Enhanced Recovery after Surgery for Cesarean Delivery Decreases Length of Hospital Stay and Opioid Consumption: A Quality Improvement Initiative.

OBJECTIVE: The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption. STUDY DESIGN: This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation. RESULTS: A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05). CONCLUSION: A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective. KEY POINTS: · Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.. · Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.. · Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use)..

Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol.

OBJECTIVE: This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD). STUDY DESIGN: We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score. RESULTS: All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5-182.5) in PRE compared with 0.0 (IQR: 0.0-72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26-4.27) compared with 2.37 days (IQR: 2.21-3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04). CONCLUSION: ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD. KEY POINTS: · ERAS protocol was associated with decreased postoperative opioid use after CD.. · ERAS protocol was associated with shorter length of stay after CD.. · ERAS protocol was associated with decreased postoperative pain after CD..

Women's experiences of intrapartum care and recovery in relation to planned caesarean sections: An interview study.

PROBLEM AND BACKGROUND: Approximately one third of women in high-income countries give birth by caesarean section (CS). Better understanding of women's CS experiences is vital in identifying opportunities to improve women's experience of care. AIM: To identify opportunities for service improvement by investigating Australian women's experiences of care and recovery when undergoing a planned CS. METHODS: Qualitative telephone interview study with 33 women who had a planned CS at one of eight Australian hospitals. Semi-structured interviews were conducted to elicit women's perspectives, experiences and beliefs surrounding their planned CS. Interviews were transcribed verbatim and analysed inductively using NVivo-12. RESULTS: Women's experiences of CS care were mixed. Regarding intrapartum care, many women stated their planned CS was a positive experience compared to a previous emergency CS, but was scarier and more medicalised compared to vaginal birth. CS recovery was viewed more negatively, with women feeling unprepared. They reported disliking how CS recovery restricted their role as a mother, wanting more time in hospital, and greater support and continuity of care. DISCUSSION: Women reported largely positive intrapartum experiences of planned CS but relatively negative experiences of CS recovery. They wished for time in hospital and support from staff during recovery, and continuity of care. CONCLUSION: By incorporating shared decision-making antenatally, clinicians can discuss women's birth expectations with them and better prepare them for their planned CS and recovery.

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.

Effect of Digital Step Counter Feedback on Mobility After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To assess the effect of a personalized repeated feedback approach using digital step counters (pedometers) on mobility after cesarean delivery in high-risk patients. METHODS: This was a randomized controlled trial at a tertiary university hospital. Patients who underwent cesarean delivery and were defined as high risk for thromboembolic events were asked to wear a pedometer around their wrists postpartum for 48 hours. Patients were randomized to the feedback group, which received personalized feedback by the research staff regarding their mobility at three set timepoints, or the control group, which received standard care. The number of steps taken by patients was compared between the groups and served as the primary outcome. Secondary outcomes included patient reported pain, physical and mental recovery, and overall satisfaction. Sample size was predetermined to detect a 25% between-group difference in the primary outcome. RESULTS: From December 2018 to July 2019, 215 patients were recruited, randomized and completed follow-up-108 in the feedback group and 107 in the control group. Patients' demographics and intrapartum course were similar between the groups. The number of steps taken was significantly higher in the feedback group compared with the control group: 5,918±3,116 vs 4,161±2,532 steps, P<.001. Pain scores were similar between the groups, as was analgesic consumption. Patients in the feedback group reported a significantly easier physical and mental postpartum recovery and were significantly more satisfied with their delivery experience. Postpartum complications did not differ between the groups. CONCLUSION: In high-risk patients after cesarean delivery, mobility was improved by using a personalized feedback approach. Enhanced mobility was not associated with a higher rate of complications or pain and was positively associated with patient satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03724760.

Enhanced recovery after surgery for cesarean delivery.

PURPOSE OF REVIEW: The aim of this article is to describe enhanced recovery after surgery (ERAS) and its application to cesarean delivery. RECENT FINDINGS: ERAS is a standardized, multidisciplinary approach to improving the care of surgical patients, from the preoperative planning through the surgery and postoperative period. ERAS is associated with many benefits, including improved patient outcomes and satisfaction as well as reduced length-of-stay and cost. Obstetric implementation of ERAS protocols has lagged compared to other surgical subspecialties. Given the volume of cesarean deliveries worldwide, improving the quality and cost of care through broad application of ERAS could have significant benefits. SUMMARY: ERAS pathways specific to cesarean delivery should be implemented and can improve the quality of care provided.

Mobility following cesarean delivery: an observational study utilizing pedometers.

Introduction: Thromboembolic events are a leading cause of maternal death, and peak in the postpartum period. We aimed to assess immediate patient mobility following cesarean delivery (CD) with digital step counters (pedometers), and to characterize factors associated with reduced mobility.Materials and methods: This was a prospective observational study at the maternity unit of the Edith Wolfson Medical Center between June 2017 and February 2018. Patients who underwent a cesarean - primary and repeat, and emergent and nonemergent - were asked to wear pedometers for 48 h following cesarean. Comparison of maternal characteristics, surgical, and postpartum course was performed between three groups: high mobility patients (n = 33), intermediate mobility patients (n = 34), and low mobility patients (n = 34), according to the upper third of steps recorded, intermediate third, and the lower third, respectively.Results: The average number of steps taken during the first 48 h following delivery was 6974 ± 2582, 2724 ± 732, and 1056 ± 454 in the high, intermediate, and low mobility groups, respectively, p < .001. Patients' demographics, parity, intrapartum, and postpartum course were not found to be associated with patient mobility. However, smokers were found to walk an additional 1549 steps following CD as compared to nonsmokers.Conclusion: This study failed to identify risk factors for reduced mobility in the immediate postpartum period, but an increased mobility was noted in smokers, most probably related to the need to ambulate outside the maternity ward. The decision to treat patients following a cesarean with thromboprophlaxis will continue to be based on previously identified risk factors.

Enhanced Recovery After Surgery to Change Process Measures and Reduce Opioid Use After Cesarean Delivery: A Quality Improvement Initiative.

OBJECTIVE: To evaluate implementation of an enhanced recovery after surgery (ERAS) program for patients undergoing elective cesarean delivery by comparing opioid exposure, multimodal analgesia use, and other process and outcome measures before and after implementation. METHODS: An ERAS program was implemented among patients undergoing elective cesarean delivery in a large integrated health care delivery system. We conducted a pre-post study of ERAS implementation to compare changes in process and outcome measures during the 12 months before and 12 months after implementation. RESULTS: The study included 4,689 patients who underwent an elective cesarean delivery in the 12 months before (pilot sites: March 1, 2015-February 29, 2016, all other sites: October 1, 2015-September 30, 2016), and 4,624 patients in the 12 months after (pilot sites: April 1, 2016-March 31, 2017, all other sites: November 1, 2016-October 31, 2017) ERAS program implementation. After ERAS implementation mean inpatient opioid exposure (average daily morphine equivalents) decreased from 10.7 equivalents (95% CI 10.2-11.3) to 5.4 equivalents (95% CI 4.8-5.9) controlling for age, race-ethnicity, prepregnancy body mass index, patient reported pain score, and medical center. The use of multimodal analgesia (ie, acetaminophen and neuraxial anesthesia) increased from 9.7% to 88.8%, the adjusted risk ratio (RR) for meeting multimodal analgesic goals was 9.13 (RR comparing post-ERAS with pre-ERAS; 95% CI 8.35-10.0) and the proportion of time patients reported acceptable pain scores increased from 82.1% to 86.4% (P<.001). Outpatient opioids dispensed at hospital discharge decreased from 85.9% to 82.2% post-ERAS (P<.001) and the average number of dispensed pills decreased from 38 to 26 (P<.001). The hours to first postsurgical ambulation decreased by 2.7 hours (95% CI -3.1 to -2.4) and the hours to first postsurgical solid intake decreased by 11.1 hours (95% CI -11.5 to -10.7). There were no significant changes in hospital length of stay, surgical site infections, hospital readmissions, or breastfeeding rates. CONCLUSIONS: Implementation of an ERAS program in patients undergoing elective cesarean delivery was associated with a reduction in opioid inpatient and outpatient exposure and with changes in surgical process measures of care without worsened surgical outcomes.

Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery.

BACKGROUND: Whilst validated quality-of-recovery (QoR) tools exist for general surgery, there is no specific obstetric equivalent. We aimed to develop and evaluate a modified QoR score after elective Caesarean delivery. METHODS: Twenty-two obstetric specific items were selected following review and modification of the QoR-40 survey by 16 experts and interviews with 50 stakeholders. Item selection was based on relevance to Caesarean delivery and endorsement by >66% of stakeholders. Items were tested on women pre-delivery, at 24 h, and 25 h post-delivery. An 11-item obstetric-specific QoR score (ObsQoR-11) was created based on correlation with a numerical rating scale (NRS) of global health status (r>0.20) at all time points. Reliability, responsiveness, acceptability, and feasibility were tested. RESULTS: One hundred and fifty-two women responded to the 22-item questionnaire pre-delivery (complete in 146), 100 at 24 h, and 10 at 25 h. The ObsQoR-11 correlated with the global health status NRS (r=0.53; 95% confidence interval: 0.43-0.62; P<0.0001) and discriminated good vs poor recovery (NRS score ≥70 vs <70 mm) at 24 h. There was a negative correlation between the ObsQoR-11 score at 24 h and hospital length of stay (r=-0.39; P=0.003). ObsQoR-11 was reliable (internal consistency: 0.85; split-half 0.76; test-retest intra-class correlation coefficient ri>0.6 in 82% of items) and responsive (Cohen effect size: 1.36; standardised response mean: 0.85). A longer 22-item ObsQoR had high (97%) completion rates and short (median: 2 min) completion times. CONCLUSIONS: The ObsQoR-11 provides a valid, reliable, and responsive global assessment of recovery after elective Caesarean delivery.

Caesarean section rate and postnatal bed occupancy: a retrospective study replacing assumptions with evidence.

BACKGROUND: Obstetric units across the UK face resource pressures alongside a rising rate of Caesarean section (CS). It is assumed that this places a further burden in the form of postnatal bed demands. The number of inpatient beds has fallen nationally, and this may be used to justify attempts to restrict the CS rate. We set out to replace such assumptions with evidence. We did not find any similar contemporary analysis in a literature search. METHODS: The postnatal length of stay (LOS) of women delivering at Watford General Hospital, a large unit hosting around 5500 deliveries per annum, was stratified by mode of delivery. Differences within and across time periods were analysed. RESULTS: The CS rate rose from 14.5% in 1995 to 30.9% in 2015. The mean LOS post-CS declined from 4.2 to 2.4 days. These data were statistically significant to p < 0.001. Over this period the standardised total postnatal bed use for all delivery modes fell from 11083 days to 7894 days. A 113% rise in the CS rate was accommodated by only a 19.8% rise in postnatal bed use attributable to CS patients. CONCLUSIONS: Whatever pressures may be exacerbated by the rising CS rate, bed occupancy is not one of them. In discussion we widen our argument to suggest that resource pressures should not be used to justify limitations in the CS rate.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1).

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.

Fucosylated oligosaccharides in mother's milk alleviate the effects of caesarean birth on infant gut microbiota.

One of the most abundant components in human milk is formed by oligosaccharides, which are poorly digested by the infant. The oligosaccharide composition of breast milk varies between mothers, and is dependent on maternal secretor (FUT2) genotype. Secretor mothers produce milk containing α1-2 fucosylated human milk oligosaccharides, which are absent in the milk of non-secretor mothers. Several strains of bacteria in the infant gut have the capacity to utilise human milk oligosaccharides (HMOs). Here we investigate the differences in infant gut microbiota composition between secretor (N = 76) and non-secretor (N = 15) mothers, taking into account birth mode. In the vaginally born infants, maternal secretor status was not associated with microbiota composition. In the caesarean-born, however, many of the caesarean-associated microbiota patterns were more pronounced among the infants of non-secretor mothers compared to those of secretor mothers. Particularly bifidobacteria were strongly depleted and enterococci increased among the caesarean-born infants of non-secretor mothers. Furthermore, Akkermansia was increased in the section-born infants of secretor mothers, supporting the suggestion that this organism may degrade HMOs. The results indicate that maternal secretor status may be particularly influential in infants with compromised microbiota development, and that these infants could benefit from corrective supplementation.

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2).

The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.

Influences of Cesarean Delivery on Breastfeeding Practices and Duration: A Prospective Cohort Study.

BACKGROUND: Mothers are encouraged to exclusively breastfeed for the first 6 months. However, cesarean delivery rates have increased worldwide, which may affect breastfeeding. Research aim: This study aimed to determine the potential effects of cesarean delivery on breastfeeding practices and breastfeeding duration. METHODS: This was a 6-month cohort study extracted from a 24-month prospective cohort study of mother-infant pairs in three communities in Hunan, China. Data about participants' characteristics, delivery methods, breastfeeding initiation, use of formula in the hospital, exclusive breastfeeding, and any breastfeeding were collected at 1, 3, and 6 months following each infant's birth. The chi-square test, logistic regression model, and Cox proportional hazard regression model were used to examine the relationship between breastfeeding practices and cesarean delivery. RESULTS: The number of women who had a cesarean delivery was 387 (40.6%), and 567 (59.4%) women had a vaginal delivery. The exclusive breastfeeding rates at 1, 3, and 6 months were 80.2%, 67.4%, and 21.5%, respectively. Women who had a cesarean delivery showed a lower rate of exclusive breastfeeding and any breastfeeding than those who had a vaginal delivery ( p < .05). In addition, cesarean delivery was related with using formula in the hospital and delayed breastfeeding initiation. Cesarean delivery also shortened the breastfeeding duration (hazard ratio = 1.40, 95% confidence interval [1.06, 1.84]). CONCLUSION: Healthcare professionals should provide more breastfeeding skills to women who have a cesarean delivery and warn mothers about the dangers of elective cesarean section for breastfeeding practices.

Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials.

Objective To investigate the efficacy and safety of ondansetron during cesarean section under spinal anesthesia. Methods We sought randomized controlled trials (RCTs) on ondansetron during spinal anesthesia for cesarean section in The Cochrane Library, PubMed, MEDLINE, and Web of Science from their inception to September 2016. Results Altogether, 21 RCTs were included in this study. Meta-analysis showed that the ondansetron group had a lower incidence of nausea/vomiting and bradycardia than the placebo group during cesarean section under spinal anesthesia [relative risk (RR) = 0.43, 95% confidence interval (CI) (0.36, 0.51) and RR = 0.45, 95% CI (0.26, 0.80), respectively]. There were no significant differences in the incidences of pruritus, hypotension, or shivering during cesarean section under spinal anesthesia [RR = 0.92, 95% CI (0.83, 1.02); RR = 0.72 (0.50, 1.06), 95% CI (0.50, 1.06); and RR = 0.89, 95% CI (0.71, 1.11), respectively]. Conclusion Ondansetron effectively reduces the incidences of nausea/vomiting and bradycardia under spinal anesthesia during cesarean section.

Short hospitalization after caesarean delivery: effects on maternal pain and stress at discharge.

PURPOSE: To characterize predischarge maternal pain and stress after caesarean delivery and short hospitalization. MATERIALS AND METHODS: This is a descriptive study with 60 women in the postoperative period of caesarean section and 60 control women after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Stress Measure (Psychological Stress Measure (PSM)), respectively, at mother-infant dyad discharge, scheduled at 36 hours after delivery. RESULTS: Caesarean section was the delivery modality with the highest MGPQ pain and sensorial, evaluative and mixed pain descriptive categories scores. The pain location involved lower abdomen, with associated localizations at back, breast and shoulders. Conversely, vaginal delivery was the delivery modality with the highest stress scores. CONCLUSION: This study provides important information on the quality of care implications of early discharge practices in puerperae after caesarean delivery, a critical time characterized by qualitatively and quantitatively high pain and stress.

Chewing gum improves postoperative recovery of gastrointestinal function after cesarean delivery: a systematic review and meta-analysis of randomized trials.

OBJECTIVE: To examine whether chewing gum hastens the return of gastrointestinal function after a cesarean delivery. METHODS: All randomized controlled trials comparing the use of chewing gum in the immediate postoperative recovery period (i.e. intervention group) with a control group were included in the meta-analysis. The primary outcome was the time to first flatus in hours. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). RESULTS: Seventeen trials, including 3041 women, were analyzed. Trials were of moderate to low quality with different inclusion criteria. In most of the included trials chewing gum was given right after delivery, three times a day for 30 min each and until the first flatus. Women who were randomized to the chewing gum group had a significantly lower mean time to first flatus (MD - 6.49 h, 95%CI -8.65 to -4.33), to first bowel sounds (MD - 8.48 h, 95%CI -9.04 to -7.92), less duration of stay (MD - 0.39 days, 95%CI -0.78 to -0.18), lower time to first feces (MD - 9.57 h, 95% CI -10.28 to 8.87) and to the first feeling of hunger (MD - 2.89 h, 95%CI -4.93 to -0.85), less number of episodes of nausea or vomiting (RR 0.33, 95%CI 0.12 to 0.87), less incidence of ileus (RR 0.39, 95%CI 0.19 to 0.80) and significantly higher satisfaction. CONCLUSIONS: Gum chewing starting right after cesarean delivery three times a day for about 30 min until the first flatus is associated with early recovery of bowel motility. As this is a simple, generally inexpensive intervention, providers should consider implementing cesarean postoperative care with gum chewing.

Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial.

OBJECTIVE: To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect. DESIGN: Multicentre randomised controlled trial. SETTING: Eleven hospitals collaborating in a consortium for women's health research in the Netherlands. POPULATION: Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography. METHODS: Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months. MAIN OUTCOME MEASURES: The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation. RESULTS: We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2-7 days) in the intervention group and 7 days (IQR 3-10 days) in the control group (P = 0.04); on a scale of 0-10, discomfort as a result of spotting had a median score of 2 (IQR 0-7) in the intervention group, compared with 7 (IQR 0-8) in the control group (P = 0.02). CONCLUSIONS: In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting-related discomfort. TWEETABLE ABSTRACT: A hysteroscopic niche resection is an effective treatment to reduce niche-related spotting.

[Comparative study about enhanced recovery after cesarean section: What benefits, what risks?] / Étude comparative sur la réhabilitation améliorée postcésarienne : quels bénéfices, quels risques ?

OBJECTIVE: The post-caesarean enhanced recovery protocol's goal is to allow a quick recovery of previous physical capabilities and increase the chances of an early release and return to normal activities. METHODS: At the Foch Hospital, we performed a case control survey including 2 consecutive groups of patients. The first group was composed of 83 patients that experienced the regular post c-section treatment and the second group of 84 patients that benefited from the enhanced recovery treatment. The characteristics of both groups were comparable. We monitored the complications, hospitalization time and full recovery time for each group. RESULTS: The average hospitalisation time for the patients that received the enhanced recovery treatment was significantly lower than for those that received the standard treatment (3,92 days vs 4,34 days P<0,01). The autonomy for the toilet and the mobility was improved. The average number of complications was not greater for the enhanced recovery group, except for acute retention of urine which were all treated with a simple urine sample return. CONCLUSION: The post-cesarean enhanced recovery seams to allow the significant improvement in recovery of autonomy and length of hospitalization stay without increasing significantly the rate of complications except for the acute retentions of urines which involve in postpartum period close monitoring patients' urination.