Preferences in cesarean delivery surgical technique: a survey of maternal–fetal medicine fellows

Adherence to best practice: Preventing surgical site infection following caesarean section in Australia

BACKGROUND

Surgical site infection (SSI) following caesarean section is a serious but underreported problem with an estimated incidence of 5-9%. It is essential to identify adherence to established prevention strategies to reduce the incidence rate.

AIMS

The aims of this study were to quantify unwarranted variation from evidence-based practice on the prevention of SSI at caesarean section in Australia; and to identify predictors of not implementing an existing infection prevention bundle: pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal.

MATERIALS AND METHODS

An online cross-sectional survey of obstetricians and obstetric Diplomates was conducted in 2016. The primary outcome was adherence to an existing infection prevention bundle, with demographic and clinical variables predicting adherence through multivariable binary logistic regression.

RESULTS

Forty-nine percent of respondents (response rate 39.6%) reported implementing zero or only one element of the infection prevention bundle. The types of respondents most likely to have poor adherence were Diplomates (adjusted odds ratio (aOR) 2.58), obstetricians practising in private hospitals (aOR 3.34), those usually practising in public and private hospitals (aOR 2.23), and those not usually implementing a surgical safety checklist (aOR 3.77).

CONCLUSIONS

Adherence to best practice at caesarean section is low among many Australian obstetricians. Infection control practitioners and obstetricians need to collaboratively implement surgical safety checklists at caesarean section, and monitor implementation using process key performance indicators, and audit and feedback. These strategies will reduce unwarranted variation from evidence-based infection control practice.

Incorporating Precesarean Vaginal Preparation Into Standard of Care for Obstetrics

Postoperative infections remain a serious concern after cesarean delivery, the most common major surgical procedure in the United States. Multiple strategies have been proposed to combat this problem, including the addition of azithromycin to the standard preoperative antibiotic prophylaxis. However, as obstetricians, we have failed to uniformly adopt precesarean vaginal preparation despite convincing evidence from randomized controlled trials that this technique reduces postoperative rates of endometritis by more than 50%. This reduction is similar to that seen with the addition of azithromycin. Vaginal preparation with povidone-iodine solution may target the same genital pathogens as azithromycin, which are commonly implicated in endometritis, a polymicrobial infection that may be under-addressed by our current antiseptic techniques. A recent review of maternal-fetal medicine fellows' practices at the time of cesarean delivery and recent publications on precesarean vaginal cleansing suggest that this practice has not yet gained hold in the United States.

Fellow Perceptions of Residency Training in Obstetrics and Gynecology

OBJECTIVE

To evaluate the perceptions of current and former fellows in obstetrics and gynecology (OBG) subspecialties of their readiness for fellowship training.

METHODS

A previously used survey was modified and distributed in 2016 to current and former fellows in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology-infertility, and female pelvic medicine and reconstructive surgery. The survey explored domains of professionalism, independent practice, psychomotor ability, clinical evaluation, and scholarship. A standard Likert scale was employed and domains/responses were tailored to each subspecialty. Standard statistical models were utilized.

RESULTS

A total of 478 fellows responded to the survey. Nearly 75% of fellows from each specialty reported feeling prepared or very prepared for fellowship. More than 65% of fellows from each specialty reported feeling very prepared to perform core surgical procedures. More than 90% of respondents reported having opportunities during residency to independently develop a plan of action for patients on labor and delivery. Fewer respondents reported opportunities to independently manage postoperative complications-40.7% of gynecologic oncology and 44.7% of female pelvic medicine and reconstructive surgery reported having such opportunities, whereas 91.9% of maternal-fetal medicine respondents reported having had such opportunities. While 46.4% of respondents received education on scientific writing during residency, 80% reported writing a manuscript as a resident.

CONCLUSIONS

The majority of current and former fellows in OBG subspecialties report feeling prepared for fellowship in terms of clinical and surgical skills. Their feedback reveals opportunities for improvement of independent practice in gynecologic scenarios, as well as formal education on scientific research, for OBG residencies.

Patient preferences for method of cesarean skin closure: secondary outcomes from a randomized trial

Objective: To assess patient preference for sutures or staples for cesarean wound closure.Methods: This is a planned secondary analysis of a randomized controlled trial of 746 women in which suture and staples were compared for cesarean skin closure. Enrolled patients were asked to complete preoperative and postoperative surveys to assess preferred closure. Reasons for expressed preferences were elicited for each patient. Preferences were stratified by a number of cesarean deliveries (CD). We sought to determine if patients had a specific preference for wound closure due to personal experience or a personal belief that one method may be more beneficial with respect to pain and appearance.Results: We surveyed 550 patients preoperatively and 627 postoperatively. Women with a prior CD were more likely to have a skin closure preference compared with women having a primary CD (p < .05). Women who had a prior closure with suture rather than staples were significantly more likely to have a preference for the same wound closure method (p < .01). Avoiding the need for staple removal was the main reason women preferred suture closure, both preoperatively and postoperatively. The higher the number of the previous CD, the greater the preference for future closure with suture over staples (p < .05).Conclusions: Women undergoing cesarean delivery prefer suture as the method for skin closure compared with staples.