Validation of a new method to assess estimated blood loss in the obstetric population undergoing cesarean delivery.

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality in developing countries and the primary cause of one-quarter of all maternal deaths globally. Inaccuracy in estimating blood loss obscures the diagnosis of postpartum hemorrhage and its management. OBJECTIVE: Our objective was to compare assessment of blood loss using the quantitative Triton system (Gauss Surgical, Inc, Los Altos, CA) with other measures of blood loss in women undergoing cesarean delivery. STUDY DESIGN: Women scheduled for cesarean deliveries at our facility were included. Intraoperative blood loss was measured using the Triton, which was masked to the clinical team, as well as estimated by the surgeon (subjective estimated blood loss). The relation between the 2 methods (Triton and subjective estimated blood loss) and postoperative hemoglobin as well as delta hemoglobin (postoperative minus preoperative hemoglobin) was determined using the Spearman correlation. Triton measurement and subjective estimated blood loss were compared between women with delta hemoglobin in the upper quartile (cases) vs all other quartiles (control). Prediction of delta hemoglobin in the upper quartile also was evaluated for each method, and the area under the receiver operating characteristic curves was compared. RESULTS: The trial enrolled 242 patients. The mean blood loss estimated by the Triton device was significantly lower than that estimated by clinical judgment (415.3±260.6 vs 799.6±215.6 mL, P<.01). The Triton estimate correlated best with delta hemoglobin. Seventy patients had delta hemoglobin in the upper quartile (delta hemoglobin ≥2). There was a significant difference in the Triton blood loss measurement between cases and controls but no difference with subjective estimated blood loss. Triton, but not subjective estimated blood loss, was predictive of delta hemoglobin ≥2 g/dL (Triton: area under the receiver operating characteristic curve, 0.66; 95% confidence interval, 0.58-0.74; P<.01 vs subjective estimated blood loss: area under the receiver operating characteristic curve, 0.53; 95% confidence interval, 0.45-0.61; P=.45). CONCLUSIONS: The Triton system provides a better estimate of blood loss than the visual estimate. Clinical trials to evaluate its benefit are warranted.

The Effect of Wearing White Coats on Patients' Appreciation of Physician Communication during Postpartum Rounds: A Randomized Controlled Trial.

OBJECTIVE: Wearing a white coat (WC) has been associated with risk of colonization and transmission of resistant pathogens. Also, studies have shown that physicians' attire in general affects patients' confidence in their physician and the patient-physician relationship. Our objective is to evaluate the hypothesis that not wearing a WC during physician postpartum rounds does not affect patient-physician communication scores. MATERIALS AND METHODS: This is an unblinded, randomized, parallel arms, controlled trial of postpartum women at a single university hospital. Women were randomly assigned to having their postpartum physicians' team wear a WC or not (no-WC) during rounds. Our primary outcome was "patient-physician communication" score. Univariable and multivariable analysis were used where appropriate. RESULTS: One hundred and seventy-eight patients were enrolled (87 in WC and 91 in no-WC groups). Note that 40.4% of patients did not remember whether the physicians wore a WC or not. There was no difference in the primary outcome (p = 0.64) even after adjusting for possible confounders. CONCLUSION: Not wearing a WC during postpartum rounds did not affect the patient-physician communication or patient satisfaction scores. In the setting of prior reports showing a risk of WC pathogen transmission between patients, our findings cannot support the routine wearing of WCs during postpartum rounds.

Early versus Late Feeding after Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: This study aims to evaluate whether early feeding after cesarean delivery (CD) shortens the time to pass flatus and bowel movement. METHODS: Women at term undergoing CD were randomly assigned to start oral intake either within 6 hours (early feeding) or after 12 hours (late feeding) from surgery completion. Women with preeclampsia, or requiring emergent CD, additional bowel surgery, or the use of general anesthesia were excluded. Our primary outcome was time of passing first flatus following surgery completion. Secondary outcomes included time of first bowel sounds, time of first bowel movement, nausea/vomiting, and length of maternal hospital stay (clinicaltrials.gov identifier NCT02396485). RESULTS: A total of 177 women were randomized to early (n = 85) or late feeding (n = 82). There was no loss to follow-up, and outcomes were available for all patients. There were no differences in baseline characteristics between the two groups. Early feeding resulted in shorter time to pass flatus (median [interquartile range], 715 [485-1,208] minutes vs. 1,300 [820-1,760] minutes; p < 0.001) and to have bowel sounds (232 [168-537.8] minutes vs. 554.5 [202-706] minutes; p = 0.001). Time to pass bowel movement was shorter in the early-feeding group, but did not reach significance. The groups did not differ in length of stay or in rates of nausea, vomiting, or ileus. CONCLUSION: In women undergoing CD, early oral intake is well tolerated and results in earlier return of bowel function.

Peripartum Abdominal Compartment Syndrome Following Extracorporeal Hemodynamic Support.

In massive pulmonary embolism (PE), anticoagulation and thrombolytics may increase the risk of retroperitoneal bleeding following vascular cannulation for extracorporeal hemodynamic support resulting in abdominal compartment syndrome (ACS). A 27-year-old women at 33 weeks of gestation presented with acute chest pain and shortness of breath. Massive PE was diagnosed. Intravenous unfractionated heparin was started together with catheter-directed tissue plasminogen activator (tPA) infusion and mechanical thrombectomy. During the procedure, cardiac arrest developed. Cardiopulmonary resuscitation, intravenous tPA, and urgent perimortem cesarean delivery were performed. After return of spontaneous circulation, profound right ventricular failure required venoarterial membrane oxygenation. Six hours afterward, ACS secondary to retroperitoneal bleeding developed, requiring surgical intervention. ACS may result from retroperitoneal bleeding following cannulation for extracorporeal hemodynamic support.