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.

Adaptation of non-technical skills behavioural markers for delivery room simulation.

BACKGROUND: Simulation in healthcare has proved to be a useful method in improving skills and increasing the safety of clinical operations. The debriefing session, after the simulated scenario, is the core of the simulation, since it allows participants to integrate the experience with the theoretical frameworks and the procedural guidelines. There is consistent evidence for the relevance of non-technical skills (NTS) for the safe and efficient accomplishment of operations. However, the observation, assessment and feedback on these skills is particularly complex, because the process needs expert observers and the feedback is often provided in judgmental and ineffective ways. The aim of this study was therefore to develop and test a set of observation and rating forms for the NTS behavioural markers of multi-professional teams involved in delivery room emergency simulations (MINTS-DR, Multi-professional Inventory for Non-Technical Skills in the Delivery Room). METHODS: The MINTS-DR was developed by adapting the existing tools and, when needed, by designing new tools according to the literature. We followed a bottom-up process accompanied by interviews and co-design between practitioners and psychology experts. The forms were specific for anaesthetists, gynaecologists, nurses/midwives, assistants, plus a global team assessment tool. We administered the tools in five editions of a simulation training course that involved 48 practitioners. Ratings on usability and usefulness were collected. RESULTS: The mean ratings of the usability and usefulness of the tools were not statistically different to or higher than 4 on a 5-point rating scale. In either case no significant differences were found across professional categories. CONCLUSION: The MINTS-DR is quick and easy to administer. It is judged to be a useful asset in maximising the learning experience that is provided by the simulation.

Second-line uterotonics and the risk of hemorrhage-related morbidity.

OBJECTIVE: Uterine atony is a leading cause of postpartum hemorrhage. Although most cases of postpartum hemorrhage respond to first-line therapy with uterine massage and oxytocin administration, second-line uterotonics including methylergonovine and carboprost are integral for the management of refractory uterine atony. Despite their ubiquitous use, it is uncertain whether the risk of hemorrhage-related morbidity differs in women exposed to methylergonovine or carboprost at cesarean delivery. STUDY DESIGN: We performed a secondary analysis using the Maternal-Fetal Medicine Units Network Cesarean Registry. We identified women who underwent cesarean delivery and received either methylergonovine or carboprost for refractory uterine atony. The primary outcome was hemorrhage-related morbidity defined as intraoperative or postoperative red blood cell transfusion or the need for additional surgical interventions including uterine artery ligation, hypogastric artery ligation, or peripartum hysterectomy for atony. We compared the risk of hemorrhage-related morbidity in those exposed to methylergonovine vs carboprost. Propensity-score matching was used to account for potential confounders. RESULTS: The study cohort comprised 1335 women; 870 (65.2%) women received methylergonovine and 465 (34.8%) women received carboprost. After accounting for potential confounders, the risk of hemorrhage-related morbidity was higher in the carboprost group than the methylergonovine group (relative risk, 1.7; 95% confidence interval, 1.2-2.6). CONCLUSION: In this propensity score-matched analysis, methylergonovine was associated with reduced risk of hemorrhage-related morbidity during cesarean delivery compared to carboprost. Based on these results, methylergonovine may be a more effective second-line uterotonic.

[Use of acupuncture for labour augmentation]. / Akupunktur til vestimulering under fødslen.

INTRODUCTION: In Denmark, 45% of all primiparas and 12% of multiparas with uneventful pregnancies are augmented in order to treat dystocia. Augmentation using oxytocin is associated with uterine hyperstimulation, uterine rupture and foetal death. Currently, no studies show that acupuncture is effective for augmentation. MATERIAL AND METHODS: A single-blinded randomized controlled trial with women diagnosed with dystocia. In the acupuncture group, the women had acupuncture in SP6, KI3, KI6, BL60, LI4 and acupressure on BL67. The control group received no treatment. The primary outcome was progression in cervical dilatation within two hours. The secondary outcomes were length of labour, length of second stage, use of augmentation, use of analgesia, caesarean section rate and number of instrumental deliveries. RESULTS: A total of 84 women were randomised. There was no significant difference between the groups with regard to dilatation from randomization to effect assessment (p = 0.54). In the acupuncture group, the mean difference was 1.3 cm (0.69-1.91). In the control group, the mean difference was 1.56 (0.6-2.52). 27% of the women with dystocia delivered spontaneously without augmentation. No major side effects of acupuncture treatment were reported. CONCLUSION: This study showed no effect of acupuncture treatment for primary or secondary inertia.

Uso de misoprostol por vía rectal en atonia uterina que no responde a tratamiento convencional / Rectal misoprostol in uterine atony nonresponsive to conventional treatment

Objetivos: Evaluar la eficacia, tolerancia y seguridad del misoprostol por vía rectal en el control de la atonía uterina. Diseño: Ensayo clínico. Lugar: Hospital Nacional "Sergio E Bernales" de Collique, Lima, durante el período setiembre 1998 a diciembre 1999. Material y métodos: pacientes que presentaron hemorragia postparto (HPP) por atonía uterina, que persiste a pesar de la aplicación de masaje uterino, oxitócicos y ergotamínicos. A siete pacientes se les aplicó 800 ug de misoprostol en la ampolla rectal, y cada 5 minutos se agregó 200 ug adicionales si persistía el sangrado. Resultados: En los 7 pacientes se controló la hemorragia en un tiempo promedio 5,8 minutos. En ningún caso se presentaron efectos colaterales. Se aplicó en 3 pacientes sólo 800 ug y en 4 mujeres 1000 ug de misoprostol como dosis total. Por la hemorragia severa, en los 7 casos la hemoglobina bajó un promedio un promedio de 3,4 mg por ciento Conclusiones: Misoprostol por vía rectal es efectivo, seguro y bien tolerado para controlar la HPP por atonía uterina. Se presenta como una gran alternativa para controlar problemas de HPP en lugares apartados que no cuentan con recurso técnicos apropiados.

Tratamiento electromecánico de la atonía uterina: balón hemostático intrauterino MMP / The electrical-mechanical treatment of uterine atonia: intrauterine hemostatic balloon MMP

Se describe el tratamiento eléctrico y mecánico (balón hemostático intrauterino MMP) de un útero atónico que no respondió a la terapia habitual de masajes, ocitócicos, metilergonovina y prostaglandina E. La utilización del balón hemostático intrauterino MMP, permitió el cese inmediato del sangrado. De manera complementaria se procedió a la desfibrilación uterina externa, la cual permitió la contracción definitiva del útero atónico

[Reflex analgesia in the combined treatment of pregnant women with a pathological preliminary period]. / Reflektornaia analgeziia v kompleksnom lechenii beremennykh s patologicheskim preliminarnym periodom.

The impact of reflex analgesia via transcutaneous electrical neurostimulation and electrical acupuncture was studied in 46 patients with an abnormal preliminary period by using tests of pain sensations and personal and reactive anxiety, ECG, hysterography, and computer-aided prediction of labor complications. Reflex analgesia was found to contribute to effective abolishment of preliminary pain sensations, to normalization of central nervous system function, autonomic reactions, uterine contractility, to reduction in pharmacological agent use and treatment duration, and to better delivery.

Homoeopathy as a practical alternative to traditional obstetric methods

A clinical trial was carried out to determine the efficacy of predelivery homoeopathic and "traditional" prophylaxis of uterine inertia and post partum haemorrhage. Under our observation, there were 206 pregnant women characterized by high risk of uterine contractile function disturbances. The 1st group of pregnant women (n=102) received only homoeopathy. The 2nd group (n=104) received conventional medical preparations including oestrogenic hormones. We studied a use of homoeopathic drug complex possessing "relatively narrow range of influence". Clinical examination, foetal cardiomonitoring and ultrasound scanning were carried out in each case. The normal methods were used to treat uterine inertia, foetal distress and post partum haemorrhage. In our opinion homoeopathy can be an effective method for prophylaxis of disturbances of uterine contractile function in delivery and at the postnatal stage for pregnant women at high risk of complications

[Electrostimulation of the uterus in uterine inertia]. / Elektrostimuliatsiia matki pri slabosti rodovoi deiatel'nosti.

The paper provides the results of electrostimulation application to the therapy for uterine inertia. Monopolarization current action on the cervix was shown to be beneficial in 83.34% females with abnormal labor. No negative effects of the method was found on the status of a fetus and a parturient.

[Changes in the biochemical indices of parturients with uterine inertia against the background of therapy]. / Izmeneniia biokhimicheskikh pokazatelei u rozhenits so slabost'iu rodovoi deiatel'nosti na fone terapii.

A comparison was made of some biochemical parameters for energy metabolism, acid-base balance, blood gases and uterine contractility in parturients with uterine inertia who were on therapy with or without hyperbaric oxygenation. The presence of hypoxemia and metabolic acidosis in the parturients was found to intensify the processes of lipid peroxidation, to affect the functional status of myometrial biomembranes, to result in hyperenzymemia and disturbed tissue metabolism and lower myometrial contractility. The use of hyperbaric oxygenation in the multimodality therapy for uterine inertia was ascertained to eliminate oxygen deficiency, to increase tissue respiration, contributing to normal labor.

[Dynamic biochemical indices of parturients with uterine inertia against a background of hyperbaric oxygen and drug treatment]. / Dinamika na biokhimichnite pokazateli pri rodilki s rodova slabost na fona na khiperbarno kislorodno i medikamentozno lechenie.

Acid-base balance, lactate dehydrogenase, creatine phosphokinase, hydroxybutyrate dehydrogenase, oxytocinase and the final products of peroxide oxygenation of lipids-malonate dialdehyde and antioxidant activity were studied on 60 parturients, divided into two groups as each group had 30 women. Hyperbaric oxygen treatment in combination with oxytocin was studied on uterine inertia. The control group consisted of 20 parturients with normal course of delivery.