Maternal complications and associated factors among mothers who underwent a cesarean section at Gebretsadik Shewa general hospital: an institution based cross-sectional study

Introduction

Cesarean sections have played a major role in lowering maternal morbidity and mortality rates, but are a major concern in developing countries. This study aims to assess the magnitude of maternal complication and its associated factors among women who underwent a cesarean section at Gebretsadik Shewa general hospital, Southwest Ethiopia.

Method

A hospital-based cross-sectional study was conducted in Gebretsadik Shewa general hospital. Data were extracted from 382 mothers' medical charts, retrieved from the labor and operations theatre log book registry using systematic random sampling technique. The extracted data was coded and entered into Epi Data version 3.0, and exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Logistic regression analysis was conducted and significance and strength association was determined considering AOR with a 95% confidence level.

Result

A total of 382 mothers' charts were reviewed; however, 368 charts were eligible for data entry. The age of the participants ranges between 16 and 42 years with mean and standard deviation of 26.1 ± 4.8 years. Maternal complication rate was 30.4% [95% CI: 25.8- 35.1]. Surgical site infection (10.3%), anemia (6.5%) and intraoperative bleeding (4.6%) were the most common. Multivariable logistic regression analysis showed that no antenatal care follow up, medical illness during pregnancy, emergency cesarean section and not receiving a prophylactic antibiotic were statistically associated with maternal complications.

Conclusion

The incidence of maternal complication following cesarean delivery was unduly high. Community based education about antenatal care follow up and its importance should be further strengthened for favorable maternal and fetal outcomes.

Considering Criteria for Active Phase Labor Management of Nulliparous Women: A Cost-Effectiveness Analysis

OBJECTIVE

The aim of the study is to evaluate differences in maternal and neonatal outcomes based on updated criteria for defining active labor at 6 cm of cervical dilation and to determine if these recommendations are cost-effective.

STUDY DESIGN

A decision-analytic model was built using TreeAge Pro 2020 software. We included maternal outcomes of mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and death. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. Costs and quality-adjusted life years (QALYs) were included from the maternal and infant perspectives. We used a willingness-to-pay threshold of $100,000 per QALY and all model inputs were subjected to sensitivity analysis.

RESULTS

In a theoretical cohort of 1.4 million women, a threshold of 6 cm to define active labor resulted in 373,668 fewer cesarean deliveries, 33,181 fewer cases of endometritis, 143 fewer postpartum hemorrhages requiring transfusions, and seven fewer maternal deaths when compared with a threshold of 4 cm. However, there were higher rates of adverse neonatal outcomes, including 484 more cases of shoulder dystocia and 17 more instances of permanent brachial plexus injury. Using 6 cm as the threshold resulted in lower costs and greater effectiveness, making it a dominant strategy. Multivariate sensitivity analysis demonstrated the model was robust over a wide range of assumptions.

CONCLUSION

In this model, considering 6 cm of cervical dilation as the threshold for the active phase of labor compared with 4 cm was a cost-effective strategy to prevent primary cesarean deliveries, lower costs, and improve maternal outcomes, despite associated increased adverse neonatal outcomes.

KEY POINTSG

· Cervical dilation of 6 cm should be considered the threshold for the active phase of labor. This is a change from the prior definition of 4 cm.. · We built a theoretical model to compare outcomes and costs associated with the new active phase definition of 6 cm.. · Using a 6-cm threshold is a cost-effective strategy for decreasing primary cesarean deliveries..

Adverse maternal outcomes associated with Cesarean deliveries and their determinants: hospital based cross sectional, mixed- methods study

Purpose

The purpose of this study was to examine adverse outcomes associated with cesarean deliveries and to assess potential confounding factors.

Design/methodology/approach

A hospital-based cross-sectional study was conducted from September 1−30, 2019 using mixed methods of data collection. Multistage sampling was used to draw the eligible study participants. The sample size was calculated using the single population proportion formula. A systematic random sampling technique was used to draw the sample size. 180 original medical records were excluded because of having missed information, leaving 1,618 women as the study population. We used the questionnaire adapted from the Ethiopian Demographic and Health Survey to collect quantitative data and analyzed using SPSS version 22, while thematic analysis for qualitative measures was used to generate themes regarding associated perspectives of participants from a community.

Findings

More than 383 women delivered by cesarean section. 20% of the mothers with the mean age at birth of 26.1 ± 4.8 experienced adverse outcomes. Adjusted odds ratio (AOR) was used to measure the association of determinants and was 2.95 (95% CI 1.19–7.29) for nonuse of antenatal care, 3.18 (95% CI 1.43–6.94) for nonuse of prophylaxis, 4.28 (95% CI 1.58−11.61) for history of medical illness and 7.09 (95% CI 1.19−45.59) for use of substandard operation set up compared with their counterparts.

Research limitations/implications

Strengths of the study include the finding of the study are reliably reported in mixed study methods examining hospital-based institutional and personal risk factors and exploring the whole community's perspectives. However, the important limitations of the study indicate that the study poses a number of challenges related to studying design, therefore there was not sufficient evidence of causality to draw conclusions from the findings. In addition, the study was conducted at a single hospital so that it is not convenient to generalize the findings of the study for setting different in social and economic status.

Originality/value

Based on the findings, attention has been drawn to healthcare personnel to provide training and consultation services for pregnant women and for health care administration to ensure standard set up for operation.

Timing of active phase labor arrest diagnosis in nulliparous women: a cost-effectiveness analysis

BACKGROUND

Recommendations from the American College of Obstetricians and Gynecologists for the safe prevention of primary cesarean deliveries propose that cesarean delivery for active phase arrest in the first stage of labor should be performed only if women fail to progress despite four hours of adequate uterine activity and no cervical change. This is a change in recommendation from a two-hour threshold.

OBJECTIVE

To determine the economic and clinical implications of waiting four hours compared to two hours for cervical progression before diagnosing active phase labor arrest.

STUDY DESIGN

We designed a cost-effectiveness analysis using TreeAge Pro 2020 software with model inputs derived from the literature. We used a theoretical cohort of 1.4 million women, the approximate number of nulliparous U.S. women reaching four centimeters in spontaneous labor. We compared maternal and neonatal outcomes and costs associated with defining active phase arrest after four hours of no cervical progression versus two hours. As a baseline assumption, active labor was defined at four centimeters. It was assumed that women with active phase arrest were delivered via cesarean delivery. In addition to cost and maternal quality-adjusted life years (QALY), outcomes included mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and maternal deaths. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. The willingness-to-pay threshold was set at $100,000/QALY.

RESULTS

In a theoretical cohort of 1.4 million women, waiting four hours instead of two hours led to 322,253 fewer cesarean deliveries, 6 fewer maternal deaths, 123 fewer postpartum hemorrhages requiring transfusions, and 28,615 fewer episodes of endometritis. There were 418 more instances of neonatal shoulder dystocia and 14 more cases of permanent brachial plexus injuries with a four-hour threshold. A four-hour threshold leads to 56% more women having a vaginal delivery in our theoretical cohort. Results from our model show that waiting four hours versus two hours to diagnose active phase labor arrest led to increased total QALYs with increased costs, with an incremental cost effectiveness ratio (ICER) below our willingness-to-pay threshold of $100,000 per QALY. Thus, it was cost effective to wait for at least four hours in the diagnosis of active phase arrest. Multivariable sensitivity analysis demonstrated the model was robust over a wide range of assumptions.

CONCLUSIONS

Increasing the time threshold from two to four hours for diagnosing active phase labor arrest beyond four centimeters is a cost-effective strategy, resulting in fewer primary cesarean deliveries and improved maternal outcomes, despite a small increase in adverse neonatal outcomes.

Postpartum Nipple Symptoms: Risk Factors and Dermatologic Characterization

Background: Nipple discomfort inhibits breastfeeding goals, particularly between 0 and 8 weeks postpartum (PP), and yet the specific dermatologic entities that contribute to nipple soreness have not been clearly delineated. Moreover, there remains a lack of evidence-based guidelines for nipple symptoms and skin diseases. Methods: A survey was distributed to 6-8-week PP women, 18-50 years of age, with an intent to exclusively or partially breastfeed ("at the breast" or "pump"). The study aimed to characterize nipple skin symptoms (pain and itching) and lesions (eczema, redness, cuts, or wounds) and any association between these nipple problems and past dermatologic history, breastfeeding outcomes, and the ability to meet her breastfeeding goals. Results: Findings paralleled Centers for Disease Control and Prevention (CDC) statistics with a 25% decline in breastfeeding rates between birth, 86.3% (189), and 6-8 weeks PP, 64.5% (145). By 6-8 weeks PP, exclusive "formula" and "exclusive feeding at the breast" showed the largest increase (+16.4%) and decrease (-22.9%), respectively. Although no significant difference was found in comparison of nipple problems to feeding methods or skin history, women who reported pumping or PP redness/eczema had higher odds ratios of a change in feeding practice, history of eczema, and sensitive skin. Strong pumping intentions were also associated with the highest risk of unmet breastfeeding goals. Conclusion: Regardless of feeding method, product, or provider use, PP nipple problems predominantly arose between 1 and 3 weeks PP. Clinical Trial Registration number 201901737.

Trajectory of cause of death among brought dead neonates in tertiary care public facilities of Pakistan: A multicenter study

BACKGROUND

Considering the fact that Pakistan is amongst the countries with very high neonatal mortality rates, we conducted a research study to determine the possible causes and characteristics of neonates presenting dead to the emergency department of tertiary public health care facilities of Pakistan using verbal autopsies.

METHODS

A descriptive case series study was conducted in emergency department/pediatrics ward/neonatal ward/nursery unit of ten tertiary care public health facilities, situated in seven major cities of Pakistan from November, 2011 to June, 2013. Precoded verbal autopsy proforma was used to collect information regarding cause of death, family narratives and other associated risks accountable for pathway to mortality.

RESULTS

We identified 431 neonates presenting dead to the emergency department (238 males and 193 females). Sepsis (26.7%), birth asphyxia (18.8%) and persistent pulmonary arrest (17.2%) were main primary causes of brought death. Around 72% brought dead neonates were referred from doctors/health care facilities and more than 28% caregivers mentioned that they were not informed about the diagnosis/ailment of their deceased newborn.

CONCLUSIONS

Findings of our study suggest that infectious disease remains the main primary cause of neonatal mortality. Underweight in newborns (64%) was estimated as a leading associated risk. Delays in referrals to respective health care facility enlightened the concern of sub-standard prerequisites of neonatal care that could be one of the major contributing risk factor of high mortality rates.

The antecedents and correlates of necrotizing enterocolitis and spontaneous intestinal perforation among infants born before the 28th week of gestation

OBJECTIVE

To identify antecedents of "medical" necrotizing enterocolitis (mNEC), "surgical" NEC (sNEC), and spontaneous intestinal perforation (SIP) in newborns delivered before 28 weeks gestation.

STUDY DESIGN

Prospective multicenter cohort study. During study period, 2002- 2004, women delivering before 28 weeks gestation at one of 14 participating institutions were enrolled. Well defined antenatal and postnatal variables were collected. Bivariate analyses were performed to identify candidates for developing multinomial multivariable time-oriented logistic regression models.

RESULTS

Of the 1320 infants, 5% had mNEC, 6% had sNEC, and 4% had SIP. Antecedents of mNEC included mother's identification as Black, consumption of aspirin during the pregnancy, and vaginal bleeding after the 12th week of gestation. For sNEC the antecedents were maternal self- support, obesity and anemia during the pregnancy, birth before the 24th week, birth weight ≤750gm, and receipt of fresh frozen plasma (FFP) during the first postnatal week. An infant was at increased risk of SIP if the placenta had increased syncytial knots, birth occurred before the 24th week, and received FFP during the first week.

CONCLUSIONS

Maternal and neonatal characteristics might help identify at-risk ELGANs for NEC and SIP, who then may potentially benefit from targeted preventive strategies.

Nipple pain, damage, and vasospasm in the first 8 weeks postpartum

BACKGROUND

Nipple pain and damage are common in the early postpartum period and are associated with early cessation of breastfeeding and comorbidities such as depression, anxiety, and mastitis. The incidence of nipple vasospasm has not been reported previously. This article describes nipple pain and damage prospectively in first-time mothers and explores the relationship between method of birth and nipple pain and/or damage.

SUBJECTS AND METHODS

A prospective cohort of 360 primiparous women was recruited in Melbourne, Australia, in the interval 2009-2011, and after birth participants were followed up six times. The women completed a questionnaire about breastfeeding practices and problems at each time point. Pain scores were graphically represented using spaghetti plots to display each woman's experience of pain over the 8 weeks of the study.

RESULTS

After birth, before they were discharged home from hospital, 79% (250/317) of the women in this study reported nipple pain. Over the 8 weeks of the study 58% (198/336) of women reported nipple damage, and 23% (73/323) reported vasospasm. At 8 weeks postpartum 8% (27/340) of women continued to report nipple damage, and 20% (68/340) were still experiencing nipple pain. Ninety-four percent (320/340) of the women were breastfeeding at the end of the study, and there was no correlation between method of birth and nipple pain and/or damage.

CONCLUSIONS

Nipple pain is a common problem for new mothers in Australia and often persists for several weeks. Further studies are needed to establish the most effective means of preventing and treating breastfeeding problems in the postnatal period.