Evidence-based cesarean delivery: preoperative management (part 7).

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Optimization of the cosmetic appearance of skin scar after caesarean section - part II physiotherapy practice.

Scar formation is a natural part of the healing process after CS. This process, lasting up to two years, depends on the number of factors including type of incision, wound size, the person's age, body weight, health condition, and many others. Abnormal scarring should not be treated only as a cosmetic defect or superficial tissue defects. Functional and anatomical considerations must also be considered. Large varieties of non-invasive treatment modalities have been used to enhance wound healing and scar treatment. The article proposes a comprehensive approach to scar prevention and remodeling. The role of manual techniques, dry needling, cupping therapy, compression therapy, Kinesio taping, and physical agents is highlighted.

Treatment with plasma exchange of a pregnant woman with anti-PP1Pk alloimmunization: A case report.

The histo-blood group antigens P, P1 and Pk are a closely related set of glycosphingolipid structures expressed by red blood cells and other tissues. None of these three characters is expressed on p cells, a null phenotype that arises in the context of homozygous mutation of the A4GALT gene. Subjects with p phenotype spontaneously develop a natural alloantibody named anti-PP1Pk, which is a mixture of IgG and IgM against P1, P and Pk. While anti-P1 is a weak cold antibody with poor clinical significance, anti-P and anti-Pk antibodies are potent haemolysins responsible for severe hemolytic transfusion reactions. The rare anti-PP1Pk alloantibodies are associated with recurrent spontaneous abortion in the first trimester of gestation. P and Pk antigens are expressed at high levels on the placenta and antibodies directed against both these structures are deleterious to placental trophoblasts. Here we describe the use of plasma exchange (PEX) in a nulliparous 39-year-old woman with anti-PP1Pk antibodies and a history of repeated spontaneous early abortions and hypofertility. The patient underwent apheresis starting from the third week throughout the pregnancy and a healthy child was delivered by cesarean section at 35 WG. The newborn required only phototherapy within a few days of life. We can state that an early treatment with the only PEX has proven to be effective and safe in the management of a fetomaternal P-incompatibility caused by a high anti-PP1Pk titer (256).

Optimally Controlled Diabetes and Its Influence on Neonatal Outcomes at a Level II Center: A Study on Infants Born to Diabetic Mothers.

Background and Objectives: We investigated the effect of optimal maternal glycemic control on neonatal outcomes among infants born to mothers with diabetes. Materials and Methods: In this prospective study, we assessed 88 eligible mothers admitted to the obstetrics department for pregnancy evaluation. Our analysis included 46 infants born to diabetic mothers (IDMs) and 138 infants born to unaffected mothers, all admitted to the Level II Neonatal Intensive Care Unit (NICU). Results: Mothers affected by diabetes were generally older and exhibited a higher body mass index (BMI) and a greater number of gestations, although parity did not differ significantly. Cesarean section emerged as the most frequently chosen mode of delivery. A significantly higher proportion of infants in the affected group presented with respiratory disease (3% vs. 19.5%), which required NICU admission (4.3% vs. 23.9%), phototherapy (18.1% vs. 43.5%), and had congenital heart defects or myocardial hypertrophy (15.2% and 26% vs. 3% and 4.3%) compared to matched controls (p < 0.05). Conclusions: This study underscores the persistence of adverse neonatal outcomes in IDMs, even when maternal glycemic control is optimized. It calls for further investigation into potential interventions and strategies aimed at enhancing neonatal outcomes in this population.

Analysis of the Analgesic Effect, Emotion, and Safety of Esketamine in Cesarean Section Analgesia for Puerperae.

Objective: This retrospective study aimed to evaluate the effectiveness and safety of esketamine as an analgesic during cesarean section procedures. Methods: 102 puerperae undergoing cesarean section were divided into a control group and an esketamine (SK) group. Various parameters, including HR, MAP, and postoperative pain, were analyzed. Blood gas analysis and Apgar scores were assessed in neonates. Postoperative depression and satisfaction were evaluated in puerperae. Drug concentrations were measured using liquid-phase tandem mass spectrometry. Results: No significant differences in dimension levels were observed between the two groups (P > .05). However, the SK group showed better HR and MAP indicators at various time points, less postoperative pain, and better mental well-being on postpartum days 1, 3, and 7 (P < .05). Adverse reaction rates were similar between groups (P > .05), but postoperative satisfaction was significantly different (P = .027). Neonatal outcomes did not differ significantly (P > .05). In the SK group, SK2 and SK3 groups had better results compared to SK1 (P < .05). Conclusion: Esketamine during cesarean section stabilized vital signs, reduced pain, and improved well-being in puerperae without affecting newborns. Optimal dosage: 30 µg/kg/h esketamine, 15 ng/kg/h sufentanil.

Treatment of uterine scar cystoid diverticulum by hysteroscopy combined with laparoscopy.

OBJECTIVE: To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization. DESIGN: A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy. SETTING: University hospital. PATIENTS: A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side. INTERVENTION: The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1-0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward. MAIN OUTCOME MEASURES: Recovery of menstruation and anatomy of the uterine isthmus. RESULTS: The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm. CONCLUSION: The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening.

Mode of delivery and maternal vitamin D deficiency: an optimized intelligent Bayesian network algorithm analysis of a stratified randomized controlled field trial.

This study aimed to elucidate the algorithm of various influential factors relating to the association between 25-hydroxyvitamin D (25(OH)D) concentration at delivery and mode of delivery. The investigation constituted a secondary analysis using data collected as part of the Khuzestan Vitamin D Deficiency Screening Program in Pregnancy, which is a stratified randomized vitamin D supplementation-controlled trial comprising 1649 eligible pregnant women. The Bayesian Network (BN) method was utilized to determine the association algorithm between diverse influential factors associated with maternal vitamin D and mode of delivery. The optimized intelligent BN algorithm revealed that women presenting with moderate (35.67%; 95% CI: 33.36-37.96) and severe vitamin D deficiency (47.22%; 95% CI: 44.81-49.63) at delivery were more likely to undergo cesarean section than those presenting with normal concentrations of this nutritional hormone (18.62%; 95% CI: 16.74-20.5). The occurrence probabilities of preeclampsia in mothers with normal, moderate, and severe vitamin D deficiency at delivery were (1.5%; 95% CI: 0.92-2.09), (14.01%; 95% CI: 12.33-15.68), and (26.81%; 95% CI: 24.67-28.95), respectively. Additionally, mothers with moderate (11.81%; 95% CI: 10.25-13.36) and severe (27.86%; 95% CI: 25.69-30.02) vitamin D deficiency exhibited a higher probability of preterm delivery in comparison to those presenting with normal concentrations (1.12%; 95% CI: 0.62-1.63). This study demonstrated that the vitamin D status of pregnant women at delivery could directly affect the mode of delivery and indirectly through maternal complications, such as preeclampsia and preterm delivery, leading to a higher occurrence probability of cesarean section.

Chinese Medicine Plaster as A New Treatment for Surgical Site Infection in Patients with Cesarean Delivery: A Randomized, Double-Blind, Controlled Trial.

OBJECTIVE: To evaluate the efficacy of Chinese plaster containing rhubarb and mirabilite on surgical site infection (SSI) in patients with cesarean delivery (CD) by performing a randomized controlled trial. METHODS: This randomized controlled trial included 560 patients with CD due to fetal head descent enrolled at a tertiary teaching center between December 31, 2018 and October 31, 2021. Eligible patients were randomly assigned to a Chinese medicine (CM) group (280 cases) or a placebo group (280 cases) by a random number table, and were treated with CM plaster (made by rhubarb and mirabilite) or a placebo plaster, respectively. Both courses of treatment lasted from the day 1 of CD, followed day 2 until discharge. The primary outcome was the total number of patients with superficial, deep and organ/space SSI. The secondary outcome was duration of postoperative hospital stay, antibiotic intake, and unplanned readmission or reoperation due to SSI. All reported efficacy and safety outcomes were confirmed by a central adjudication committee that was unaware of the study-group assignments. RESULTS: During the recovery process after CD, the rates of localized swelling, redness and heat were significantly lower in the CM group than in the placebo group [7.55% (20/265) vs. 17.21% (47/274), P<0.01]. The durution of postoperative antibiotic intake was shorter in the CM group than in the placebo group (P<0.01). The duration of postoperative hospital stay was significantly shorter in the CM group than in the placebo group (5.49 ± 2.68 days vs. 8.96 ± 2.35 days, P<0.01). The rate of postoperative C-reactive protein elevation (≽100 mg/L) was lower in the CM group than in the placebo group [27.6% (73/265) vs. 43.8% (120/274), P<0.01]. However, there was no difference in purulent drainage rate from incision and superficial opening of incision between the two groups. No intestinal reactions and skin allergies were found in the CM group. CONCLUSIONS: CM plaster containing rhubarb and mirabilite had an effect on SSI. It is safe for mothers and imposes lower economic and mental burdens on patients undergoing CD. (Registration No. ChiCTR2100054626).

[Effect of thumb-tack needle on gastrointestinal function recovery after cesarean section under the concept of enhanced recovery after surgery].

OBJECTIVE: To observe the synergistic effect and safety of combined use of houpo paiqi mixture and thumb-tack needle on promoting gastrointestinal function recovery after cesarean section. METHODS: Parturients receiving cesarean section were randomly divided into the control group (29 cases), the traditional Chinese medicine (TCM) group (30 cases) and needle+TCM group (30 cases). The control group received only routine postoperative treatment. Besides the treatment as the control group, parturients in the TCM group were given 50 mL houpo paiqi mixture 6 h and 10 h after cesarean section respectively. Besides the treatment as the TCM group, parturients in the needle+TCM group received thumb-tack needle treatment at bilateral Zusanli(ST36), Tianshu(ST25), Shangjuxu(ST37) and Sanyinjiao(SP6), Zhongwan(CV12), Qihai(CV6), with auricular pressure at bilateral otopoints Zigong(Uterus), Wei(Stomach) and Dachang(Large intestine), within 1 h after the parturients returned to the ward after the operation. Each acupoint was pressed for 10 s and performed acupressure every 4 h (except sleeping hours), continuously for 3 d. The time of bowel sound recovery, the time to the first postoperative exhaust and defecation, the time of postoperative semi-fluid diet recovery, incidence of postoperative nausea and vomiting (PONV) and abdominal distention, and abdominal pain VAS score were recorded and analyzed. The safety of the treatments was also evaluated. RESULTS: Compared with the control group, the time of bowel sounds recovery, the time to the first postoperative exhaust and the time of postoperative semi-fluid diet recovery were significantly shortened in the TCM and needle+TCM groups (P<0.01); the time to the first postoperative defecation were significantly shortened (P<0.01), incidence of both abdominal distention and PONV were significantly decreased in the needle+TCM group (P<0.05, P<0.01); incidence of abdominal distention were significantly decreased in TCM group (P<0.05). Compared with the TCM group, the time of bowel sounds recovery, the time to the first postoperative exhaust and defecation, and the time of postoperative semi-fluid diet recovery were significantly shortened (P<0.01), and incidence of both abdominal distention and PONV were significantly decreased in the needle+TCM group (P<0.05). VAS scores of the three groups decreased gradually over time (P<0.01). Compared with the control and TCM groups, VAS scores of the needle+TCM group significantly decreased at 24 h, 48 h and 72 h after operation (P<0.01). No treatment-related adverse reactions were observed during the whole trial. CONCLUSION: On the base of the treatment with houpo paiqi mixture, the addition of thumb-tack needle treatment exerted positive synergistic effect on gastrointestinal function recovery after cesarean section, with high safety, which is worthy of clinical application.

[Physiotherapy in the sequelae of cesarean childbirth. A systematic review.] / Fisioterapia en las secuelas del parto por cesárea. Una revisión sistemática.

OBJECTIVE: Caesarean section is a surgical intervention that consists of the extraction of the fetus by abdominal route through the incision in the uterus. Like any surgical intervention, caesarean section is not exempt from complications and these can be classified as short-term (acute pain) and long-term (adhesions in the scar, lumbar and pelvic pain, intestinal obstruction and ectopic pregnancies). Physiotherapy has different tools to address these complications. The aim of this study was to review the scientific bibliography to know the effects of physiotherapy on patients who have given birth by cesarean section. METHODS: A search for articles was carried out during the month of December 2021 in the databases: PubMed, Medline, Cinahl, Scopus, PEDro and WOS using the search terms Cesarean Section, Physical Therapy Modalities and Physical therapy. As an inclusion criterion, it was established that the type of study was a Randomized Clinical Trial (RCT). RESULTS: A total of 280 articles were obtained, of which 9 were selected after applying the eligibility criteria. In them, the most used physiotherapy intervention was electrotherapy, followed by massage therapy and therapeutic exercise. Studies show effects of these forms of physiotherapy, with a determined duration and frequency, with improvements in pain, activities of daily living, comfort level, joint ranges and reduction in the consumption of analgesics. CONCLUSIONS: Physiotherapy has various modalities with which to attend complications after cesarean section, both in an immediate and a late phase, especially highlighting the reduction of pain.

OBJETIVO: La cesárea es una intervención quirúrgica que consiste en la extracción del feto por vía abdominal. Como cualquier intervención quirúrgica, la cesárea no está exenta de complicaciones y éstas se pueden clasificar en a corto plazo (dolor agudo) y a largo plazo (adherencias en la cicatriz, dolores lumbares y pélvicos, obstrucción intestinal y embarazos ectópicos). La fisioterapia cuenta con diferentes herramientas para abordar estas complicaciones. El objetivo de este trabajo fue revisar la bibliografía científica para conocer los efectos de la fisioterapia en las consecuencias del parto por cesárea. METODOS: Se realizó una búsqueda de artículos durante el mes de diciembre de 2021 en las bases de datos PubMed, Medline, Cinahl, Scopus, PEDro y WOS empleando los términos de búsqueda Cesarean Section, Physical Therapy Modalities y Physical Therapy. Como criterio de inclusión se estableció que el tipo de estudio fuese Estudio Clínico Aleatorizado (ECA). RESULTADOS: Se obtuvieron un total de 280 artículos, de los cuales 9 fueron seleccionados tras aplicar los criterios de elegibilidad. En ellos, la intervención más utilizada de fisioterapia fue electroterapia, seguida de masoterapia y ejercicio terapéutico. Los estudios arrojan efectos de estas formas de fisioterapia, con una duración y frecuencia determinada, con mejoras en el dolor, las actividades de la vida diaria, el nivel de comodidad, los rangos articulares y la reducción del consumo de analgésicos. CONCLUSIONES: La fisioterapia cuenta con diversas modalidades con las que atender tanto en una fase inmediata como en una tardía las complicaciones tras una cesárea, destacando especialmente la reducción del dolor.

Epidemiology of Caesarean section on maternal request in Australia: A population-based study.

OBJECTIVE: To explore the trends, determinants, and short-term maternal and neonatal health outcomes of Caesarean section on maternal request (CSMR). DESIGN: Population-based record linkage study. SETTING: Birth registry data for all births in Queensland, Australia, from 2008 to 2017. PARTICIPANTS: Pregnancies resulting in live or intrapartum stillbirth with >=20 gestational weeks and/or >=400 gm birth weight were the study population. The analytic sample was restricted to low-risk pregnancies by excluding preterm, non-cephalic pregnancies with medical risk factors. MEASUREMENTS: CSMR was defined as a first-time C-section in singleton, term pregnancies with an ICD-10-AM code of O-82/O-47. CSMR trend was reported in age-standardised rate using a join-point regression model. The determinants and perinatal outcomes of CSMR were tested against Spontaneous vaginal births (VBs) and planned VBs including assisted VBs and emergency C-sections in this group. The generalised estimating equation technique was used for regression analysis and reported in the odds ratio (OR) at a 95% Confidence Interval (CI). FINDINGS: Of total C-sections (n = 204,863), the average annual change in CSMR rate was 4.4% (95% CI: 2.1-6.7%, p<0.01) for the total pregnancies (N=613,375) Of the analytic sample (N=365568), nulliparous women with age ≥35 years (OR: 2.32,95% CI: 2.09-2.57), delivered at private hospitals (OR:4.90; 95% CI: 4.65-5.18); with mood disorders (OR: 2.15; 95% CI: 1.88-2.43) were positive and midwives birth attendant (OR 0.28; 95% CI: 0.26 to 0.30) was negative influencing factors for CSMR. In a propensity score matched sample; CSMR observed an increasedrisk of anaesthetic complications (OR: 8.00; 95% CI:1.95-32.82) and slightly reduced odds of birth asphyxia (OR:0.20;95%CI:0.06-0.60)against planned VBs while the overall incidence of birth-asphyxia was low (1.29%) However, neonatal morbidities (OR:1.61; 95% CI:1-2.59) and special care admission (OR:2.15; 95% CI:1.03-4.5) were higher after CSMR in comparison to SVBs CONCLUSION: Despite being linked with adverse perinatal health outcomes, the incidence of CSMR increased 1.75-fold during the past 10 years. Maternal educational interventions to provide adequate information, including the long-term risks and benefits of C-sections, can help reduce the growing rates of CSMR.

Does antenatal cholecalciferol supplementation affect the mode or timing of delivery? Post hoc analyses of the MAVIDOS randomized controlled trial.

BACKGROUND: Observational studies relating maternal 25-hydroxyvitamin D status to timing and mode of delivery have reported inconsistent results. We assessed the effect of antenatal cholecalciferol supplementation on the incidence of preterm birth, delivery mode and post-partum haemorrhage (PPH). METHODS: MAVIDOS was a randomized, double-blind, placebo-controlled trial of 1000 IU/day cholecalciferol from 14 weeks' gestation until delivery. Gestational age, mode of delivery [categorized as spontaneous vaginal delivery (SVD), instrumental (including forceps and vacuum extraction) or Caesarean section] and PPH (>500 ml estimated blood loss) were determined from medical records. RESULTS: A total of 965 women participated in the study until delivery. Gestation at birth and incidence of preterm birth (cholecalciferol 5.7%, placebo 4.5%, P = 0.43) were similar between the two treatment groups. SVD (versus instrumental or Caesarean delivery) was more likely in women randomized to cholecalciferol [Relative Risk (RR) 1.13, 95% confidence interval (CI) 1.02,1.25] due to lower instrumental (RR 0.68, 95%CI 0.51,0.91) but similar risk of Caesarean delivery (RR 0.94, 95%CI 0.74,1.19). PPH was less common in women randomized to cholecalciferol [32.1% compared with placebo (38.1%, P = 0.054) overall], but similar when stratified by delivery mode. CONCLUSIONS: Antenatal cholecalciferol supplementation did not alter timing of birth or prevalence of preterm birth but demonstrated a possible effect on the likelihood of SVD.

Cesarean Scar Pregnancies Treated by Uterine Artery Chemotherapy Embolization Combined With Ultrasound-Guided Dilation and Curettage: A Retrospective Study.

OBJECTIVES: To explore the effect of cesarean scar pregnancy (CSP) treatment by comparing uterine artery chemotherapy embolization (UACE) combined with dilation and curettage (D&C) with or without ultrasound guidance. METHODS: CSP patients treated with UACE combined with D&C from January 2013 to December 2020 at Shuguang Hospital, affiliated to Shanghai University of Traditional Chinese Medicine were included in this retrospective study. The patients were divided into groups A and B according to whether D&C was guided by ultrasound. RESULTS: Forty-eight patients with CSP diagnosed by transvaginal ultrasound were included in this study, whose gestational age was <8 weeks. There were no significant differences in the basic clinical characteristics of the two groups. The success rates of the 2 groups were no significant difference, 100% (27/27) in group A and 85.7% (18/21) in group B. The maximal intraoperative blood loss of group A was 100 mL and that of group B was 150 mL. There was no uterine perforation during the operation. Ultrasound guidance can shorten the D&C operation time, reduce intraoperative bleeding during D&C, and decrease the residual rate of trophoblastic tissue after D&C. CONCLUSIONS: Ultrasound guidance can improve the safety and efficiency of UACE combined with D&C in the treatment of CSP and reduce its complications. We believe it is an optimal treatment for CSP patients who do not plan to have children in the future.

Effect of Acupressure Applied After Cesarean Section Under Spinal Anesthesia Postpone the Duration of Taking Analgesics and on The Gastrointestinal System: A Randomized Controlled Trial.

OBJECTIVES: Cesarean deliveries are one of the primary conditions associated with postoperative decreased motility of the gastrointestinal system and are characterized by acute pain and distention. The aim of the present study was to investigate the application of acupressure and the administration of analgesics for women who underwent cesarean section under spinal anesthesia could be delayed and how spontaneous gastrointestinal system motility could be achieved in the postoperative period. DESIGN: Randomized controlled trial SETTING: Private Medipol Nisa Hospital, Istanbul, Turkey INTERVENTION: This trial was conducted with 112 primipara pregnant women who delivered via cesarean section under spinal anesthesia and were randomly assigned into the acupressure (n=52) and control (n=60) groups. The participants in the acupressure group (n=52) were treated for 20 minutes. The participants in the control group (n=60) were treated per the hospital protocol (analgesics for pain, flatulation and defecation, no pharmacological or non-pharmacological application was performed). RESULTS: The time that elapsed for the administration of analgesics was significantly later in the acupressure group than in the control group (p <.001). The first occurrence of flatulation and defecation were significantly earlier in the acupressure group (19 and 23 hours, respectively) than in the control group (34 and 27 hours, respectively) (p <.001). CONCLUSION: Acupressure is an easy, non-invasive method that postpones the administration of analgesics in the postoperative period and prevents flatulence and constipation caused by the decreased motility of GIS.

Influence of transcutaneous electrical nerve stimulation on pain intensity and functional activities following lower segment cesarean section.

BACKGROUND: Postoperative incisional pain following lower segment cesarean section (LSCS) is one of the commonly reported complaints which may affect mother-infant bonding, and restrict mobility and functional activities. PURPOSE: To study the influence of transcutaneous electrical nerve stimulation (TENS) on pain intensity and functional activities using the Numerical Pain Rating Scale (NPRS) and the Patient Specific Functional Scale (PSFS) following LSCS from the postoperative day (POD) 1 to POD 4. METHODS: This quasi-experimental study consisted of 50 postpartum women who underwent LSCS and were assigned to an intervention group (IG) that received TENS and a control group (CG) that received routine hospital care. RESULTS: NPRS scores between CG and IG (pre-TENS application) showed a statistically significant difference (ηp2 = 0.542, p < .001) from POD 1 to POD 4. Study participants showed an improvement in PSFS scores (ηp2 = 0.412, 0.488, 0.661, 0.304, 0.262, and 0.395, p < .001) in IG compared to CG for bed transitions, bed transfers, sitting, sit to stand, walking, and toileting activities respectively from POD 1 to POD 4 which was statistically significant. CONCLUSIONS: Our study results suggest that administration of TENS following LSCS shows an improvement in pain intensity and functional activities as reported on NPRS and PSFS respectively.

Effect of Foot Reflexology and Benson Relaxation on Pain, Breastfeeding and Weight of Neonates of Women Undergoing a Cesarean Section.

BACKGROUND: Given the negative effect of postoperative pharmacological pain control on breastfeeding, the present study aimed to compare the effects of reflexology and Benson relaxation methods on pain, breastfeeding, and infant weight gain in women undergoing a cesarean section (C/S). METHODS: This randomized clinical trial was conducted on 135 women undergoing a C/S in the Gynecology Ward of Bushehr Persian Gulf Martyrs Hospital in Bushehr, Iran, in 2020. The participants were selected using convenience sampling, and randomly divided into three groups of foot reflexology, Benson relaxation, and control. The interventions were performed two hours post-operation and six hours after the first intervention. The pain score was measured and recorded immediately, and 30 and 60 minutes after each intervention. Breastfeeding frequency and duration were also assessed in the first 18 hours of birth. The infants' weight was assessed at birth and 10 days later. Data analysis was performed using inferential statistics, chi-square or Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U or one-way ANOVA, Wilcoxon test and logistic regression analysis. RESULTS: There was a larger decrease in the pain score of the reflexology and Benson relaxation (P<0.01) groups after the first and second interventions, compared to the control group. The breastfeeding frequency was higher in the two intervention groups, compared to the control group (P<0.001). Furthermore, the rate of return to the birth weight in ten days of birth was higher in the reflexology (P<0.01) and Benson groups (P<0.05) than the control group. CONCLUSION: Both the reflexology and the Benson relaxation methods effectively decreased pain and increased breastfeeding frequency and the infant's weight gain.

Chinese Medicine Plaster as A New Treatment for Surgical Site Infection in Patients with Cesarean Delivery: A Randomized, Double-Blind, Controlled Trial / 中国结合医学杂志

OBJECTIVE@#To evaluate the efficacy of Chinese plaster containing rhubarb and mirabilite on surgical site infection (SSI) in patients with cesarean delivery (CD) by performing a randomized controlled trial.@*METHODS@#This randomized controlled trial included 560 patients with CD due to fetal head descent enrolled at a tertiary teaching center between December 31, 2018 and October 31, 2021. Eligible patients were randomly assigned to a Chinese medicine (CM) group (280 cases) or a placebo group (280 cases) by a random number table, and were treated with CM plaster (made by rhubarb and mirabilite) or a placebo plaster, respectively. Both courses of treatment lasted from the day 1 of CD, followed day 2 until discharge. The primary outcome was the total number of patients with superficial, deep and organ/space SSI. The secondary outcome was duration of postoperative hospital stay, antibiotic intake, and unplanned readmission or reoperation due to SSI. All reported efficacy and safety outcomes were confirmed by a central adjudication committee that was unaware of the study-group assignments.@*RESULTS@#During the recovery process after CD, the rates of localized swelling, redness and heat were significantly lower in the CM group than in the placebo group [7.55% (20/265) vs. 17.21% (47/274), P<0.01]. The durution of postoperative antibiotic intake was shorter in the CM group than in the placebo group (P<0.01). The duration of postoperative hospital stay was significantly shorter in the CM group than in the placebo group (5.49 ± 2.68 days vs. 8.96 ± 2.35 days, P<0.01). The rate of postoperative C-reactive protein elevation (≽100 mg/L) was lower in the CM group than in the placebo group [27.6% (73/265) vs. 43.8% (120/274), P<0.01]. However, there was no difference in purulent drainage rate from incision and superficial opening of incision between the two groups. No intestinal reactions and skin allergies were found in the CM group.@*CONCLUSIONS@#CM plaster containing rhubarb and mirabilite had an effect on SSI. It is safe for mothers and imposes lower economic and mental burdens on patients undergoing CD. (Registration No. ChiCTR2100054626).

Parathyroid carcinoma during pregnancy: a novel pathogenic CDC73 mutation - a case report.

BACKGROUND: Parathyroid carcinoma is an uncommon cause of PTH-dependent hypercalcemia. Only a handful of cases have been reported of parathyroid carcinoma during pregnancy. CASE PRESENTATION: Twenty-four - Year - old female presented with proximal myopathy was found to have hypercalcemia. Her serum corrected total calcium was - 15 mg/dl (8.5 - 10.3), serum phosphate - 2.3 mg/dl (2.5 - 4.5), intact PTH - 118 pg/ml (20 - 80), Vitamin D - 15 ng/ml and Urine Ca/Cr ratio - 2.1 (0.1 - 0.2). Her CECT-neck revealed a well-defined mass lesion posterior to the right lobe of the thyroid - 2.6 cm × 2.5 cm × 2.9 cm in size. She was started on vitamin D supplementation, and she underwent right lower focal parathyroidectomy. Her PTH levels normalized following surgery. Her histology revealed an atypical parathyroid adenoma. She was treated with calcium and vitamin D. Her follow up was uneventful. One year following initial surgery the patient became pregnant and at 16 weeks of POA, the patient presented with a rapidly enhancing neck mass for one week duration. Her biochemical investigations were suggestive of a recurrence of primary hyperparathyroidism. Her ultrasound scan of the neck revealed a well-defined discreate hypoechoic nodule, superior to the thyroid isthmus which was confirmed by a non-contrast MRI scan of the neck. She underwent an uncomplicated second trimester parathyroid tumour excision with normalization of post op PTH. Her histology revealed a parathyroid carcinoma with vascular and capsular invasion. Her genetic studies revealed a novel frameshift mutation of the CDC73 gene. She was treated with calcium and vitamin D supplementation and closely followed up with ionized calcium and PTH levels which were normal throughout the pregnancy. She had an uncomplicated caesarean section at a POA of 37 weeks. Currently she is twelve weeks post-partum, in remission of disease. CONCLUSION: This case shows the importance of stringent follow up of atypical parathyroid adenoma patients, the benefit of second trimester surgery in management of hypercalcemia due to parathyroid carcinoma during pregnancy and the importance of identifying the novel CDC73 gene mutation.

Successful laparoscopic surgical removal of a caesarean scar pregnancy (CSP) using temporary uterine artery ligation.

STUDY OBJECTIVE: To demonstrate a laparoscopic technique to remove a scar pregnancy. DESIGN: Stepwise demonstration of the surgical technique. SETTING: Santa Croce and Carle Hospital, Cuneo. INTERVENTION: Patient B.B. is a woman referred to our center for a suspected cesarean scar pregnancy (CSP) at 9 weeks gestation. CSP occurs approximately in 6% of all ectopic pregnancies. The estimated incidence is reported to be 1:1800 to 1:2500 in cesarean deliveries. Depending on its location, CSP can be categorized as either type 1, if the growth is in the uterine cavity, or type 2, if it expands toward the bladder and the abdominal cavity. If inadequately managed, it can lead to severe complications; most of them are hemorrhagic and can threaten the woman's life. There are several therapeutic approaches: local excision seems to be the most effective choice in type 2 CSP. In expert hands, the laparoscopic approach is perhaps the best surgical choice as tissue dissection, electrosurgical hemostasis, and vascular control can be effectively managed with minimal invasive access. Because severe intraoperative bleeding can occur, retroperitoneal vascular control is mandatory in this surgery. In type 1 CSP curettage, aspiration or hysteroscopic approach can be considered if the CSP is of small dimensions. A hysteroscopic approach can also be helpful in type 2 CSP during the laparoscopic removal, as intrauterine guidance. A potassium chloride local injection can be considered in a preoperative stage in the presence of a fetal heart rate. The systemic administration of methotrexate is usually ineffective as single agent, but it can be useful if administered as adjuvant therapy. Uterine artery embolization can be useful in an emergency setting to manage severe bleeding, but it can lead to complications in subsequent pregnancies and, more rarely, to premature ovarian failure. Considering poor bleeding at presentation, feasible dimensions, and the woman's desire for future pregnancy, ultrasound-guided aspiration and curettage was attempted. Because endouterine removal was incomplete, methotrexate injection was proposed as adjuvant therapy, but the administration was postponed as the patient tested positive for coronavirus disease 2019. A month later, beta-human chorionic gonadotropin level dropped from over 16 000 to 271 mU/mL, so an ultrasound and biochemical follow-up was performed. A month later, despite a low beta-human chorionic gonadotropin value, an increase in dimensions was observed at ultrasound, so surgical laparoscopic removal was offered. In this video article, laparoscopic removal of scar pregnancy is discussed in the following surgical steps: (1) Temporary closure of uterine arteries at the origin, using removable clips. (2) Retroperitoneal dissection to safely manage the scar pregnancy. (3) Dissection of the myometrial-pregnancy interface. (4) Double layer suture on the anterior uterine wall. CONCLUSION: Laparoscopic surgical management is a very effective surgical approach to remove CSP. Knowledge of retroperitoneal dissection and vascular control is necessary to carry out this surgical intervention safely and effectively.