Reducing post-caesarean delivery surgical site infections: a narrative review.

Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.

A review of blood pressure measurement in obese pregnant women.

Blood pressure monitoring is a critical component of antenatal, peripartum and postnatal care. The accurate detection and treatment of abnormal blood pressure during pregnancy is essential for the optimisation of maternal and neonatal outcomes. Increasing maternal obesity in western populations is well documented. The presence of a large arm circumference in obese pregnant women may lead to difficult and inaccurate blood pressure measurements. Difficulties measuring blood pressure in non-pregnant obese patients are well described. In the literature, the problem is uncommonly mentioned in relation to pregnant patients. This topic review will discuss the importance and challenges of blood pressure measurement in pregnancy. The currently available equipment for blood pressure monitoring in pregnancy will be identified and the process of validating devices described. The limitations of the current validation protocols in pregnancy will be highlighted. It is concluded that a pregnancy-specific validation protocol is required: this would facilitate the introduction of new technology for use in high-risk pregnant women. More accurate blood pressure measurement has the potential to improve the diagnosis and management of abnormal blood pressure in pregnancy and influence maternal and neonatal outcomes.

Anaesthetic management of obese parturients: what is the evidence supporting practice guidelines?

Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant women. Various governing bodies have published clinical guidelines for the care of obese parturients. These guidelines refer to two components of anaesthetic care: anaesthetic consultation in the antenatal period for women with a body mass index (BMI) ≥ 40 kg/m2 and the provision of early epidural analgesia in labour. These recommendations are based on the increased incidence of obstetric complications and the predicted risks and difficulties in providing anaesthetic care. The concept behind early epidural analgesia is logical-site the epidural early, use it for surgical anaesthesia and avoid general anaesthesia if surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the management of labour epidurals in obese women is complicated and that women with extreme obesity require higher rates of general anaesthesia. Anecdotally, anaesthetists view and apply the early epidural recommendation inconsistently and the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies addressing epidural extension ('top-up') in obese parturients would help inform practice, audit of local practice may better answer the question "is early epidural analgesia beneficial to obese women in my practice?".

Anaesthetists' experiences with the early labour epidural recommendation for obese parturients: a qualitative study.

Caring for obese pregnant women presents challenges for all medical professionals. Despite a lack of supporting evidence, expert opinion and international guidelines suggest early labour epidural insertion for obese women. Anecdotally this is not supported by all anaesthetists. This qualitative study explored the experiences of anaesthetists regarding early epidural analgesia in obese parturients, to answer the research question: Are anaesthetists consistent in how they apply early epidural analgesia in obese parturients? Personal in-depth interviews with 42 specialist anaesthetists working in south-east Queensland, Australia, were completed between February and April, 2015. Leximancer™ text analysis software applied a validated algorithm to the data to identify themes and concepts. The major themes were explored by the first author to answer the research question. Three major themes were identified: the demands associated with caring for obese women; concern regarding the anaesthetic technique used in obese women; and the importance of communication with obstetric staff. Disagreement regarding interpretation and application of early epidural analgesia was identified within this group of anaesthetists. These anaesthetists were inconsistent in how they interpreted and applied early epidural analgesia for obese parturients, with some questioning the validity of the practice. The combination of uncertainty, urgency and technical difficulty presented by obese parturients provoked anxiety in these clinicians, particularly the anticipation of unplanned general anaesthesia. Consistent anaesthetic practice could improve the implementation of early epidural analgesia in obese parturients.

Weight-related risk perception among healthy and overweight pregnant women: a cross-sectional study.

OBJECTIVE: The objective of this study was to evaluate weight-related risk perception in early pregnancy and to compare this perception between women commencing pregnancy healthy weight and overweight. STUDY DESIGN: Pregnant women (n=664) aged 29±5 (mean±s.d.) years were recruited from a metropolitan teaching hospital in Australia. A self-administered questionnaire was completed at around 16 weeks of gestation. Height measured at baseline and self-reported pre-pregnancy weight were used to calculate body mass index. Cross-sectional analysis was conducted.Differences between groups were assessed using chi-squared tests for categorical variables and t-tests or Mann-Whitney U tests for continuous variables depending on distribution. RESULT: Excess gestational weight gain (GWG) during pregnancy was more important in leading to health problems for women or their child compared with pre-pregnancy weight. Personal risk perception for complications was low for all women, although overweight women had slightly higher scores than healthy-weight women (2.4±1.0 vs 2.9±1.0; P<0.001). All women perceived their risk for complications to be below that of an average pregnant woman. CONCLUSION: Women should be informed of the risk associated with their pre-pregnancy weight (in the case of maternal overweight) and excess GWG. If efforts to raise risk awareness are to result in preventative action, this information needs to be accompanied by advice and appropriate support on how to reduce risk.

Does a history of hypertensive disorders of pregnancy help predict future essential hypertension? Findings from a prospective pregnancy cohort study.

Hypertensive disorder of pregnancy (HDP) is considered an important determinant in the prediction of future hypertension. The aim of this study is to examine whether HDP improves prediction of future hypertension, over prediction based on established risk factors measured during pregnancy. We used a community based cohort study of 2117 women who received antenatal care at a major hospital in Brisbane between 1981 and 1983 and had blood pressure assessed 21 years after the index pregnancy. Of these 2117 women, 193 (9.0%) experienced HDP and 345 (16.3%) had hypertension at 21 years postpartum. For women with HDP, the odds of being hypertensive at 21 years postpartum were 2.46 (95% CI 1.70, 3.56), adjusted for established risk factors including age, education, race, alcohol, cigarettes, exercise and body mass index. Addition of HDP did not improve the prediction model that included these established risk factors, with the area under the curve of receiver operator (AUROC) increasing from 0.710 to 0.716 (P-value for difference in AUROC=0.185). Our findings suggest that HDP is strongly and independently associated with future hypertension, and women who experience this condition should be counselled regarding lifestyle modification and careful ongoing blood pressure monitoring. However, the development of HDP during pregnancy does not improve our capacity to predict future hypertension, over risk factors identifiable at the time of pregnancy. This suggests that counseling regarding lifestyle modification and ongoing blood pressure monitoring might reasonably be provided to all pregnant and postpartum women with identifiable risk factors for future hypertension.

Pregnancy in type 2 diabetes mellitus--problems & promises.

The parallel epidemics of obesity and Type 2 diabetes (T2DM) are progressing rapidly in Australia. The high prevalence of obesity and sedentary lifestyle in the population, compounded by later child bearing, has led to an increase in the prevalence of T2DM pre-dating pregnancy. In some centers, pregnant women with T2DM now outnumber those with type 1 diabetes (T1DM). Although there is controversy as to whether T2DM is associated with worse outcomes than T1DM in pregnancy, modern reports clearly acknowledge the seriousness of this condition. There is a clear association between obesity and adverse pregnancy outcomes (cesarean section, gestational diabetes, hypertensive disorders, birth defects and prematurity). Aside from obesity and the metabolic syndrome, additional factors may contribute to these adverse outcomes: A lack of preconception planning, a failure to achieve tight glycaemic control early in pregnancy and socio-economic disadvantage. It's likely that obesity and diabetes have compounding effects on pregnancy outcomes. In this review, we evaluate both the underlying pathogenesis of T2DM and obesity in the pregnancy context and the adverse clinical maternal and perinatal outcomes described in pregnancies complicated by maternal T2DM and obesity. We highlight the need for a comprehensive strategy to improve clinical outcomes in these pregnancies.