Prevention of RhD Alloimmunization: A Comparison of Four National Guidelines.

OBJECTIVE: The objective of this study was to compare national guidelines on the prevention of RhD alloimmunization. STUDY DESIGN: We performed a review of four national guidelines on prevention of alloimmunization from the American Congress of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynaecologists, Society of Obstetricians and Gynaecologists of Canada, and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. We compared the indications/contraindications, timing, dosing, formulation and route of anti-D immune globulin, and management of unique circumstances. The references were compared with regard to the number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. RESULTS: Variation exists in recommendations on the timing and need for consent prior to routine antenatal anti-D immune globulin administration, prophylaxis for unique circumstances (e.g., threatened abortion < 12 weeks, complete molar pregnancy), and the use of cell-free fetal DNA testing for fetal RhD genotype. CONCLUSION: These variations in recommendations reflect the heterogeneity of the literature on the prevention of alloimmunization and highlight the need for synthesis of evidence to create an international guideline on prevention of alloimmunization. This may improve safety, quality, optimize outcomes, and stimulate future trials.

Peripartum Morbidity after Cesarean Delivery for Arrest of Dilation at 4 to 5 cm Compared with 6 to 10 cm.

OBJECTIVE: Given that recent consensus guidelines established to decrease cesarean delivery (CD) rates use 6 cm to define the onset of the active phase of labor, our objective was to evaluate maternal and neonatal outcomes after CD for the indication of arrest of dilation at 4 to 5 cm compared with ≥ 6 cm. STUDY DESIGN: We performed a secondary analysis using data from the Maternal Fetal-Medicine Units Network Cesarean Registry. We included nulliparous women with term, singleton, vertex gestations who underwent primary CD for arrest of dilation. We compared those who reached a maximum cervical dilation of 4 to 5 cm with those of ≥6 cm. Our primary outcome was composite maternal morbidity that included chorioamnionitis, endometritis, transfusion, wound complication, operative injury, intensive care unit admission, or death. RESULTS: Of the 73,257 women in the dataset, 5,681 met the inclusion criteria. After adjusting for confounders, there was no difference in composite maternal (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 0.94-1.52) or neonatal morbidity (aOR: 0.94; 95% CI: 0.79-1.10) between the groups. CONCLUSION: In this historical cohort, maternal and neonatal outcomes after CD for arrest of dilation ≥ 6 cm were comparable to those performed at 4 to 5 cm and support recent labor management guidelines.

Restriction of oral intake during labor: whither are we bound?

In 1946, Dr Curtis Mendelson suggested that aspiration during general anesthesia for delivery was avoidable by restricting oral intake during labor. This suggestion proved influential, and restriction of oral intake in labor became the norm. These limitations may contribute to fear and feelings of intimidation among parturients. Modern obstetrics, especially in the setting of advances in obstetric anesthesia, does not mirror the clinical landscape of Mendelson; hence, one is left to question if his findings remain relevant or if they should inform current recommendations. The use of general anesthesia at time of cesarean delivery has seen a remarkable decline with increased use of effective neuraxial analgesia as the standard of care in modern obstetric anesthesia. While the American College of Obstetricians and Gynecologists now endorses clear liquids during labor, current recommendations continue to suggest that solid food intake should be avoided. Recent evidence from a systematic review involving 3130 women in active labor suggests that oral intake should not be restricted in women at low risk of complications, given there were no identified benefits or harms of a liberal diet. Aspiration and other adverse maternal outcomes may be unrelated to oral intake in labor and as such, qualitative measures such as patient satisfaction should be paramount. It is time to reassess the impact of oral intake restriction during labor given the minimal risk of aspiration during labor in the setting of modern obstetric anesthesia practices.

Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines.

OBJECTIVE: The purpose of this study was to compare 4 national guidelines for the prevention and management of postpartum hemorrhage (PPH). STUDY DESIGN: We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists practice bulletin, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Obstetrician and Gynaecologists (RCOG), and the Society of Obstetricians and Gynaecologists of Canada on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation. RESULTS: PPH was defined differently in all 4 guidelines. Risk factors that were emphasized in the guidelines conferred a high risk of catastrophic bleeding (eg, previous cesarean delivery and placenta previa). All organizations, except the American College of Obstetrician and Gynecologists, recommended active management of the third stage of labor for primary prevention of PPH in all vaginal deliveries. Oxytocin was recommended universally as the medication of choice for PPH prevention in vaginal deliveries. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for nonsurgical treatment strategies such as uterine packing and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy "sooner rather than later" with the assistance of a second consultant. CONCLUSION: Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.

Early term versus term delivery in the management of fetal growth restriction: a comparison of two protocols.

OBJECTIVE: This study aims to compare two management protocols in pregnancies diagnosed with fetal growth restriction (FGR). STUDY DESIGN: All singleton pregnancies diagnosed and managed with FGR at our institution during two protocol periods were analyzed. The early term protocol (January 2008-February 2010) specified delivery at 37(0/7) weeks if antenatal testing was reassuring, but did not specify the timing of delivery if umbilical artery (UA) Doppler systolic:diastolic (S:D) ratios were elevated (>95th percentile for gestational age [GA]). The term protocol (March 2010-July 2012) specified delivery at 39(0/7) weeks with normal S:D ratios and 37(0/7) weeks with elevated S:D ratios when antenatal testing was reassuring. RESULTS: There were 228 and 312 women in the early term and term protocol, respectively, who met inclusion criteria. Compared with the early term group, the term group had an increased median GA at delivery (37.1 vs. 38.6%, p < 0.001), decreased deliveries less than 37(0/7) weeks (37 vs. 24%, p = 0.01) and decreased neonatal intensive care unit (NICU) admissions (38 vs. 28%, p = 0.02). CONCLUSION: A protocol specifying delivery at 39(0/7) weeks when UA S:D ratios are normal and delivery at 37(0/7) weeks when UA S:D ratios are elevated when other antenatal testing is reassuring in FGR: (1) prolonged gestation, (2) decreased preterm births, and (3) decreased NICU admissions.

Prediction of abnormal postpartum glucose tolerance testing in mild gestational diabetes mellitus.

OBJECTIVE: To describe the liikelihood of women with gestational diabetes mellitus (GDM)--who are at increased risk for developing overt diabetes--undergoing postpartum testing, and the patient characteristics associated with abnormal postpartum glucose tolerance testing (GTT) in mild GDM. STUDY DESIGN: This was a retrospective chart review that included mild GDM patients, defined as those with fasting plasma glucose levels < 95 mg/dL on a 3-hour 100-g oral glucose tolerance test (OGTT). Patients who underwent postpartum testing were assessed and predictive factors for abnormal results evaluated. RESULTS: Mild GDM was diagnosed in 414 (39.6%) women, 201 (48.6%) of whom completed a postpartum 2-hour 75-g OGTT. Abnormal testing was seen in 69 (34.3%), with diabetes in 6 (3%); those with abnormal testing had been diagnosed with GDM at an earlier gestational age, had higher 1-hour 50-g OGTT values, and were also more likely to require pharmacologic therapy. Combining several variables produced a predictive model with positive and negative predictive values of 50% and 84%, respectively. CONCLUSION: Antenatal factors (alone or in combination) do not allow for prediction of abnormal postpartum OGTT results in mild GDM patients. Patients with mild GDM are at a slightly decreased postpartum risk of developing diabetes and prediabetes as compared to other patients with GDM.

Trauma in pregnancy: an updated systematic review.

We reviewed recent data on the prevalence, risk factors, complications, and management of trauma during pregnancy. Using the terms "trauma" and "pregnancy" along with specified mechanisms of injury, we queried the PubMed database for studies reported from Jan. 1, 1990, through May 1, 2012. Studies with the largest number of patients for a given injury type and that were population-based and/or prospective were included. Case reports and case series were used only when more robust studies were lacking. A total of 1164 abstracts were reviewed and 225 met criteria for inclusion. Domestic violence/intimate partner violence and motor vehicle crashes are the predominant causes of reported trauma during pregnancy. Management of trauma during pregnancy is dictated by its severity and should be initially geared toward maternal stabilization. Minor trauma can often be safely evaluated with simple diagnostic modalities. Pregnancy should not lead to underdiagnosis or undertreatment of trauma due to unfounded fears of fetal effects. More studies are required to elucidate the safest and most cost-effective strategies for the management of trauma in pregnancy.

Evidence-based surgery for cesarean delivery: an updated systematic review.

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.

Pregnancy-induced changes in immune protection of the genital tract: defining normal.

OBJECTIVE: Both the state of pregnancy as well as disruption of vaginal flora and immune mediators may increase the risk of human immunodeficiency virus-1 acquisition. The objective of this study was to define immune changes in lower genital and systemic immunity associated with normal pregnancy. STUDY DESIGN: This prospective cohort enrolled low-risk pregnant and nonpregnant women ages 18-35 years. Pregnant women at <14 weeks and nonpregnant women in follicular phase of the menstrual cycle were included. Cervical and vaginal fluid was collected. Concentrations of immune mediators were measured using enzyme-linked immunosorbent assay-based methods or multiplex immunoassay. Samples were inoculated onto various culture media allowing for growth of Lactobacillus species, Gardnerella vaginalis, Escherichia coli, Enterococcus species, anaerobic gram-negative rods, Candida, Staphylococcus aureus, Ureaplasma species, and Mycoplasma hominis. Concentrations of immune mediators and vaginal colonization frequencies were compared between the pregnant and nonpregnant groups. RESULTS: Genital tract concentration of interleukin-1ß was higher during pregnancy compared to nonpregnant participants. Serum C-reactive protein concentrations were higher in all trimesters of pregnancy. Concentrations of secretory leukocyte protease inhibitor did not differ between groups. Lactobacillus was more commonly isolated from vaginal cultures of nonpregnant participants (100% vs 70.2%, P = .02). Identification of Candida, G vaginalis, M hominis, and S aureus was common and not different between groups. Ureaplasma species was isolated from >60% pregnant participants. CONCLUSION: The proinflammatory cytokine, interleukin-1ß, as well as the systemic marker of inflammation, C-reactive protein, are increased during pregnancy. The impact of these proinflammatory changes during pregnancy deserves further study.

Screening for intrauterine growth restriction in uncomplicated pregnancies: time for action.

A randomized clinical trial (RCT) noted that sonographic examination in the third trimester, in conjunction with delivery at term for abnormalities of fetal growth, significantly decreased the likelihood of small-for-gestational-age (SGA) neonates in uncomplicated pregnancies. We identified 15 characteristics of screening tests and attempted to determine if there is evidence to routinely obtain sonographic estimates of fetal weight in the third trimester and decrease rates of SGA. Of the 15 suggested characteristics, currently 10 (67%) are fulfilled, two are uncertain (sonographic examination is cost-effective or reliable), and one (the test must do its job) is possibly valid. Due to the lack of RCTs demonstrating reduction in morbidity, there is potential for lead-time and length bias. To observe a 36% decrease (from 4.1 to 2.6%) decrease in composite perinatal morbidity, 6000 women need to be randomized to at least two sonographic examinations in the third trimester versus routine prenatal care. Such an RCT is warranted and justified.

Amniotic fluid volume in normal pregnancy: comparison of two different normative datasets.

AIM: The aim of the present study was to compare the two normative datasets of amniotic fluid volume (AFV). MATERIAL AND METHODS: The similarity of the two datasets to classify AFV as oligohydramnios, normal, and polyhydramnios based on fixed cut-offs, stratified by gestational ages (<24 weeks, 24-33(6/7), 34-36(6/7) , and >37 weeks, and to identify oligohydramnios/small for gestational age (SGA) and polyhydramnios/large for gestational age (LGA) was evaluated. RESULTS: Of the 209 pregnancies assessed, the AFV was 94 ≤ 500 mL, 101 between 501 and 1999 mL, and 14 ≥ 2000 mL. The datasets were in agreement classifying the AFV as oligohydramnios, normal, and polyhydramnios in 76% of the pregnancies. Brace classified more overall patients with oligohydramnios (19%) versus Magann (3%) (P < 0.001). In term pregnancies (>37 weeks), Brace was more likely to classify pregnancies with oligohydramnios (15%) than Magann (3%) (P = 0.004). The likelihood ratio (LR) to detect oligohydramnios/SGA was greater with Magann (LR 12.9) versus Brace (LR 2.75). CONCLUSION: The two datasets classify AFV differently in 24% of cases. Brace's dataset is more likely to categorize patients as having oligohydramnios and Magann's dataset is a more useful test for oligohydramnios/SGA identification.

Postpartum management of hypertension and effect on readmission rates.

BACKGROUND: Postpartum hypertension is a source of significant morbidity and mortality in the United States. While advances have been made in the peripartum management of hypertension, there is little data to guide ongoing management postpartum. OBJECTIVE: To determine whether an association exists between (1) hospital readmission and (2) hypertension in the 12 hours before discharge and the prescription of antihypertensive medications at the time of discharge. The secondary objective included evaluating the median time to readmission for hypertensive complications. STUDY DESIGN: This was a retrospective cohort study of all women with peripartum hypertension at a single tertiary care center over a 3-year period (2017-2019). Peripartum hypertension was defined as any systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on 2 occasions, 4 hours apart, in the electronic medical record during the patients' admission for delivery. As potential risk factors for readmission, we also identified if the patients were discharged with a prescription for antihypertensive medication and assessed the blood pressure measurements during the 12 hours before discharge. The primary outcome of interest was postpartum readmission because of hypertensive complications. Readmission was defined as emergency room evaluation or hospital readmission because of hypertensive complications. Analysis was stratified into 4 comparison groups on the basis of the blood pressure and antihypertensive medications on discharge. The rate of postpartum readmissions was calculated. The risks of readmission were estimated using logistic regression and were adjusted for appropriate confounding variables. RESULTS: Of 14,577 women who gave birth during the study period, 3480 (24%) met the definition of peripartum hypertension. Of those, 176 (5.1%) were readmitted within a median of 3 days from discharge. Sixty percent of patients readmitted had an International Classification of Diseases, Tenth Revision code for peripartum hypertension assigned by providers during their admission. Women with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg before discharge were at a higher risk of readmission irrespective of being discharged with antihypertensive medication. Compared with those who were discharged normotensive, women who had hypertension in the 12 hours before discharge and were discharged with an antihypertensive prescription were at a significantly increased risk of readmission, adjusted odds ratio, 2.90; 95% confidence interval, 1.11-7.57. CONCLUSION: Untreated hypertension within 12 hours before discharge was associated with a 32% higher risk of readmission in those who were not prescribed antihypertensive medications at discharge and a 3-fold increased risk of readmission in patients discharged on antihypertensive medication. These findings highlight the importance of treatment to normalize the blood pressure for at least 12 hours before discharge.

Does the International Classification of Disease (ICD-9) code accurately identify neonates who clinically have hypoxic-ischemic encephalopathy?

BACKGROUND/AIMS: Hypoxic-ischemic encephalopathy (HIE) refers to neonatal neurological signs and symptoms of hypoxia and/or ischemia. Our aim was to determine the accuracy of ICD-9 codes to identify newborns with HIE confirmed by umbilical cord blood analysis. METHODS: ICD-9 codes in the newborn chart for birth trauma, birth asphyxia, intrauterine hypoxia, and fetal distress were used to identify newborns with suspected HIE by neonatal personnel. Maternal charts were reviewed for umbilical cord gases meeting the HIE clinical criteria. RESULTS: There were 21,008 deliveries at center I and 17,540 at center II. ICD-9 codes identified 172 neonates, 49 infants (2.3‰ births) at center I and 123 neonates (7‰) at center II. Only 3 neonates (6%) were ≥34 weeks and none met ACOG criteria [umbilical artery pH <7.00 or base excess (BE) ≥12 mmol/l at center I]. At center II, 80 infants were ≥34 weeks but only 5/123 (4%) met the ACOG clinical criteria for HIE (pH <7.00, BE ≥12 mmol/l, and Apgar ≤3 at 5 min). CONCLUSIONS: ICD-9 codes are unreliable in identifying birth asphyxia and cannot identify newborns meeting the clinical criteria for intrapartum HIE.

The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees.

In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.

A comparison of placental pathology between small for gestational age infants at < 5 % versus 5-9.

INTRODUCTION: Among SGA newborns, those < 5th % for GA are more likely to have adverse outcomes than those at 5-9th %. The differential morbidity and mortality may be due to abnormal placental pathology between groups. Our purpose was to compare placental pathology characteristics and composite placental pathology among SGA infants with birth weights <5th % vs. 5-9th %. METHODS: This study is a secondary analysis of a multicenter, retrospective cohort study. Placental pathological variables and composite placental pathology (CPP) among SGA infants <5th % and 5-9th % were compared. Multivariable logistic regression was used to model the probability of an infant's birth weight being classified as <5th % based on pathology characteristics. RESULTS: Of 11,487 live singleton births, 925 SGA infants met inclusion criteria. Placental pathology was available for review in 407 (44 %) SGA infants: 210 (51.6 %) <5th % and 197 (48.4 %) 5-9th %. A decreased placental weight for GA, was more common in the <5th % group compared to the 5-9th % group (p = 0.0019). No significant differences in the distribution of pathological variables or in CPP (p = 0.3) was observed between the two centile groups. A decreased placental weight was the only reliable predictor of an infant's birth weight centile group (p = 0.0018). CONCLUSIONS: Placental hypoplasia, reflected by a decreased placental weight for GA, was significantly more common among SGA infants < 5th % compared to the 5-9th %. There was no difference in placental pathological features or CPP between the two centile groups of SGA infants.

Obstetric Emergencies: Shoulder Dystocia and Postpartum Hemorrhage.

Shoulder dystocia and postpartum hemorrhage represent two of the most common emergencies faced in obstetric clinical practice, both requiring prompt recognition and management to avoid significant morbidity or mortality. Shoulder dystocia is an uncommon, unpredictable, and unpreventable obstetric emergency and can be managed with appropriate intervention. Postpartum hemorrhage occurs more commonly and carries significant risk of maternal morbidity. Institutional protocols and algorithms for the prevention and management of shoulder dystocia and postpartum hemorrhage have become mainstays for clinicians. The goal of this review is to summarize the diagnosis, incidence, risk factors, and management of shoulder dystocia and postpartum hemorrhage.

Cerclage Use: A Review of 3 National Guidelines.

IMPORTANCE: Preterm birth is a major contributor to perinatal morbidity and mortality. The most common intervention performed to improve perinatal outcomes for a woman experiencing cervical dilation in the second trimester without signs or symptoms of preterm labor is the cerclage. OBJECTIVE: We sought to review and compare available national guidelines on cerclage use. EVIDENCE ACQUISITION: We performed a descriptive review of 3 national guidelines on cerclage: The American Congress of Obstetricians and Gynecologists Practice Bulletin on "Cerclage for the Management of Cervical Insufficiency," Green-top Guideline from the Royal College of Obstetricians and Gynaecologists entitled "Cervical Cerclage," and the Society of Obstetricians and Gynaecologists of Canada Clinical Practice Bulletin entitled "Cervical Insufficiency and Cervical Cerclage." Guidelines were compared, and the following aspects of cerclage use for prevention of preterm delivery were summarized: indications and contraindications, risk factors for cervical insufficiency, perioperative considerations, and timing of removal. Recommendations and strength of evidence were reviewed based on each guideline's method of reporting. The references were compared with regard to the total number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. RESULTS: The variations highlighted in the guidelines reflect the heterogeneity of the literature contributing to guidelines and the challenges of diagnosing and managing cervical insufficiency. CONCLUSIONS: A cohesive international guideline may improve safety and quality and optimize patient outcomes. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES: After completing this activity, the learner should be better able to outline variations in indications and contraindications for cervical cerclage use by international guideline, identify variation in perioperative considerations for cervical cerclage use by international guideline, and recognize variation in timing of removal by international guideline.

Cervical Cerclage During Periviability: Can We Stabilize a Moving Target?

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recently published consensus guidelines on periviable birth recommending that obstetric interventions (antenatal corticosteroids, tocolysis, magnesium sulfate, antibiotics for preterm premature rupture of membranes or group B streptococcus prophylaxis, and cesarean delivery for fetal indications) may be considered at 23 0/7 weeks of gestation and neonatal resuscitation at 22 0/7 weeks of gestation. Cervical cerclage significantly decreases preterm delivery and improves perinatal outcomes in women with a singleton pregnancy, prior spontaneous preterm birth, and transvaginal cervical length less than 25 mm before 24 0/7 weeks of gestation or in women who experience painless cervix dilation in the second trimester. Randomized trials assessing ultrasonogram-indicated and physical examination-indicated cerclage report a procedure-related complication rate of 0.3% and 0.9%, respectively. If previability is a requisite for receiving a cerclage, an increasing subset of women may not be afforded an intervention that has known benefit, because obstetric and neonatal interventions are likely to occur at earlier gestational ages. Given the low procedure-related complication rate demonstrated in randomized trials, appropriately selected women should continue to be offered the procedure up to 24 0/7 weeks of gestation. Based on current evidence, cerclage placed after 24 0/7 weeks of gestation cannot be recommended, and future inquiry in the form of a well-designed randomized trial after this gestational age should be considered. The goal of this commentary is to review the history of cerclage and discuss the indications, risks, benefits, and implications on future research of this procedure as it relates to gestational age during periviability.

Evidence-Based Cesarean Delivery for the Nonobstetrician.

Cesarean delivery (CD) is one of the most common major surgeries performed in the United States and worldwide. Surgical techniques evaluated in well-designed randomized controlled trials (RCTs) that demonstrate maternal benefit should be incorporated into practice. The objective of this review is to provide a summary of surgical techniques of the procedure and review the evidence basis for them for the nonobstetrician. The following techniques with the strongest evidence should be commonly performed, when feasible: (1) prophylactic antibiotics with a single dose of ampicillin or first-generation cephalosporin prior to skin incision; (2) postpartum hemorrhage prevention with oxytocin infusion of 10 to 40 IU in 1 L crystalloid over 4 to 8 hours; (3) low transverse skin incision; (4) blunt or sharp subcutaneous and fascial expansion; (5) blunt, cephalad-caudad uterine incision expansion; (6) spontaneous placental removal; (7) blunt-tip needle usage during closure; (8) subcutaneous suture closure (running or interrupted) if thickness is ≥2 cm; and (9) skin closure with suture. Although the number of RCTs designed to optimize maternal and neonatal outcomes of this common procedure is encouraging, further work is needed to minimize surgical morbidity. Optimal methods for postpartum hemorrhage prevention, adhesion prevention, and venous thromboembolism prophylaxis remain ongoing areas of active research, with outcomes that could markedly improve maternal morbidity and mortality. If evidence of a surgical technique appears preferred over another, clinicians should be comfortable adopting the evidence-based technique when performing and teaching CD.