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.

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.

Effective Dose of Prophylactic Oxytocin Infusion During Cesarean Delivery in 90% Population of Nonlaboring Patients With Preeclampsia Receiving Magnesium Sulfate Therapy and Normotensives: An Up-Down Sequential Allocation Dose-Response Study.

BACKGROUND: Oxytocin administration during cesarean delivery is the first-line therapy for the prevention of uterine atony. Patients with preeclampsia may receive magnesium sulfate, a drug with known tocolytic effects, for seizure prophylaxis. However, no study has evaluated the minimum effective dose of oxytocin during cesarean delivery in women with preeclampsia. METHODS: This study compared the effective dose in 90% population (ED90) of oxytocin infusion for achieving satisfactory uterine tone during cesarean delivery in nonlaboring patients with preeclampsia who were receiving magnesium sulfate treatment with a control group of normotensives who were not receiving magnesium sulfate. This prospective dual-arm dose-finding study was based on a 9:1 biased sequential allocation design. Oxytocin infusion was initiated at 13 IU/h, on clamping of the umbilical cord, in the first patient of each group. Uterine tone was graded as satisfactory or unsatisfactory by the obstetrician at 4 minutes after initiation of oxytocin infusion. The dose of oxytocin infusion for subsequent patients was decided according to the response exhibited by the previous patient in the group; it was increased by 2 IU/h after unsatisfactory response or decreased by 2 IU/h or maintained at the same level after satisfactory response, in a ratio of 1:9. Oxytocin-associated side effects were also evaluated. Dose-response data for the groups were evaluated using a log-logistic function and ED90 estimates were derived from fitted equations using the delta method. RESULTS: The ED90 of oxytocin was significantly greater for the preeclampsia group (n = 27) than for the normotensive group (n = 40) (24.9 IU/h [95% confidence interval {CI}, 22.4-27.5] and 13.9 IU/h [95% CI, 12.4-15.5], respectively); the difference in dose requirement was 10.9 IU/h (95% CI, 7.9-14.0; P < .001). The number of patients with oxytocin-related hypotension, defined as a decrease in systolic blood pressure >20% from baseline or to <90 mm Hg, was significantly greater in the preeclampsia group (92.6% vs 62.5%; P = .030), while other side effects such as ST-T depression, nausea/vomiting, headache, and flushing, were not significantly different. There was no significant difference in the need for additional uterotonic or uterine massage, estimated blood loss, and need for re-exploration for uncontrolled bleeding. CONCLUSIONS: Patients with preeclampsia receiving preoperative magnesium therapy need a greater intraoperative dose of oxytocin to achieve satisfactory contraction of the uterus after fetal delivery, as compared to normotensives.

The effect of transcutaneous electrical nerve stimulation (TENS) on pain control and phenylethanolamine-N-methyltransferase (PNMT) gene expression after cesarean section.

Transcutaneous electrical nerve stimulation (TENS) is one of the non-pharmacological methods of pain relief that has been able to reduce pain by 70 to 90% in postoperative pain control. This study aimed to determine the effect of TENS on pain control after cesarean section and its effect on PNMT gene expression. For this purpose, a double-blind randomized clinical trial was performed on 70 Chinese patients with elective cesarean section. Patients were divided into case and control groups. In the case group, TENS and analgesic drugs were used to relieve pain, and in the control group, the only analgesic drug was used. Then the severity of pain, recurrence of pain attacks, the number of analgesic drugs used and the amount of analgesic drug used in the first 24 hours after surgery were evaluated and compared. Blood samples were also taken from patients to evaluate PNMT gene expression. The semi-quantitative RT-PCR was used to study changes in gene expression. The results showed that the group treated with TENS had less pain intensity and less recurrence of pain attacks than the group that received only analgesic medication. Also, the frequency of analgesic drug use and its dose in the TENS group were significantly lower than in the control group. TENS, on the other hand, has been able to greatly reduce the expression of the PNMT gene, which is produced during times of stress. Therefore, it is recommended that TENS be used as a non-invasive and non-pharmacological adjuvant effective in reducing pain after cesarean section.

Adequacy of maternal anesthesia depth with two sodium thiopental doses in elective caesarean section: a randomized clinical trial.

BACKGROUND: Administration of an optimal dose of anesthetic agent to ensure adequate depth of hypnosis with the lowest risk of adverse effects to the fetus is highly important in cesarean section. Sodium thiopental (STP) is still the first choice for induction of anesthesia in some countries for this obstetric surgery. We aimed to compare two doses of STP with regarding the depth of anesthesia and the condition of newborn infants. METHODS: In this clinical trial, parturient undergoing elective Caesarian section were randomized into two groups receiving either low-dose (5 mg/kg) or high-dose (7 mg/kg) STP. Muscle relaxation was provided with succinylcholine 2 mg/kg and anesthesia was maintained with O2/N2O and sevoflurane. The depth of anesthesia was evaluated using isolated forearm technique (IFT) and bispectral index (BIS) in various phases. Additionally, infants were assessed using Apgar score and neurobehavioral test. RESULTS: Forty parturient were evaluated in each group. BIS was significantly lower in high-dose group at skin incision to delivery and subcutaneous and skin closure. Also, significant differences were noticed in IFT over induction to incision and incision to delivery. Apgar score was significantly lower in high-dose group at 1 min after delivery. Newborn infants in low-dose group had significantly better outcomes in all three domains of the neurobehavioral test. CONCLUSION: 7 mg/kg STP is superior to 5 mg/kg in creating deeper hypnosis for mothers. However, it negatively impacts Apgar score and neurobehavioral test of neonates. STP seems to has dropped behind as an acceptable anesthetic in Cesarean section. TRIAL REGISTRATION: IRCT No: 2016082819470 N45 , 13/03/2019.

Arteriovenous malformation as a cause for acute confusion and gastrointestinal bleeding in a primigravida pregnancy.

Acute confusion in pregnancy is generally uncommon, given the relatively young and healthy population obstetricians care for. We present an unusual and rare case of acute confusion in a term pregnancy with antecedent history of gastrointestinal (GI) bleeding. A primigravida with no medical history of note, was found to have a haemoglobin of 67 g/L at booking and was commenced on oral iron supplementation. In the third trimester, she presented with haematochezia and had several admissions, requiring 18 units of red blood cells during her pregnancy. At term, she was admitted with acute confusion and GI bleeding, and was subsequently delivered by caesarean section to facilitate ongoing investigation and management of her symptoms. She was diagnosed postnatally with an arteriovenous malformation in the jejunum which required interventional radiology and surgical management for symptom resolution. Her confusion was attributed to hyperammonaemic levels secondary to her high protein load.

Effects of Umbilical Cord Milking on Term Infants Delivered by Cesarean Section.

OBJECTIVE: Umbilical cord milking (UCM) is an efficient way to achieve optimal placental transfusion in term infants born by cesarean section (CS). However, it is not frequently performed due to concern for short-term adverse effects of increased blood volume, such as polycythemia and hyperbilirubinemia. The aim of this study is to evaluate the short-term effects of UCM on term infants delivered by CS. STUDY DESIGN: We conducted a pre- and postimplementation cohort study comparing term infants delivered by CS who received UCM five times (141 infants, UCM group) during a 6-month period (August 1, 2017 to January 31, 2018) to those who received immediate cord clamping (ICC) during the same time period (105 infants, postimplementation ICC) and during a 3-month period (October1, 2016 to December 31, 2016) prior to the implementation of UCM (141 infants, preimplementation ICC). RESULTS: Mothers were older in UCM group compared with both ICC groups. There were no significant differences in other maternal or neonatal characteristics. Although this study was not powered to detect differences in outcomes, the occurrence of hyperbilirubinemia needing phototherapy, symptomatic polycythemia, NICU admissions, or readmissions for phototherapy was similar between the groups. CONCLUSION: UCM intervention was not associated with increased incidence of phototherapy or symptomatic polycythemia in term infants delivered by CS.

Effects of acupressure, gum chewing and coffee consumption on the gastrointestinal system after caesarean section under spinal anaesthesia.

This study evaluated the efficacy and safety of postoperative acupressure in the recovery of the gastrointestinal system (GIS) after caesarean section. A total of 160 primipara pregnant women delivered by caesarean section under spinal anaesthesia were randomised into four groups: group 1 (those who received acupressure), group 2 (coffee was provided three times a day), group 3 (chewed sugar-free gum for 15 min with an interval of 4 h from the second postoperative hour), and group 4 (control group). The first gas outflow and defaecation times of the women were compared among the groups. The first flatus and defaecation exit times of the women in the acupressure group were statistically earlier than those of the other groups. No difference was found among the gum-chewing, coffee, and control groups. Acupressure is effective in reducing the flatus and defaecation exit times due to GIS inactivity after abdominal surgery including caesarean section.Impact statementWhat is already known about the topic. The slowing of gastrointestinal system (GIS) motility also occurs after caesarean section aside from other surgical operations. If normal GIS movements do not occur, then several problems, such as the negative increase in the duration of breastfeeding and the mother-baby attachment during the postpartum period, may arise. Therefore, the early onset of bowel functions is important in women who give birth by caesarean section.What do the results of this study add. In the postoperative period, spontaneous GIS motility can be achieved by applying acupressure. The effective use of acupressure in the postoperative period prevents the need for pharmacological methods to eliminate the discomfort caused by the decreased motility of the GIS in women in the postpartum period.What are the implications of these findings for clinical practice and further research. Acupressure, a non-invasive, easy-to-use, and cost-effective method, plays a role in preventing GIS immotility. Midwives or obstetricians should receive training on acupuncture or acupressure and should ensure that acupuncture or acupressure practices are converted into a protocol to be implemented in the postoperative period. With this transformation, the treatment methods to increase GIS motility and the reduced medication use can decrease the mother's and the newborn's duration of hospital stay and the cost of hospitalisation.

Compliance with antibiotic prophylaxis guidelines in surgery: Results of a targeted audit in a large-scale region-based French hospital network.

INTRODUCTION: While regional monitoring of antibiotic use has decreased since 2011 by 3.2%, in some healthcare facilities a significant increase (+43%) has occurred. The purpose of this study was to assess regional antibiotic prophylaxis (ABP) compliance with national guidelines. MATERIAL AND METHODS: In 2015, 26 healthcare facilities, both public and private, were requested to audit five items: utilization of antibiotic prophylaxis, the antimicrobial agent (the molecule) administered, time between injection and incision, initial dose, number of intraoperative and postoperative additional doses. Seven surgical procedures were selected for assessment: appendicectomy (APP), cataract (CAT), cesarean section (CES), colorectal cancer surgery (CCR), hysterectomy (HYS), total hip arthroplasty (THA) and transurethral resection of the prostate (TURP). A statistical analysis of the 2303 records included was carried out. RESULTS: The general rate of antibiotic prophylaxis compliance was 64%. The antimicrobial agent used and initial dose were in compliance with the guidelines for 93% and 97.4% of cases respectively, and administration of antibiotic prophylaxis was achieved 60minutes before incision in 77.6% of the records included. Regarding gastrointestinal surgery, amoxicillin/clavulanic acid was used in 32% of patients. In 26% of appendectomy files, administration occurred after incision, and one out of two files showed non-complaint perioperative and postoperative consumption. CONCLUSION: Compliance with nationwide ABP guidelines is in need of pronounced improvement, especially with regard to time interval between injection and incision and the molecule prescribed. An action plan based on specific recommendations addressed to each establishment and an updated regionwide ABP protocol are aimed at achieving better and reduced consumption of antimicrobial agents.

Influence of non-pharmacological obstetric interventions on adverse outcomes of childbirth under regional analgesia.

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Clinical outcomes of prophylactic compression sutures for treatment of uterine atony during the cesarean delivery of twins.

BACKGROUND: Twin pregnancy has a high risk for developing uterine atony (UA). This study aimed to evaluate efficacy and clinical outcomes of prophylactic compression sutures to treat UA during twin cesarean section (CS). METHODS: All patient records of twin deliveries by CS after gestational age of 24 weeks in a large maternity hospital in South Korea between January 2013 and June 2018 were reviewed. Patients with monochorionic monoamniotic twins were excluded from data analysis. In total, 953 women were eligible for data analysis. RESULTS: Of the 953 patients, compression sutures were applied to 147 cases with postpartum bleeding that were refractory to uterine massage and uterotonics. Out of the 147, two patients (1.4%) proceeded to additional uterine artery ligation to achieve hemostasis, yielding a success rate of 98.6%. The rate of transfusion after the first 24 h of delivery in the suture group was not significantly different from that in the non-suture group, suggesting that both groups achieved hemostasis at an equal rate after the first 24 h of delivery. The difference in the operation time between the two groups was only 8.5 min. The rate of subsequent pregnancy among the patients who received compression sutures was 44.4%. CONCLUSIONS: Overall, our findings suggest that with early and fast implementation of compression sutures, UA can be treated in the setting of twin cesarean delivery without significantly increasing maternal morbidity.

Implementing Delayed Umbilical Cord Clamping in Cesarean Birth Using a Novel Method: A Pilot Study of Feasibility and Safety.

INTRODUCTION: Although delayed cord clamping (DCC) is regarded as the standard of care for all vigorous newborns, those born via cesarean birth are less likely to be afforded this option, especially for longer than 30 to 60 seconds. This pilot study was undertaken to determine whether removal of the placenta before cord clamping to allow for DCC of at least 3 minutes during term, uncomplicated cesarean birth is feasible and without apparent safety issues in order to support a large prospective study on the benefits of this method. METHODS: Women having a term, uncomplicated cesarean birth who consented to the study were enrolled. Safety was assessed by comparing estimated maternal blood loss, newborn Apgar scores, temperatures, transcutaneous bilirubin levels, need for phototherapy, and neonatal intensive care unit admissions with a matched historical control group of women whose newborns had immediate cord clamping. Feasibility was measured by evaluating staff and maternal comfort with the intervention and by the ability to complete the protocol steps. RESULTS: Seventeen women consented to participate. The protocol was successfully completed in 94% of births. There were no differences in maternal and neonatal safety outcome measures between groups. There was high comfort level with the protocol among staff, and there was universal maternal satisfaction. DISCUSSION: This method of DCC in cesarean birth appears feasible and safe in this small pilot study and was associated with high maternal satisfaction and clinician comfort. Major organizations such as the American College of Nurse-Midwives and the World Health Organization have called for DCC of up to 3 to 5 minutes in all births, and this simple method has the potential to reach that goal in cesarean birth with minimal apparent risk. A large randomized controlled trial is warranted to determine the neonatal and maternal benefits and safety of this technique compared with a 30-to-60-second delay.

The identification of key indicators to drive quality improvement in obstetric anaesthesia: results of the Obstetric Anaesthetists' Association/National Perinatal Epidemiology Unit collaborative Delphi project.

A three-stage Delphi survey process was undertaken to identify the quality indicators considered the most relevant to obstetric anaesthesia. The initial quality indicators assessed were derived from national peer-reviewed publications and were divided into service provision, service quality and clinical outcomes. A range of stakeholders were invited to participate and divided into three panels: obstetric anaesthetists; other maternity care health professionals; and women who had used maternity services. In total, 133 stakeholders registered to participate with 80% completing all three phases of the survey process. Participants ranked indicators for their relative importance using the grading of recommendations assessment, development and evaluation scale. From an initial list of 31 quality indicators, 11 indicators were rated as extremely important by > 90% of participants in at least two panels. These 11 indicators were presented to stakeholders; they were asked to vote for the five indicators they considered most relevant and useful for assessing and benchmarking the quality of obstetric anaesthesia provided. The indicators chosen were: the percentage of women who had an epidural/combined spinal-epidural for labour analgesia with accidental dural puncture; the presence of guidelines for the referral of patients to an anaesthetist for antenatal review; whether there are dedicated elective caesarean section lists; the availability of point-of-care testing for estimation of haemoglobin concentration; and the percentage of epidurals for labour analgesia that provided adequate pain relief within 45 min of the start of epidural insertion. These indicators may be used for quality improvement and national benchmarking to support the implementation of quality standards in obstetric anaesthesia.

The effect of delayed umbilical cord clamping on cord blood gas analysis in vaginal and caesarean-delivered term newborns without fetal distress: a prospective observational study.

OBJECTIVE: To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress. DESIGN: Prospective observational study. SETTING: University hospital. SAMPLE: CBG from 97 VDs and 124 CDs without fetal distress. METHODS: Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs. MAIN OUTCOME MEASURES: Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO2 ), partial pressure of carbon dioxide (pCO2 ), pH, and postpartum haemorrhage. RESULTS: Arterial cord blood pH, bicarbonate ( HCO3- , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO3-  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO3-  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO2 increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit. CONCLUSIONS: After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs. TWEETABLE ABSTRACT: By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively.

Maternal hyperuricemia as a marker of post-spinal hypotension and uterine tone during cesarean delivery: a prospective observational study.

PURPOSE: Raised serum uric acid, a marker of oxidative stress, is known to increase vascular tone and depress myometrial contractility. A rise in serum uric acid levels has also been reported during labor, warranting its correlation with post-spinal hypotension and uterine tone. METHODS: Serum UA sample was drawn from enrolled healthy, laboring parturients. Of these, 100 women who required emergency cesarean delivery were re-sampled prior to surgery. Following spinal anesthesia we recorded episodes of hypotension (MAP < 80% of baseline), use of vasopressors and supplemental uterotonics. The primary outcome was maternal hyperuricemia (1SD > appropriate for gestation age) and its correlation with post-spinal hypotension. Secondary outcomes were total vasopressors used, duration of labor and its effect on uric acid levels, uterine tone and neonatal outcome. RESULTS: Hyperuricemia was observed in 33% of parturients. On comparing with women showing normal uric acid levels, hyperuricemic parturients experienced significantly lower incidence of post-spinal hypotension (45.5% vs. 67.2%; p value = 0.04) and lower vasopressor usage (p value = 0.06). Clinically, an increased use of supplemental uterotonics in these parturients was noted (p = 0.20). The duration of labor had no impact on uric acid levels. Neonatal outcome was unaffected. CONCLUSIONS: In healthy, normotensive parturients undergoing emergency cesarean delivery, maternal hyperuricemia is associated with lower incidence of post-spinal hypotension and reduced need of vasopressors. Elevated serum uric acid levels may also be associated with decreased uterine tone, necessitating greater requirement of supplemental uterotonics. However, further prospective trials are needed to strongly establish this association.

Relation between Length of Exposure to Epidural Analgesia during Labour and Birth Mode.

OBJECTIVE: To appraise the relationship between the length of exposure to epidural analgesia and the risk of non-spontaneous birth, and to identify additional risk factors. This study is framed within the MidconBirth project. STUDY DESIGN: A multicentre prospective study was conducted between July 2016 and November 2017 in three maternity hospitals in different Spanish regions. The independent variable of the study was the length of exposure to epidural analgesia, and the dependent variable was the type of birth in women with uncomplicated pregnancies. The data was analyzed separately by parity. A multivariate logistic regression was performed. The odds ratios (OR), using 95% confidence intervals (CI) were constructed. MAIN OUTCOME MEASURES: During the study period, 807 eligible women gave birth. Non-spontaneous births occurred in 29.37% of the sample, and 75.59% received oxytocin for augmentation of labour. The mean exposure length to epidural analgesia when non-spontaneous birth happened was 8.05 for primiparous and 6.32 for multiparous women (5.98 and 3.37 in spontaneous birth, respectively). A logistic regression showed the length of exposure to epidural during labour was the major predictor for non-spontaneous births in primiparous and multiparous women followed by use of oxytocin (multiparous group). CONCLUSIONS: The length of exposure to epidural analgesia during labour is associated with non-spontaneous births in our study. It highlights the need for practice change through the development of clinical guidelines, training programs for professionals and the continuity of midwifery care in order to support women to cope with labour pain using less invasive forms of analgesia. Women also need to be provided with evidence-based information.

Effect of grape seed extract ointment on cesarean section wound healing: A double-blind, randomized, controlled clinical trial.

BACKGROUND: and purpose: Complications of the delayed recovery of cesarean section (CS) wound can include stress, discomfort, and dissatisfaction of the mother in the postpartum period. This study tried to determine the effect of grape seed extract ointment on CS wound healing. MATERIALS AND METHODS: This is a double-blind, randomized, controlled clinical trial incorporating 129 women eligible for CS in eastern Iran. Participants were selected through convenience sampling method and were subsequently randomly assigned into three groups: 2.5% grape seed extract ointment, 5% grape seed extract ointment, and petrolatum. CS wound healing indices were assessed before the intervention, and 6 and 14 days after the intervention using the REEDA scale (redness, edema, ecchymosis, discharge, and approximation). RESULTS: The mean scores on days 6 and 14 after intervention were respectively 2.02 ±â€¯0.52 and 0.98 ±â€¯0.61 in the 5% ointment group, 2.83 ±â€¯0.54 and 1.58 ±â€¯0.67 in the 2.5% ointment group, and 2.91 ±â€¯0.51 and 1.55 ±â€¯0.74 in the petrolatum group. While the mean score in the 5% ointment group was significantly different from those of 2.5% ointment and petrolatum groups (P < 0.001), the mean score in the 2.5% ointment group was not significantly different from that of the petrolatum group on days 6 and 14 after intervention (P = 0.38 and P = 0.79, respectively). CONCLUSION: The current results suggest that 5% grape seed extract may have beneficial therapeutic effects in promoting CS wound healing.

Effectiveness of acupuncture for recovery of flatulence after cesarean section: A case report.

RATIONALE: Postoperative ileus with flatulence is a common symptom in patients who have undergone cesarean section, and it can lead to peritonitis and intestinal perforation. However, few previous reports described therapeutic effects of acupuncture in women with flatulence after cesarean delivery. We reported a case of 29-year-old woman with abdominal flatulence after cesarean section. PATIENT CONCERNS: The patient developed right abdominal pain and distention with no discharging bowel movement or passage of gas through the anus after cesarean section. DIAGNOSIS: The computed tomography revealed bowel loops filled with gas. She was diagnosed with postoperative ileus. INTERVENTIONS: From the second day after cesarean section, acupuncture was administered at the bilateral Zusanli (ST36), Shangjuxu (ST37), Yinlingquan (SP9), Sanyinjiao (SP6), Zhigou (TE6), and Hegu (LI4) acupoints. OUTCOMES: The patient exhibited the successful passage of gas through the anus 30 minutes after acupuncture needles were removed. The time to first defecation with a normal total stool weight and moderate hardness was 3 hours after acupuncture treatment. LESSONS: Acupuncture can be an effective alternative treatment in patients with flatulence after cesarean section.

Effects of Connective Tissue Massage on Pain in Primiparous Women After Cesarean Birth.

OBJECTIVE: To evaluate the efficacy of connective tissue massage to reduce postoperative pain in primiparous women on Postoperative Day 1 after unplanned cesarean birth. DESIGN: A randomized controlled trial with three groups: intervention (Group 1), control or standard care (Group 2), and individualized attention (Group 3). SETTING: Family/newborn units of a large teaching hospital in the Northeastern United States. PARTICIPANTS: A total of 165 women who experienced unplanned cesarean births of singleton newborns at term gestation. METHODS: Participants were randomized to three groups: those in Group 1 received a 20-minute massage, those in Group 2 received the usual standard of care, and those in Group 3 received 20 minutes of individualized attention. On Postoperative Day 1, participants completed questionnaires to measure overall pain, stress, and relaxation at Time 1 and again 60 minutes later. Daily numeric pain ratings and medication consumption data were retrieved from the electronic health care records. Latent growth modeling and analysis of variance were used to analyze data, as appropriate. RESULTS: Participants in Group 1 had increased relaxation (p < .001), decreased pain (p < .001), decreased stress (p < .001), and decreased opioid use on Day 1 (p = .031) and Day 2 (p = .006) of the hospital stay after the intervention compared with the other groups. Additionally, opioid use in Group 1 decreased linearly, whereas the control groups had a nonlinear pattern of change. CONCLUSION: Using massage therapy during postoperative hospitalization improved relaxation and decreased pain, stress, and opioid use in this sample of women after unplanned cesarean births.