Placental cord drainage impact on third stage of labor: A randomized controlled trial.

BACKGROUND: The third stage of labor is a pivotal phase in obstetric care. Management may be physiological or active. Although the use of prophylactic placental cord drainage has been assessed in prior data, there is still no clear-cut evidence supporting its effectiveness in improving key obstetric outcomes. OBJECTIVE: The aim of the study was to investigate the impact of placental cord drainage during the third stage of labor on the amount of maternal bleeding, duration of the third stage, and incidence of postpartum hemorrhage. STUDY DESIGN: A randomized controlled trial was conducted at a high-volume tertiary obstetric center between May 2021 and December 2022. A total of 212 pregnant women with a singleton uncomplicated pregnancy were randomly assigned to undergo placental cord drainage or standard care without drainage. The randomization was manual, using pre-marked cards drawn by the participants. The power calculation determined a sample size of 92 participants per group to achieve 80% power at a 5% significance level, aiming to detect 20% difference in bleeding amount between the groups. In practice, we included more than 100 women in each group. The primary outcome was the amount of bleeding during the third stage of labor, while secondary outcomes included the duration of the third stage and incidence of postpartum hemorrhage. After delivery, all participants received 10 units of oxytocin via intravenous drip and delayed cord clamping was performed. In the study group, the maternal umbilical cord was then unclamped. Blood was allowed to drain into a plastic bag placed under the women's buttocks. If an episiotomy or perineal tear was observed, pressure packing was applied to reduce bleeding. The collected blood was measured in milliliters after placental expulsion. RESULTS: A total of 212 women were recruited of whom 104 underwent placental cord drainage and 108 received standard care without drainage. No significant differences were observed between the intervention and control groups in mean duration of the third stage of labor (10.56±6.12 vs. 10.95±6.33 minutes, P=0.65), incidence of postpartum hemorrhage (3.84% vs. 7.41%, P=0.38), or mean amount of bleeding during the third stage of labor (292±200 vs. 300±242 ml, P=0.79). Furthermore, there were no significant between-group differences in the mean amount of bleeding on separate analysis of nulliparous women (356±246 vs. 330±240 ml, P=0.68), multiparous women (265±171 vs. 289±244 ml, P=0.50), women who were not exposed to external oxytocin during labor (287±204 vs. 317±250 ml, P=0.59), and women who were exposed to external oxytocin (296±198 vs. 289±238 ml, P=0.39). CONCLUSIONS: Placental cord drainage during the third stage of labor showed no statistically significant impact on bleeding amount, third-stage length, or postpartum hemorrhage rate. The findings suggest that placental cord drainage may not offer additional benefits in preventing postpartum hemorrhage in women with uncomplicated pregnancies.

Open access gastroscopy in hospitalized patients.

BACKGROUND: Open access gastroscopy allows physicians to refer patients for endoscopic procedures without a prior consultation. OBJECTIVES: To compare the safety and efficacy of OAG with gastroscopy performed after a gastroenterological consultation. METHODS: Patients referred for gastroscopy directly (open access) or after consultation with a gastroenterologist, by physicians in the departments of internal medicine and surgery at a major tertiary center, were compared for indications, background disease, outcome and diagnostic yield. The data were collected prospectively over a 5 month period following the introduction of OAG at the center. Physicians in both departments participated in an education program on the indications and procedure of gastroscopy. For each patient referred for OAG the attending physician completed a specially designed questionnaire that had to be signed by a senior physician. Data were managed and analyzed with Excel and SPSS software. RESULTS: The study sample comprised 494 patients, of whom 236 were referred for OAG and 258 after prior consultation. On multivariate analysis, hospitalization in the department of internal medicine was the only independent factor for OAG. Severe background disease and aspirin treatment had no effect on physician use of OAG, although they served as a "red light" for the gastroenterology consultants. There was no difference in the diagnostic yield of the procedures (26.4% normal findings for OAG and 28.3% for consultations) or in mortality rates. The main indications for referral to gastroscopy in the surgery department were melena, hematemesis and "coffee grounds," and anemia and vomiting in the internal medicine department. CONCLUSIONS: OAG is feasible and beneficial in an academic medical center setting, with no bias in appropriateness of indications or decrease in the diagnostic yield compared to the traditional approach. More attention should be directed to safety issues by the referring physicians.

Screening for colorectal cancer in personnel of an academic medical center.

The colorectal cancer (CRC) screening program in Israel offers the average-risk population fecal occult blood tests from the age of 50 years. Compliance, however, is very low, reaching only 6% of eligible persons in 2005. Our aim in this study was to describe the results of an improved CRC screening program directed at the in-house staff of Beilinson Hospital. All employees of Beilinson Hospital over age 50 years were sent a letter explaining the new CRC screening program and an accompanying questionnaire. Responders who reported a family history of CRC or related cancers or symptoms were offered colonoscopy; the remainder were offered sigmoidoscopy or, if they preferred, colonoscopy. Two hundred twenty of the 888 candidates (24.7%) completed the questionnaire, of whom 144 (16.2%) agreed to further investigation. These included 90 of 105 patients with a positive questionnaire and 20 of 115 with a negative questionnaire who underwent colonoscopy and 34 of 115 with a negative questionnaire who underwent sigmoidoscopy. The colonoscopy group included 26 of the 30 patients (86.6%) with a positive family history. Early-stage CRC was diagnosed in three patients (1.36%), all with a positive questionnaire. There were no pathologic findings on sigmoidoscopy. The sensitivity, specificity, and positive and negative predictive values of the questionnaire for identifying subjects with CRC or advanced adenoma were 100.00%, 18.86%, 2.27%, and 100.00%, respectively. In conclusion, using hospital facilities, we initiated a unique CRC screening program for employees. Our method may be applicable in other medical centers for the detection of adenomas and CRCs in the early, curative stages.

Preparation for colonoscopy in hospitalized patients.

Successful colonoscopy depends on good preparation of the colon before the procedure. Inadequate preparation may lead to cancelled or repeat procedures and compromise patient safety, quality of care, and cost effectiveness. The primary aim of this study was to isolate factors that affect preparation success, especially in older, more severely ill, bedridden patients. The secondary aim was to examine the possible differences in preparation quality between ambulatory and hospitalized patients and the impact of a staff educational program on the preparation of hospitalized patients for colonoscopy. The study group included 303 consecutive ambulatory patients and 104 hospitalized patients referred for colonoscopy between January and March 2002, before the department introduced an educational program on colonoscopy preparation, and 310 ambulatory patients and 105 hospitalized patients referred for colonoscopy between January and March 2003. All patients completed an ad hoc questionnaire, and the findings were compared between ambulatory and hospitalized patients and between patients treated before and after the educational program. Polyethylene glycol was used significantly more often for colonoscopy preparation in hospitalized patients than in ambulatory patients (53.1% versus 8.8%; P=.0001). The hospitalized group was characterized by more incomplete or repeated colonoscopies and poorer preparation quality. On multivariate analysis, the variables found to be independent predictors of good preparation were successful patient completion of the preparatory procedure according to instructions, colonoscopy performed for follow-up after polypectomy, and preparation with sodium phosphate. The educational intervention had no impact on the quality of preparation. In conclusion, sodium phosphate preparation and complete adherence to preparation instructions are the most important factors for successful colonoscopy preparation. Current preparatory methods for hospitalized and severely ill patients need to be revised.