. Maternal hemorrhage, postoperative and neonatal complications did not reach clinical significance. The statistical analysis revealed that, when compared with women who had fewer repeat cesarean deliveries using endometrium-free uterine closure technique, those with the most had a lesser risk of forming PP and less blood loss, as measured by both hematocrit and hemoglobin evaluation. CONCLUSION In this retrospective cohort study, the exclusion of the endometrium during the endometrium-free uterine closure technique was associated with fewer placental abnormalities in subsequent pregnancies and reduced life-threatening maternal morbidity for future cesarean deliveries.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - Ricardo N Pimentel
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - E Albert Reece
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cheongeun Oh
- Department of Population Health, Division of Biostatistics, New York University School of Medicine, New York, NY, USA
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A Case of Pelvic Abscess Caused by Edwardsiella tarda followed by Laparoscopic Resection of a Hematoma Derived from Caesarean Section. Case Rep Infect Dis 2018; 2018:4970854. [PMID: 29951327 PMCID: PMC5987234 DOI: 10.1155/2018/4970854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 05/03/2018] [Accepted: 05/12/2018] [Indexed: 12/02/2022] Open
Abstract
Edwardsiella tarda (E. tarda) infections are rare and can be fatal. We report a case of an E. tarda abscess which developed in the hematoma originally derived from a caesarean section. A 24-year-old gravida 1 woman was admitted to our hospital with a complaint of abdominal pain. Approximately one month before her admission, pelvic hematoma had developed derived from caesarean section. Followed by the failure of conservative management, she underwent laparoscopic surgery to remove the hematoma 6 days before her admission. On computed tomography examination, we found that the abscess with a diameter of 9 cm was located in the right pelvic space. We punctured the abscess and identified E. tarda in the abscess. We continued administering antibiotics, but her symptoms, including fever and abdominal pain, became worse, and the abscess enlarged. We performed laparotomy drainage and ileocecal resection on the 10th posthospitalization day. After drainage surgery, the patient's condition improved gradually, and the patient was discharged uneventfully. There are no reports in patients of E. tarda infection during the perinatal period. E. tarda infection can be a life-threatening illness even in immunocompetent patients. In the case of E. tarda infection, intensive care and surgical procedures should be considered.
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Grobman WA, Bailit J, Sandoval G, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Caritis SN, Prasad M, Tita ATN, Saade GR, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE. The Association of Decision-to-Incision Time for Cesarean Delivery with Maternal and Neonatal Outcomes. Am J Perinatol 2018; 35:247-253. [PMID: 28915515 PMCID: PMC5801156 DOI: 10.1055/s-0037-1606641] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to estimate whether the decision-to-incision (DTI) time for cesarean delivery (CD) is associated with differences in maternal and neonatal outcomes. METHODS This analysis is of data from women at 25 U.S. medical centers with a term, singleton, cephalic nonanomalous gestation and no prior CD, who underwent an intrapartum CD. Perinatal and maternal outcomes associated with DTI intervals of ≤ 15, 16 to 30, and > 30 minutes were compared. RESULTS Among 3,482 eligible women, median DTI times were 46 and 27 minutes for arrest and fetal indications for CD, respectively (p < 0.01). Women with a fetal indication whose DTI interval was > 30 minutes had similar odds to the referent group (DTI of 16-30 minutes) for the adverse neonatal and maternal composites (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.40-1.71 and OR: 0.89, 95% CI: 0.63-1.27). For arrest disorders, the odds of the adverse neonatal composite were lower among women with a DTI of > 30 minutes (OR: 0.25, 95% CI: 0.08-0.77), and the adverse maternal composite was no different (OR: 1.15, 95% CI: 0.81-1.63). CONCLUSION In this analysis, DTI times longer than 30 minutes were not associated with worse maternal or neonatal outcomes.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Jennifer Bailit
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Grecio Sandoval
- Biostatistics Center, George Washington University, Washington, District of Columbia
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mona Prasad
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Bergh EP, Vieira LA, Bigelow CA, Overbey JR, Fox NS. Emergent primary cesarean delivery and maternal operative morbidity. J Matern Fetal Neonatal Med 2017; 32:1880-1883. [PMID: 29278969 DOI: 10.1080/14767058.2017.1421930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND It is unknown how variations in surgical entry time in primary cesarean delivery (CD) may affect operative outcomes and maternal morbidity. OBJECTIVE Determine whether performing a primary CD in labor emergently ("stat") is associated with adverse maternal outcomes. STUDY DESIGN Retrospective cohort study of patients who underwent primary CD at The Mount Sinai Hospital during the years of 2011-2016. Women with a singleton pregnancy and without a prior uterine scar attempting a trial of labor were included. An emergent CD was defined as a skin-to-uterine incision (I-U) time of ≤3 minutes. Subjects were dichotomized into those with an I-U time of ≤3 minutes or ≥5 minutes. RESULTS 1722 patients underwent primary CD and met eligibility criteria. 72 patients with an I-U time of 4 minutes were removed from the analysis. 196 patients (11.9%) had an I-U time ≤3 minutes and 1454 patients (88.1%) had an I-U time ≥5 minutes. There were no differences in any outcomes between groups. The likelihood of transfusion, hysterectomy, or admission to the intensive care unit (ICU) was 1.5% in the emergent group and 1.0% in the control group (p = .334). Postpartum length of stay was also similar between the groups (3.3 versus 3.2 days, p = .259). When 384 patients with I-U times >10 minutes were excluded, surgical outcomes remained similar between groups. Among the subgroup of patients who reached the second stage of labor, surgical outcomes were also similar between groups. CONCLUSIONS Emergent primary CD is not associated with increased maternal morbidity.
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Affiliation(s)
- Eric P Bergh
- a Department of Obstetrics, Gynecology and Reproductive Science , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Luciana A Vieira
- a Department of Obstetrics, Gynecology and Reproductive Science , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Catherine A Bigelow
- a Department of Obstetrics, Gynecology and Reproductive Science , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Jessica R Overbey
- b Center for Biostatistics, Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Nathan S Fox
- a Department of Obstetrics, Gynecology and Reproductive Science , Icahn School of Medicine at Mount Sinai , New York , NY , USA.,c Maternal Fetal Medicine Associates , PLLC , New York , NY , USA
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Arlier S, Seyfettinoğlu S, Yilmaz E, Nazik H, Adıgüzel C, Eskimez E, Hürriyetoğlu Ş, Yücel O. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arch Gynecol Obstet 2016; 295:303-311. [PMID: 27770246 DOI: 10.1007/s00404-016-4221-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 10/14/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE OF INVESTIGATION We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS We analyzed intra-abdominal adhesions of 672 patients. RESULTS Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS Emergency operations and adhesions increased complications.
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Affiliation(s)
- Sefa Arlier
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey.
| | - Sevtap Seyfettinoğlu
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - EsraSaygili Yilmaz
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Hakan Nazik
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Cevdet Adıgüzel
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Eda Eskimez
- Department of Obstetrics and Gynecology, Harran University, Sanliurfa, Turkey
| | - Şerif Hürriyetoğlu
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Oğuz Yücel
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
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