Maternal and Neonatal Consequences of Early Augmentation of Labor Among Women With Spontaneous Onset of Labor: A National Population-Based Study.

BACKGROUND: While some labor interventions are essential in preventing maternal and neonatal morbidity, there is little evidence to support systematic early augmentation of labor (EAL). Our objective was to assess the association between EAL and cesarean delivery rate, postpartum hemorrhage and adverse neonatal outcomes. METHODS: Population-based study using data from the 2016 French Perinatal Survey. Women with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. "EAL" was defined by artificial rupture of the membranes (AROM) and/or oxytocin within 1 h of admission and/or duration between interventions of less than 1 h. Women without EAL were women without labor augmentation or without EAL. The primary endpoint, cesarean delivery and the secondary endpoints were compared between women with and without EAL using univariate analysis. A multivariable logistic regression was adjusted on the suspected confounders and a propensity score approach was then performed. RESULTS: Among the 7196 women included, 1524 (21.2%) had EAL. Cesarean delivery rates were significantly higher in the EAL group compared with the no EAL group, 8.40% versus 6.15% (p < 0.01). EAL was associated with cesarean delivery in the multivariable analysis aOR 1.45 95% CI [1.15-1.82] and in the cohort matched on the propensity score, OR 1.56 [1.17-2.07]. EAL was not associated with severe postpartum hemorrhage, low 5-min Apgar score, low neonatal cord pH or transfer to NICU. CONCLUSION: EAL is frequent, involving one in five spontaneous laboring women in France. This practice is associated with an increased cesarean delivery risk.

Obstetric and neonatal outcomes in women with Ankylosing spondylitis - an evaluation of a population database.

BACKGROUND: Ankylosing Spondylitis (AS) is a systemic chronic rheumatic disease characterized by involvement of the axial skeletal and sacroiliac joints. Although this disease is not rare amongst women of reproductive age, data regarding pregnancy outcomes have demonstrated conflicting results. We therefore aimed to compare pregnancy and perinatal outcomes between women who suffered from AS to those who did not. METHODS: A retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). Included in the study were all pregnant women who delivered or had a maternal death in the US between 2004 and 2014. Women with an ICD-9 diagnosis of AS before or during pregnancy were compared to those without. Pregnancy, delivery, and neonatal outcomes were compared between the two groups using multivariate logistic regression models adjusting for potential confounders. RESULTS: A total of 9,096,788 women were inclusion in the analysis. Amongst them, 383 women (3.8/100,000) had a diagnosis of AS and the rest were controls. Women with AS, compared to those without, were more likely to be older; Caucasian; from higher income quartiles; suffer from thyroid disorders, and have multiple pregnancies (p < 0.001, all). After adjusting for confounders, patients in the AS group, compared to those without, had a higher rate of cesarean delivery (CD) (aOR 1.47, 95% CI 1.14-1.91, p = 0.003); gestational diabetes (aOR 1.55, 95% CI 1.02-2.33, p = 0.038); and placenta previa (aOR 3.6, 95% CI 1.6-8.12, p = 0.002). Regarding neonatal outcomes, patients with AS, compared to those without, had a higher rate of small-for-gestational-age (SGA) neonates (aOR 2.19, 95% CI 1.22-3.93, p = 0.009); and intrauterine fetal death (IUFD) (aOR 3.46, 95% CI 1.11-10.83, p = 0.033). CONCLUSION: Women diagnosed with AS have an increased risk of obstetric complications, including CD, as well as an increased risk of SGA and IUFD.

Early postpartum unilateral vulvar edema leading to diagnosis of a Pfannenstiel incisional hernia following cesarean delivery.

Advantages of the low transverse Pfannenstiel incision include lower rates of incisional hernia, wound infection, hematoma formation, direct postoperative pain and distinctly improved aesthetic appearance. Relative disadvantages include insufficient intraoperative exposure of the upper abdomen and an increased incidence of superficial nerve entrapment. Incisional hernia following Pfannenstiel incision is a rare event with a reported incidence of between 0 and 0.5% while in contrast midline vertical incisions are considerably more common with a reported incidence of 5 to 30%. Symptomatology of Pfannenstiel incisional hernia has been reported to include: bulging, pain or discomfort, and distention of the surgical area. We report an unusual case of early postpartum unilateral vulvar edema, which led to imaging diagnosis of Pfannenstiel incisional hernia in a 41 year-old woman on Day 2 following Cesarean delivery due to preeclampsia with worsening severe features, at 30 weeks' gestation.

Early hospital discharge after cesarean delivery: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: The aim of this systematic review and meta-analysis was to assess whether earlier discharge from hospital after cesarean delivery (CD) affects the rate of maternal readmission. DATA SOURCE: The research was conducted using PubMed, Embase, Web of Sciences, Scopus, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to August 2023 with RCT as publication type. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included only RCTs comparing the effect of earlier vs later hospital discharge after CD. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was the rate of maternal readmission. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of Mentel-Haenszel. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity. "Earlier" and "later" hospital discharge was first considered according to each study's definition and then a subgroup analysis was performed including only studies defining as "earlier" a discharge within 24-28 hours and "later" a discharge at 48 hours after CD. The study was registered on PROSPERO (CRD 42024529885). RESULTS: Seven RCTs including 4,267 individuals, of which 2,125 (49.8%) randomized in the early discharge and 2,142 (50.2%) in the late discharge group were included. There was no difference between the two groups in the rate of maternal readmission (3.6% vs 3.4%, RR 1.10; 95% CI 0.80-1.52). There was no significant difference in both maternal complications diagnosed within 6 weeks after CD and neonatal complications. Early discharge after CD was associated with improved psychological wellbeing and was cost-effective. The subgroup analysis of the primary outcomes only in high-quality studies showed similar results: no difference in the rate of maternal readmission was observed (3.8% vs 3.2%, RR 1.20; 95% CI 0.63-2.30) between the two groups. When focusing only on studies comparing 24-28-hour vs 48-hour hospital discharge, the rate of maternal readmission did not differ between the two groups, while the rates of neonatal readmission and neonatal jaundice were significantly higher in the earlier discharge group. CONCLUSIONS: There is no increase in the rate of maternal readmission following early hospital discharge at 24-28 hours as opposed to later hospital discharge after a CD. The rates of neonatal readmission and neonatal jaundice were significantly higher in the earlier discharge group. Patients undergoing uncomplicated CDs might be discharged from the hospital at 24-28 hours postpartum, as long as close neonatal outpatient follow-up is done in 1-2 days; if this is unfeasible, discharge at 48 hours seems to be safe and effective for both mother and baby. Early discharge after CD was associated with improved psychological wellbeing and was cost-effective.

Mode of delivery and behavioral and neuropsychological outcomes in children at 10 years of age.

OBJECTIVES: Previous studies have reported that mode of delivery, particularly cesarean delivery (CD), is associated with neurodevelopmental outcomes in children. This study evaluates behavioral and neuropsychological test scores in children based on mode of delivery. METHODS: Children enrolled in the Raine Study from Western Australia, born between 1989 and 1992 by instrumental vaginal delivery (IVD), elective CD, and non-elective CD, were compared to those with spontaneous vaginal delivery (SVD). The primary outcome was the Child Behavior Checklist (CBCL) administered at age 10. Secondary outcomes included evaluations of language, motor function, cognition, and autistic traits. Multivariable linear regression was used to evaluate score differences by mode of delivery adjusted for sociodemographic and clinical characteristics, and Poisson regression was used to evaluate for increased risk of clinical deficit. RESULTS: Of 2,855 children, 1770 (62.0 %) were delivered via SVD, 480 (16.8 %) via IVD, 346 (12.1 %) via elective CD, and 259 (9.1 %) via non-elective CD. Non-elective CD was associated with higher (worse) CBCL Internalizing (+2.09; 95 % CI 0.49, 3.96; p=0.01) scores, and elective CD was associated with lower (worse) McCarron Assessment of Neuromuscular Development (MAND) (-3.48; 95 % CI -5.61, -1.35; p=0.001) scores. Differences were not seen in other outcomes, and increased risk of clinical deficit was not observed with either the CBCL Internalizing or MAND scores. CONCLUSIONS: Differences in behavior and motor function were observed in children delivered by CD, but given that score differences were not associated with increased incidence of clinical deficit, clinical significance may be limited.

Anesthetic and obstetric predictors of general anesthesia in urgent or emergent Cesarean delivery: a retrospective case-control study.

PURPOSE: While regional anesthesia (RA) is considered preferable to general anesthesia (GA) for Cesarean delivery (CD), certain situations necessitate GA. This study reviewed the practice patterns around the use of GA for CD to identify modifiable predictors of GA with the goal of reducing GA rates. METHODS: This was a retrospective, case-control study. Patients undergoing urgent/emergent CD over a 3-year period were identified, from which 102 patients undergoing GA and 102 patients undergoing RA were randomly selected. The data included patient characteristics, obstetrical indications for CD, type/indication of anesthetic, characteristics of airway management (GA group)/neuraxial anesthesia (RA group), and neonatal outcomes. RESULTS: Abnormal fetal heart rate (aFHR) was the most common obstetrical indication for urgent/emergent CD amongst the cases (39%) and controls (39%). GA administration was most commonly due to "limited time due to maternal/fetal compromise" (56%), followed by "maternal contraindication to RA" (25%) and "inadequate RA" (17%). The most frequent modifiable anesthetic indication for GA was inadequate neuraxial anesthesia (17%). Anesthetic and obstetric predictors for GA included ASA classification [OR 0.11 (0.06-0.21)], emergency code activation [OR 13.55 (1.73-106.40)], failure to progress [OR 0.15 ((0.06-0.36)], labor in a patient scheduled for CD [OR 0.16 (0.05-0.57)], pregnancy-related illness [OR 8.63 (1.06-70.38)], cord/fetal prolapse [14.85(1.90-115.94)], and gestational age (OR 0.86 (0.81-0.92)). CONCLUSION: Abnormal fetal heart rate, specifically bradycardia, was the most common obstetrical indication of GA for urgent/emergent CD, while inadequate neuraxial anesthesia was the most  modifiable anesthetic indication. Our data suggest aFHR and cord/fetal prolapse as potentially modifiable risk factors for GA in certain situations.

Impact of high-order repeat cesarean deliveries on early maternal complications among major placenta previa patients in Southern Saudi Arabia.

OBJECTIVES: To investigate the rates and odds ratios (ORs) of early maternal complications among patients with major placenta previa (PP) who have undergone high-order repeat cesarean deliveries (HOR-CDs) in comparison to those with low-order repeat cesarean deliveries (LOR-CDs). METHODS: We carried out a retrospective review of all major PP patients (n=184) who delivered through second or subsequent repeat CDs, from January 2012 to December 2021 (Abha Maternity and Children's Hospital, Abha, Saudi Arabia). The patients were categorized into 2 groups: the LOR-CDs group (n=100), comprising individuals with their second and third CDs (CD2-CD3) and the HOR-CDs group (n=84), consisting of those undergoing their fourth to seventh CDs (CD4-CD7). RESULTS: In comparison to the LOR-CDs, the HOR-CDs group with major PP exhibited significantly higher rates and ORs of early maternal complications, including MRI-diagnosed placenta accreta spectrum (PAS, OR=2.67), transfusions of packed red blood cells (OR=2.71), moderate to severe intra-operative bleeding (OR=1.80), emergency hysterectomy (OR=2.96), urological injuries (OR=3.17), and length of post-operative hospital stay (OR=3.91). The major PP subgroup undergoing CD6-CD7 showed the highest rates and ORs for PAS diagnosis at 84.6% (OR=3.98) and emergency hysterectomy at 28.6% (OR=4.04). CONCLUSION: Among patients with major PP, undergoing more than 3 CDs is associated with a notable increase in both the rates and ORs of various early maternal complications. This trend of increasing many complications correlates directly with an ascending number of CDs.

Early oral feeding within two hours for parturients compared with delayed oral feeding after cesarean section: a systematic review and meta-analysis.

BACKGROUND: It is recommended that postpartum women undergo early oral feeding (EOF) after cesarean section (CS). However, the optimal early time for oral feeding after CS is unclear. We performed a meta-analysis to assess whether EOF within two hours is superior to delayed oral feeding (DOF) after CS. METHODS: The PubMed, Embase, Cochrane Library, and Google Scholar databases were searched from inception to February 2024 for randomized controlled trials comparing EOF versus DOF after CS. Primary outcomes included the time to normal bowel function. The secondary outcomes included postoperative complications, the time to ambulation after surgery, the time to removal of the catheter, the time to start of a regular diet, the length of hospital stay and patient satisfaction. RESULTS: Data from 8 studies involving a total of 2572 women were obtained. EOF within two hours was significantly associated with shorter durations of return bowel movement (WMD, - 2.41, 95% CI, - 3.80-- 1.02; p < 0.001; I2 = 96%), passage flatus after surgery (WMD, - 3.55, 95% CI, - 6.36-- 0.75; p = 0.01; I2 = 98%), ambulation after surgery (WMD, - 0.96, 95% CI, - 1.80-- 0.13; p = 0.02; I2 = 53%), removal of catheters (WMD, - 15.18, 95% CI, - 25.61-- 4.74; p = 0.004; I2 = 100%) and starting a regular diet (WMD, - 7.03, 95% CI, - 13.13-- 0.92; p = 0.02; I2 = 99%) compared with DOF. EOF was not related to increased vomiting (RR, 1.08; 95% CI, 0.74-1.57; p = 0.69; I2 = 0%), nausea (RR, 1.21; 95% CI, 0.83-1.77; p = 0.33; I2 = 37%), abdominal distension (RR, 0.76; 95% CI, 0.31-1.89; p = 0.55; I2 = 54%) or ileus (RR, 0.91; 95% CI, 0.40-2.06; p = 0.81; I2 = 12%). CONCLUSIONS: This meta-analysis provides evidence that EOF within two hours after CS has comparable safety with DOF, and can accelerate the recovery time for normal bowel function. TRIAL REGISTRATION: INPLASY202320055.

Fear of Childbirth Impairs Breastfeeding Success Independent of Mode of Birth.

Background: The good qualities of breastfeeding are well known. The aim of this study was to closely examine the impact of specific maternal, prenatal, obstetric, and early neonatal factors on the success of breastfeeding. Materials and Methods: We used data from the Kuopio Birth Cohort study and analyzed 2,521 online questionnaires, which were answered by women 1 year after giving birth. Breastfeeding variables were divided into successful breastfeeding (breastfeeding exclusively with one's own breast milk ≥4 months or breastfeeding with formula ≥6 months) and poor breastfeeding (breastfeeding exclusively with one's own milk <4 months and duration of all breastfeeding <6 months) for univariate and multivariable analyses. Results: In this study, 97.8% (N = 2,466) reported breastfeeding their newborns for ≥1 postnatal week, and 75.2% (N = 1,896) breastfed newborns for ≥6 months. The rate of breastfeeding for ≥6 months increased from 71.3% to 84.7% between 2013 and 2020. In the multivariable analysis, poor breastfeeding success was associated most significantly with smoking during pregnancy (adjusted odds ratio [aOR] 4.64; 95% confidence interval [CI] 2.75-7.81), twin pregnancy (aOR 4.13; 95% CI: 2.10-8.15), maternal obesity (body mass index > 35) (aOR 3.27; 95% CI: 2.15-4.99), fear of childbirth (aOR 2.80; 95% CI: 1.89-4.13), and birth during the period of 2013-2014 (aOR 2.94; 95% CI: 2.08-4.14) or 2015-2016 (aOR 2.62; 95% CI: 1.85-3.70). Other significant factors related to poor success were younger maternal age, nonmarried family relationships, passive or quitting smoking before or in the first trimester, any hypertensive disorder during pregnancy, birth by nonelective cesarean, and lowest or highest quartiles of birth weight. Conclusions: Mother's fear of childbirth is strongly associated with the poor breastfeeding success even after controlling for mode of birth.

Comparison of ultrasound-guided erector spinae plane block versus transmuscular quadratus lumborum block for postoperative analgesia after caesarean delivery: A prospective randomized non-inferiority clinical trial.

Background and Aims: Regional techniques are a part of multimodal analgesia following cesarean delivery. Cesarean delivery warrants a regional technique, which can provide somatic and visceral analgesia-like quadratus lumborum block (QLB) and erector spinae plane block (ESPB). In this study, we investigated the non-inferiority of ESPB at T12 and transmuscular-QLB (TQLB) at L2-L3 for postoperative analgesia in cesarean delivery. Material and Methods: In this prospective, randomized, non-inferiority trial, 124 patients undergoing cesarean delivery were enrolled to receive bilateral TQLB or ESPB with 20 mL of 0.25% ropivacaine on each side. All patients received prophylactic acetaminophen and ketorolac for 2 days. Our primary objective was to compare the total tramadol consumption in the first 48 h between the two groups. Secondary objectives were to compare cumulative tramadol consumption, postoperative Numeric Rating Scale (NRS) score at rest, and with movement at various time points, the time for first rescue analgesic requirement, development of complications related to the block, and patient satisfaction with analgesia between the two groups. Results: The total tramadol consumption in 48 h (47.3 ± 34.9 mg in ESPB and 50.9 ± 38.7 mg in TQLB), duration of first rescue analgesic (22.8 ± 15.8 h in ESPB and 22.7 ± 15.6 h in TQLB), and patient satisfaction were similar between the two groups. Both groups had similar pain scores except at rest at 6 h and on movement at 4 h, 6 h, and 36 h, whereas the ESPB group had lower NRS scores (P < 0.05). Conclusion: The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB post-caesarean delivery.

A Collaborative Quality Improvement Project to Reduce Surgical Site Infection in Cesarean Delivery.

Introduction: Cesarean delivery (CD) facilitates delivery of the baby through an incision and is performed in situations where vaginal delivery poses risks to the mother, baby, or both. Over 1.2 million CDs are performed in the United States annually. Methods: An interdisciplinary council was created to drive regular data analysis and sharing, interdisciplinary collaboration, and standardized processes to reduce surgical site infections (SSI) following CD. The standardized infection ratio (SIR), a summary measure used to track hospital-acquired infections at a national, state, or local level over time, was used. Bundle components included pre- and postsurgical education and access to follow-up, peri- and intraoperative practice changes, and a risk stratification tool for postoperative dressing selection. Results: The bundle was initiated in April 2022. After use was established for 6 months, the SIR was evaluated in the fourth quarter of 2022. For this one quarter, the expected SIR for the hospital was 2.64, and the calculated SIR measured 0.38. In 2022, which included 3 months prebundle and 9 months postbundle, the expected SIR was 10.57, with a calculated SIR of just 0.66 for the full year. In 2023, the expected SIR was 11.10, with a calculated SIR of 0.27. The SSI rate reflects an observed 75% reduction in SSI between the years 2021 and 2023. Zero SSI have been observed from January to May 2024. For the patients who underwent planned CD, 98% received the full perioperative obstetric bundle. Discussion: The ongoing analysis and sharing of data, the implementation of standardized processes, and interdisciplinary collaboration were imperative to the success of this hospital's quality improvement project to reduce SSI for patients undergoing CD.

Disentangling Safety Culture's Role in Reducing Cesarean Overuse: Creating a Revised Labor Culture Survey.

Objective: To measure and assess the relationship of patient safety culture to reducing cesarean overuse. Study Setting: Maternity care hospitals in Michigan. Study Design: Cross-sectional observational design, combining individual survey data with hospital characteristics using existing databases. Multivariate Poisson regression assessed the associations between survey scores and hospital nulliparous term singleton vertex cesarean rates. Factor analysis determined the scalability of survey items. Data Collection Methods: Electronic survey distributed at the hospital site level. Principal Findings: A total of 3091 clinicians from 54 out of 57 eligible hospitals completed the survey. Confirmatory factor analysis demonstrated best fit with a univariate model with two local factors. The new scale encompassing both local factors, including vaginal birth microculture and safety culture, is entitled "Unit Norms." The safety culture subdomain demonstrated an association with a reduction in hospital cesarean rate [-0.15; 95% CI: -0.27 to -0.04; incident rate ratio (IRR) 0.86], parallel to but lower in magnitude to vaginal birth microculture (-0.18; 95% CI: -0.35 to -0.02; IRR 0.84). Conclusions: Vaginal birth microculture remains the strongest predictor of cesarean delivery overuse; however, safety culture characteristics, including teamwork, psychological safety, and communication, correlate with lower cesarean delivery rates. Measuring these aspects of hospitals' culture may be important for other areas of quality improvement initiatives focused on quality and safety.

Spontaneous rupture of an unscarred uterus at the early third trimester due to placenta percreta: a case report.

Uterine rupture during pregnancy is a complication of placenta percreta. We present the case of a woman in her early 30s with a history of incomplete abortion treated by dilatation and curettage who was admitted with abdominal pain and vomiting at 30 weeks of gestation. She was diagnosed with thrombophilia and was administered anticoagulant drugs. After 10 hours of monitoring, the patient abruptly deteriorated. An emergency cesarean delivery showed a ruptured uterus due to placenta percreta. She accepted localized excision and uterine repair, and recovered well. Rupture of an unscarred uterus due to placental percreta is an extremely rare obstetric complication with high maternal and fetal mortality. This condition should be suspected in all pregnant women who have severe abdominal pain without being in labor. The treatment of uterine rupture due to placental percreta should be individualized, and repair of the uterus is possible in the majority of women.

The Impact of Indication for Cesarean on Blood Loss.

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality worldwide. Quantitative blood loss assessment at the time of cesarean delivery is a more accurate measure of blood loss than is simple estimation. Risk factors for postpartum hemorrhage are well described; however, contemporary, systematic investigations into the impact of the indication for cesarean delivery on quantitative blood loss are lacking. OBJECTIVE: To investigate whether there are clinically significant differences in quantitative blood loss and postpartum hemorrhage risk based on the indication for cesarean delivery. STUDY DESIGN: A cohort of 4,881 cesarean deliveries performed at a large academic hospital between 2020 and 2022 was identified. Primary and repeat cesarean deliveries were analyzed separately and further subdivided into seven indications: elective, labor arrest, fetal heart rate abnormalities, placenta previa, placenta accreta, malpresentation, and other. Quantitative blood loss and rates of postpartum hemorrhage ( > 1000 cc and >1500cc) were compared among the different indications. RESULTS: Mean quantitative blood loss for primary, repeat and total cesarean deliveries was 886 cc, 697 cc and 792 cc, respectively. Excluding cases of placenta accreta, the greatest blood loss in both primary and repeat groups was seen in cesareans performed for labor arrest, with blood loss exceeding 1500 cc in 18% and 13% of all cases. Blood loss exceeding 1500cc was seen in 1% and 2% of elective cesarean deliveries. The mean blood loss for planned repeat cesarean/hysterectomies for placenta accreta was < 400cc greater than primary cesareans performed for labor arrest (1442 cc vs. 1065 cc), despite the addition of an often-complex hysterectomy to the procedure. CONCLUSIONS: Clinically and statistically significant differences in blood loss exist based on the indication for cesarean delivery. Large differences in rates of serious postpartum hemorrhage (>1500cc) with negligible differences in mean quantitative blood loss suggests the presence of frequent, large clinical outliers not reflected in a statistical mean. The indication for cesarean and the possibility of such outliers, rather than the predicted "average blood loss for cesarean delivery" should be considered in determining risk and the degree of necessary pre-operative blood preparation. These data raise questions about whether current, traditional techniques of non-accreta related cesarean delivery can be justified in non-emergent cases when such procedures could be performed with significantly less blood loss using accreta-specific techniques.

Recovery quality of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery: A randomized trial.

STUDY OBJECTIVE: This study aimed to investigate the effect of liposomal bupivacaine in transversus abdominis plane block (TAP) on recovery quality after cesarean delivery. DESIGN: A randomized trial. SETTING: An operating room, a post-anesthesia care unit, and a hospital ward. PATIENTS: A total of 147 women scheduled for cesarean delivery under spinal anesthesia were enrolled and randomized to receive a TAP block with plain bupivacaine (bupivacaine group), liposomal bupivacaine (liposomal group), or a mixture of plain bupivacaine and liposomal bupivacaine (mixture group). INTERVENTIONS: The bupivacaine group received bilateral TAP blocks with plain bupivacaine 50 mg alone. The liposomal group received bilateral TAP blocks with liposomal bupivacaine 266 mg alone. The mixture group received bilateral TAP blocks with plain bupivacaine 50 mg followed by liposomal bupivacaine 266 mg. MEASUREMENTS: The primary outcome was the Quality of Recovery-15 (QoR - 15) score assessed 24 h postoperatively. Secondary outcomes encompassed the QoR - 15 score at 48 h post-surgery, the VAS pain score at rest and with movement at 24, 48, and 72 h postoperatively, opioid consumption within the 0-24 h and 24-48 h periods following surgery, as well as patient's satisfaction with analgesic. MAIN RESULTS: The QoR - 15 score at 24 h postoperatively was significantly higher in both the liposomal group and the mixture group compared to the bupivacaine group. Specifically, the QoR - 15 score for the liposomal group versus the bupivacaine group (median [IQR]: 120 [107, 128] vs. 109 [104, 120]; median difference, 7; 95 % CI, 2 to 13; P = 0.011) and for the mixture group versus the bupivacaine group (median [IQR]: 122 [112, 128] vs. 109 [104, 120]; median difference, 9; 95 % CI, 4 to 14; P = 0.001). The QoR - 15 score in both the liposomal group and the mixture group were also higher than those in the bupivacaine group at 48 h postoperatively, though the difference was not clinically meaningful. Additionally, both the liposomal and mixture groups exhibited lower pain score at 24 h and 48 h postoperatively compared to the bupivacaine group, but no significant clinical differences were achieved in either pain scores or opioid consumption. Patients in both the liposomal and mixture groups reported higher satisfaction score with analgesia than those in the bupivacaine group. CONCLUSIONS: TAP block using either liposomal bupivacaine or a mixture of plain bupivacaine and liposomal bupivacaine provided superior quality of recovery at 24 h after cesarean delivery compared to using plain bupivacaine alone.

Associations of primiparous pre-pregnancy body mass index and gestational weight gain with cesarean delivery after induction: a prospective cohort study.

Objective: The effects of Pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) in primiparas remain unclear. This study examines the associations of pre-pregnancy BMI and GWG with cesarean delivery after induction (CDaI) in primiparous women. Methods: This prospective cohort study included 3,054 primiparous women. We recorded pre-pregnancy BMI, first, second, and third trimester weight values, as well as instances of CDaI and other pregnancy outcomes. We analyzed the associations of pre-pregnancy BMI and GWG with CDaI by conducting a multivariate logistic regression analysis after adjusting for covariates, and adjusted risk ratios (aRR) and 95% confidence intervals were reported. Results: We recorded 969 CDaIs. In the vaginal delivery group, each increase of 1 standard deviation in the pre-pregnancy BMI was correlated with a 6% increase in the CDaI risk [aRR (95% CI), 1.06 (1.01-1.11)]. Each increase of 1 standard deviation in the rate of weight gain during the entire pregnancy was correlated with a 21% increase in the CDaI risk [aRR (95% CI), 1.21 (1.14-1.29)]. Compared to women with a normal weekly GWG in the second and third trimester, those with slow GWG had a 19% increased risk of CDaI [aRR (95% CI), 1.19 (1.01-1.37)]. The subgroup analysis results showed that increases in pre-pregnancy BMI could increase the CDaI risk regardless of the induction method. Conclusion: High pre-pregnancy BMI, excessive GWG, and rapid first trimester weight gain are risk factors for CDaI in primiparous women. Excessive first trimester weight gain, may associated with increased risks of CDaI in primiparous women.

Maintenance infusion rate of oxytocin after initial 1-IU bolus for elective Cesarean delivery: a dose-finding study.

PURPOSE: The purpose of our study was to determine the minimum effective dose of oxytocin maintenance infusion required to maintain adequate uterine tone in 90% of patients (ED90) after administration of the initial bolus at elective Cesarean delivery (CD) under spinal anesthesia. METHODS: We conducted a prospective, double-blind dose-finding study with biased coin up-down design. Immediately after delivery, a 1-IU oxytocin bolus was administered, followed by a maintenance infusion. The obstetrician assessed the uterine tone by palpation as satisfactory or unsatisfactory. In case of unsatisfactory response, the dose for the next patient was increased by 2 IU·hr-1. For satisfactory response, the dose for the next patient was either decreased by 2 IU·hr-1 with a probability of 1/9, or remained unchanged. The primary outcome was a satisfactory uterine tone from five minutes after delivery until discharge from postanesthesia care unit. The secondary outcomes were blood loss, need for additional uterotonics, and side effects. RESULTS: We analyzed data for 40 patients. The ED90 of oxytocin maintenance infusion was 4.5 IU·hr-1 (95% confidence interval, 3.3 to 5.5) based on the isotonic regression estimator. The median [interquartile range] blood loss was 861 [553-1,181] mL; 18% received additional uterotonics, and 38% developed hypotension post delivery. CONCLUSION: Based on the results of this dose-finding study, we recommend a maintenance infusion rate of 4.5 IU·hr-1 following an oxytocin bolus of 1 IU for adequate uterine tone in pregnant patients undergoing elective CDs. This infusion rate is four-fold lower than that required without an initial bolus. STUDY REGISTRATION: ClinicalTrials.gov ( NCT04946006 ); first submitted 25 June 2021.

RéSUMé: OBJECTIF: L'objectif de notre étude était de déterminer la dose minimale efficace de perfusion d'entretien d'ocytocine nécessaire pour maintenir un tonus utérin adéquat chez 90 % des personnes parturientes (DE90) après l'administration du bolus initial lors d'une césarienne programmée sous rachianesthésie. MéTHODE: Nous avons réalisé une étude prospective et en double aveugle de détermination de la dose avec une méthodologie de conception biaisée type « up-and down ¼. Immédiatement après l'accouchement, un bolus d'ocytocine de 1 UI a été administré, suivi d'une perfusion d'entretien. L'obstétricien·ne a évalué le tonus utérin par palpation comme satisfaisant ou insatisfaisant. En cas de réponse insatisfaisante, la dose pour la personne suivante a été augmentée de 2 UI·h−1. Lors d'une réponse satisfaisante, la dose pour la personne suivante a été diminuée de 2 UI·h−1 avec une probabilité de 1/9, ou est restée inchangée. Le critère d'évaluation principal était un tonus utérin satisfaisant de cinq minutes après l'accouchement jusqu'à la sortie de la salle de réveil. Les critères d'évaluation secondaires étaient la perte de sang, la nécessité d'utérotoniques supplémentaires et les effets secondaires. RéSULTATS: Nous avons analysé les données de 40 patient·es. La DE90 de perfusion d'entretien d'ocytocine était de 4,5 UI·h−1 (intervalle de confiance à 95 %, 3,3 à 5,5) basé sur l'estimateur de régression isotonique. La perte de sang médiane [écart interquartile] était de 861 [553-1 181] mL; 18 % ont reçu des utérotoniques supplémentaires et 38 % ont développé une hypotension après l'accouchement. CONCLUSION: D'après les résultats de cette étude de détermination de la dose, nous recommandons un débit de perfusion d'entretien de 4,5 UI·h−1 après un bolus d'ocytocine de 1 UI pour un tonus utérin adéquat chez les personnes parturientes bénéficiant d'une césarienne programmée. Ce débit de perfusion est quatre fois inférieur à celui requis sans bolus initial. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT04946006 ); première soumission le 25 juin 2021.

Prenatal identification of invasive placentation using ultrasound in women with placenta previa and prior cesarean delivery.

OBJECTIVE: To evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery. STUDY DESIGN: This was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32-34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 - 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface. RESULTS: 180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not. CONCLUSION: Prenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery.

Racial inequities in cesarean use among high- and low-risk deliveries: An analysis of childbirth hospitalizations in New Jersey from 2000 to 2015.

OBJECTIVE: To examine racial inequities in low-risk and high-risk (or "medically appropriate") cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak. STUDY SETTING AND DESIGN: This retrospective repeated cross-sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed-level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM). DATA SOURCES AND ANALYTIC SAMPLE: We used all-payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP-code Tabulation Area (ZCTA)-level racialized economic segregation index data were from the 2007-2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases-9-CM (ICD-9) diagnosis and procedure codes and Diagnosis-Related Group codes, and created an indicator of cesarean delivery using ICD-9 codes. PRINCIPAL FINDINGS: Among low-risk deliveries, Black patients, particularly those in the age group of 35-39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black-adjusted predicted probability = 24.0%; vs. White-adjusted predicted probability = 17.3%). Among high-risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts. CONCLUSIONS: This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low-risk Black patients at higher odds of cesarean delivery and high-risk Black patients at lower odds of cesarean than their White counterparts. The significant Black-White inequities highlight the need to address misalignment of evidence-based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients.

Development of the obstetric unanticipated difficult video-laryngoscopy algorithm through a quality improvement randomized open-label in situ simulation study.

BACKGROUND: Video-laryngoscopy is increasingly used during general anesthesia for emergency cesarean deliveries. Given the heightened risk of difficult tracheal intubation in obstetrics, addressing challenges in airway management is crucial. In this simulation study, we hypothesized that using a flexible bronchoscope would lead to securing the airway faster than the Eschmann introducer when either device is used in addition to video-laryngoscopy. METHODS: Twenty-eight anesthesia trainees (n=14/group) were randomized to use either one of the rescue devices and video-recorded in a simulated scenario of emergency cesarean delivery. The primary outcome was the time difference in establishing intubation; secondary outcomes were the differences in incidence of hypoxemia, need for bag and mask ventilation, and failed intubation between the two rescue devices. RESULTS: Mean (±SD) time to intubation using flexible bronchoscopy was shorter compared to using an Eschmann introducer (24 ±â€¯10 vs 86 ±â€¯35 s; P<0.0001; difference in mean 62 seconds, 95% CI 42 to 82 seconds). In the fiberoptic bronchoscopy group, there were no episodes of hypoxemia or need for bag and mask ventilation; in contrast both such events occurred frequently in the Eschmann introducer group (71%, 10/14); P=0.0002). All flexible bronchoscopy-aided intubations were established on the first attempt. The incidence of failed intubation was similar in both groups. CONCLUSIONS: Our data from simulated emergency tracheal intubation suggest that flexible bronchoscopy combined with video-laryngoscopy results in faster intubation time than using an Eschmann introducer combined with video-laryngoscopy.