Postpartum obstetric complications: a guide for radiologists.

The puerperium refers to the 6-8 weeks following delivery, and is a dynamic period in which maternal anatomy and physiology are restored to their prepregnant state. Postpartum complications can be divided into non-obstetric and obstetric. The latter are the topic of this article and can be further classified as infectious, thrombotic, hemorrhagic or cesarean-related. Transvaginal US is often the initial modality in the evaluation of puerperal disorders. CT is probably the most valuable imaging technique when life-threatening conditions are suspected. Pelvic MRI is being increasingly used in cases of inconclusive findings or if further characterization is needed, especially in the setting of postsurgical complications or placental disorders. Diagnostic and interventional radiologists play a pivotal role in the evaluation and management of a variety of puerperal complications. Many of these conditions pose a diagnostic challenge, as imaging findings often overlap with normal postpartum changes, so keeping in mind the patient's clinical information is key.

Intravenous initial bolus during prophylactic norepinephrine infusion to prevent spinal hypotension for cesarean delivery: A randomized controlled, dose-finding trial.

BACKGROUND: Previous studies have shown that a 0.05 µg/kg/min of norepinephrine infusion in combination with an initial bolus reduces the incidence of spinal hypotension during cesarean delivery. The initial norepinephrine bolus influences the incidence of spinal hypotension during continuous norepinephrine infusion; however, the ideal initial bolus dose for 0.05 µg/kg/min of continuous infusion remains unknown. METHODS: This randomized, controlled, dose-finding study randomly allocated 120 parturients scheduled for elective cesarean delivery to receive initial bolus doses of 0, 0.05, 0.10, and 0.15 µg/kg of norepinephrine, followed by continuous infusion at a rate of 0.05 µg/kg/min. The primary outcome was the dose-response relationship of the initial norepinephrine bolus in preventing the incidence of spinal hypotension. Spinal hypotension was defined as systolic blood pressure (SBP) decreased to <80% of the baseline value or to an absolute value of <90 mmHg from intrathecal injection to delivery, and severe spinal hypotension was defined as SBP decreased to <60% of the baseline value. The secondary outcomes included the incidence of nausea and/or vomiting, hypertension, and bradycardia, as well as the Apgar scores and results of the umbilical arterial blood gas analysis. The effective dose (ED) 90 and ED95 were estimated using probit regression. RESULTS: The per-protocol analysis included 117 patients. The incidence of spinal hypotension varied significantly among the groups: Group 0 (51.7%), Group 0.05 (44.8%), Group 0.10 (23.3%), and Group 0.15 (6.9%). The ED90 and ED95 values were 0.150 µg/kg (95% confidence interval [CI], 0.114-0.241 µg/kg) and 0.187 µg/kg (95% CI, 0.141-0.313 µg/kg), respectively. However, the ED95 value fell outside the dose range examined in this study. The incidence of severe spinal hypotension differed significantly (P = 0.02) among Groups 0 (17.2%), 0.05 (10.3%), 0.10 (3.3%), and 0.15 (0.0%); however, the incidence of hypertension and bradycardia did not. The incidence of nausea and/or vomiting decreased with an increase in the initial bolus dose (P = 0.03). The fetal outcomes were comparable among the groups. CONCLUSIONS: An initial bolus of 0.150 µg/kg of norepinephrine may be the optimal dose for preventing spinal hypotension during cesarean delivery with a continuous infusion rate of 0.05 µg/kg/min, and does not significantly increase the incidence of hypertension but substantially reduces the risk of nausea and/or vomiting.

Comparison between high transverse and low transverse Pfannenstiel skin incisions during cesarean delivery for morbidly obese patients.

OBJECTIVE: This study aimed to evaluate if placement of transverse cesarean skin incision above or below the overhanging pannus is associated with wound morbidity in morbidly obese patients. STUDY DESIGN: We identified a cohort of patients with body mass index (BMI) ≥40 kg/m2 undergoing cesarean delivery at a single center from 2017-2020 with complete postpartum records. Data was abstracted after institutional review board exemption, and patients were grouped by low transverse or high transverse skin incision. The primary outcome was a composite of wound infection, fascial dehiscence, incisional hernia, therapeutic wound vacuum, and reoperation. Secondary outcomes included the individual components of the composite, blood transfusion, operative time, and immediate neonatal outcome. T test and χ2 were used for continuous and categorical comparisons. Logistic regression was used to compute adjusted odds ratios for categorical outcomes and linear regression to compare operative times adjusting for factors associated with wound complications and surgical duration respectively. RESULTS: 328 patients met inclusion criteria: 65 with high transverse (infraumbilical and supraumbilical) and 263 with low transverse (Pfannenstiel) incision. 11% of patients had wound morbidity; high transverse incision was associated with 3.64-fold increased odds of composite wound morbidity (23.1% vs 8%, aOR 3.64, 95% CI 1.52-8.70) and 5.73-fold increased odds of wound infection (13.8% vs. 4.9%, aOR 5.73, 95% CI 1.83-17.96). Time from skin incision to delivery was 1.87 min longer (11.09 vs 14.98 min, ß = 1.87, 95% CI 0.17-4.61). There was no significant difference in neonatal outcomes, non-low transverse hysterotomy, or total operative time. CONCLUSION: High transverse skin incision for cesarean delivery was strongly associated with increased wound morbidity in morbidly obese patients.

Outcomes after cesarean delivery were assessed for 328 patients with morbid obesity.High transverse skin incision for cesarean delivery was associated with increased wound morbidity and wound infection.Prospective studies will be needed to determine if skin incision placement causes wound morbidity.

A randomized controlled trial reducing cesarean delivery rates in China by introducing trial of labor after cesarean and electrohysterography.

OBJECTIVE: A cesarean delivery (CD) can affect health of both mother and child and future pregnancies. Since the abandonment of the one-child policy in China, obstetricians tend to perform a repeat CD rather than a trial of labor after cesarean (TOLAC). This study aims to reduce CD rates by increasing vaginal births after cesarean (VBAC) rates and introducing electrohysterography (EHG) for accurate monitoring. METHODS: In total, 82 women received counseling regarding TOLAC at the Shijiazhuang Sixth Hospital in China. Women opting for TOLAC were randomized for either external tocodynamometry (TOCO, i.e. standard care) or EHG. The primary outcome was the VBAC rate. Secondary outcomes were indications for CD, percentage of assisted vaginal deliveries, labor duration, maternal blood loss, complications and neonatal outcomes. RESULTS: After accounting for preterm delivery and dropouts, all counseled women opted for a TOLAC (100%). After randomization, 42 women were included in the TOCO-group and 37 in the EHG-group. Women did not receive pain medication and labor was not augmented with oxytocin. The VBAC rate was 71.4% in the TOCO-group, versus 78.4% in the EHG-group (p = .48). Birth was assisted with forceps in 11.9% of TOCO-group versus 2.7% of EHG-group (p = .21). One secondary CD (i.e. a shift from intended vaginal delivery to surgical delivery within the same labor) was performed because of a suspicion of uterine rupture (TOCO-group). Other indications for CD were: fetal distress, labor dystocia, fetal position, cephalopelvic disproportion. There were no significant differences in secondary study outcomes. No complications were reported. CONCLUSION: This study showed an average VBAC rate of 75%, without any complications, in a hospital with no previous experience with TOLAC. The VBAC rate with EHG-monitoring was higher than TOCO, although this difference was not significant. To demonstrate a significant difference, larger clinical studies are necessary. TRIAL REGISTRATION: The Daily Board of the Medical Ethics Committee of The Maternal and Child Hospital of Shijiazhuang approved the study protocol (number 20171018, Dutch Trial Register NL8199).

The effect of cesarean delivery on the neonatal gut microbiome in an under-resourced population in the Bronx, NY, USA.

BACKGROUND: Neonatal and early-life gut microbiome changes are associated with altered cardiometabolic and immune development. In this study, we explored Cesarean delivery effects on the gut microbiome in our high-risk, under-resourced Bronx, NY population. RESULTS: Fecal samples from the Bronx MomBa Health Study (Bronx MomBa Health Study) were categorized by delivery mode (vaginal/Cesarean) and analyzed via 16 S rRNA gene sequencing at four timepoints over the first two years of life. Bacteroidota organisms, which have been linked to decreased risk for obesity and type 2 diabetes, were relatively reduced by Cesarean delivery, while Firmicutes organisms were increased. Organisms belonging to the Enterococcus genus, which have been tied to aberrant immune cell development, were relatively increased in the Cesarean delivery microbiomes. CONCLUSION: Due to their far-reaching impact on cardiometabolic and immune functions, Cesarean deliveries in high-risk patient populations should be carefully considered.

Predicting the Severity of Acute Pain after Cesarean Delivery: A Narrative Review.

PURPOSE OF THE REVIEW: Cesarean delivery is one of the most common surgical procedures performed worldwide. Approximately 28-78% of the patients have reported experiencing severe pain after Cesarean delivery, which is associated with adverse outcomes. Current analgesic management strategies employ a one-size-fits-all approach, which may not be suitable for all post-Cesarean patients. Our ongoing research and the purpose of this review are focusing on preoperative risk assessment to identify patients at risk of severe pain or needing higher doses of opioid or other analgesics. RECENT FINDINGS: Recent clinical investigations have found that by utilizing the demographic and psychological evaluations, screening tests, quantitative sensory testing, and assessment of response to local anesthetic infiltration, clinicians were potentially able to stratify the risks for severe post-cesarean pain. Several modalities demonstrated significant correlations with pain outcomes, although most of these correlations were weak to modest. Since consensus statement regarding predicting post-CD pain control are still lacking, these correlations can be clinically helpful. It is possible to identify patients at high risk of developing severe acute pain after cesarean section by preoperative demographic data, screening questionnaires, or other tools. Further studies are needed to identify additional variables or screening tools for more accurate prediction and investigate whether personalized analgesic regimens can lead to improved analgesic outcomes.

The French Ambulatory Cesarean Section: Safety and Recovery Characteristics.

OBJECTIVES: The French AmbUlatory Extraperitoneal Cesarean Section (FAUCS) is aimed at improving patients' birth experience and recovery. However, data are scarce regarding its maternal and neonatal safety. This study seeks to compare maternal and neonatal outcomes between FAUCS and conventional cesarean deliveries at term. METHODS: This was a retrospective cohort study involving women who underwent scheduled cesarean deliveries at term. We compared a total of 810 cases using the FAUCS technique with 217 cases using conventional cesarean deliveries. Surgical complications, adverse neonatal events, and maternal recovery parameters were compared. RESULTS: The incidence of overall surgical complications was comparable between the 2 groups, with rates of 1.97% for FAUCS and 1.85% for the conventional cesarean deliveries. The rates of specific complications such as bladder injury (0.1%), bowel injury (0.1%), blood transfusion (1.35%), and postpartum hemorrhage (1%) were consistent with existing literature. Neonatal outcomes, including neonatal acidemia and admission rates to the neonatal intensive care unit, were comparable between the groups and demonstrated favourable comparisons with previously reported data. Notably, women in the FAUCS group required less analgesia, with only 0.8% receiving morphine, as opposed to 38% in the control group. Furthermore, the FAUCS group demonstrated significantly quicker recovery, with 86% achieving autonomy and early discharge at their discretion within 48 hours after operation, in contrast to only 17% in the control group. CONCLUSIONS: When performed by experienced practitioners, FAUCS proves to be a safe procedure, with no increased risk for maternal or neonatal complications. Its significant benefits in terms of enhancing maternal recovery are noteworthy.

Maternal Morbidity following Trial of Labor after Cesarean in Women Experiencing Antepartum Fetal Death.

This study aims to investigate whether trial of labor after cesarean delivery (TOLAC) in women with antepartum fetal death, is associated with an elevated risk of maternal morbidity. A retrospective multicenter. TOLAC of singleton pregnancies following a single low-segment incision were included. Maternal adverse outcomes were compared between women with antepartum fetal death and women with a viable fetus. Controls were matched with cases in a 1:4 ratio based on their previous vaginal births and induction of labor rates. Univariate analysis was followed by multiple logistic regression modeling. During the study period, 181 women experienced antepartum fetal death and were matched with 724 women with viable fetuses. Univariate analysis revealed that women with antepartum fetal death had significantly lower rates of TOLAC failure (4.4% vs. 25.1%, p < 0.01), but similar rates of composite adverse maternal outcomes (6.1% vs. 8.0%, p = 0.38) and uterine rupture (0.6% vs. 0.3%, p = 0.56). Multivariable analyses controlling for confounders showed that an antepartum fetal death vs. live birth isn't associated with the composite adverse maternal outcomes (aOR 0.96, 95% CI 0.21-4.44, p = 0.95). TOLAC in women with antepartum fetal death is not associated with an increased risk of adverse maternal outcomes while showing high rates of successful vaginal birth after cesarean (VBAC).

Placenta Accreta Spectrum (PAS): Diagnosis, Clinical Presentation, Therapeutic Approaches, and Clinical Outcomes.

Placenta accreta spectrum (PAS) refers to the abnormal adhesion of the placenta to the myometrium, with varying degrees of severity. Placenta accreta involves adhesion to the myometrium, placenta increta invades the myometrium, and placenta percreta extends through the serosa to adjacent organs. The condition is linked to deficient decidualization in scarred uterine tissue, and the risk increases when placenta previa is present and with each prior cesarean delivery. Other risk factors include advanced maternal age, IVF, short intervals between cesareans, and smoking. PAS incidence has risen due to the increase in cesarean deliveries. Placenta previa combined with PAS significantly raises the risk of severe peripartum bleeding, often necessitating a cesarean section with a total hysterectomy. Recognizing PAS prepartum is essential, with sonographic indicators including intraplacental lacunae and uterovesical hypervascularization. However, PAS can be present without sonographic signs, making clinical risk factors crucial for diagnosis. Effective management requires a multidisciplinary approach and proper infrastructure. This presentation covers PAS cases treated at University Hospital Freiburg, detailing patient conditions, diagnostic methods, treatments and outcomes.

Determination of ED90s of Phenylephrine and Norepinephrine Infusion for Prevention of Spinal Anesthesia-Induced Hypotension in Patients with Preeclampsia During Cesarean Delivery.

Background: Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. Methods: 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 µg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 µg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. Results: The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) µg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) µg/kg/min, respectively, with an efficacy ratio of 12.1:1. Conclusion: The administration of 0.6 µg/kg/min phenylephrine and 0.05 µg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.

A retrospective study of pre-operative fasting times prior to elective or emergency cesarean birth in a large maternity hospital: Lessons to be learned to minimize the fasting time.

INTRODUCTION: When managing elective and emergency cesarean births in the same operating room, unpredictable variations in the start times of the cesareans can prolong fasting periods. METHODS: The fasting times were retrospectively analyzed on 279 consecutive cesarean births at Helsinki University Women's Hospital, Finland, during January-February 2023. The fasting times were compared between the urgency groups and for elective cesareans according to their scheduled order on the operation list. The primary outcome was the difference in the fasting times for food and drink, while the secondary outcome was fasting for both food >12 h and fluids >4 h. The fasting times were compared by one-way ANOVA and chi-squared test, respectively. Dichotomous data are presented as unadjusted odds ratios (OR with 95% CI). RESULTS: Increasing urgency was associated with shorter fasting times. Fasting times for elective cesareans increased with the scheduled order on the daily list. The mean fasting periods (SD) increased from 10.55 h (SD=1.57) to 14.75 h (SD=2.02) from the first to the third cesarean of the day (p<0.01). The unadjusted odds ratio (95% CI) for fasting of the scheduled cesareans to exceed 12 h for solid foods and 4 h for clear fluids was 6.53 (95% CI: 2.67-15.9, p<0.001), for the third and fourth cesareans compared to the first two cesareans of the day. CONCLUSIONS: When elective and emergency cesareans are performed by the same team, the woman undergoing the third elective surgery of the day should be advised to have breakfast before 5 a.m. at home. While waiting for the operation, a carbohydrate drink should be offered to limit the fast.

Friedreich's Ataxia and Cesarean Delivery: A Case Report of Epidural Anesthesia With Ropivacaine.

Friedreich's ataxia (FRDA), a rare inherited neurodegenerative disease, presents distinctive complexities in obstetrical anesthesia. Available research about FRDA in obstetrics is extremely limited. In this report, the anesthetic management of a 40-year-old primigravida with FRDA undergoing cesarean delivery is presented. An uneventful cesarean delivery with effective epidural anesthesia with ropivacaine at the L2-L3 intervertebral space was performed in our case. Neither hypotension nor bradycardia was observed, and vital signs remained stable, with no need for administration of vasoactive drugs. After discharge, the parturient reported no change in her neurologic symptoms. Conclusive recommendations are contingent upon more extensive studies. Overall management and the choice to proceed with neuraxial anesthesia in a woman with FRDA should be based on comprehensive consultations in both cardio-obstetrics and pre-anesthetic evaluations.

Lateness of Acetaminophen and Non-steroidal Anti-inflammatory Drug Administrations in a Retrospective Cohort of Medication Administration Records Among Patients After Cesarean Delivery.

INTRODUCTION: In an earlier study of patients after cesarean delivery, the concurrent versus alternating administration of acetaminophen and non-steroidal anti-inflammatory drugs was associated with a substantial reduction in total postoperative opioid use. This likely pharmacodynamic effect may differ if the times when nurses administer acetaminophen and non-steroidal anti-inflammatory drugs often differ substantively from when they are due. We examined the "lateness" of analgesic dose administration times, the positive difference if administered late, and the negative value if early. METHODS: The retrospective cohort study used all 67,900 medication administration records for scheduled (i.e., not "as needed") acetaminophen, ibuprofen, and ketorolac among all 3,163 cesarean delivery cases at the University of Iowa between January 2021 and December 2023. Barcode scanning at the patient's bedside was used right before each medication administration. RESULTS: There were 95% of doses administered over a 4.8-hour window, from 108 minutes early (97.5% one-sided upper confidence limit 105 minutes early) to 181 minutes late (97.5% one-sided lower limit 179 minutes late). Fewer than half of doses (46%, P <0.0001) were administered ±30 minutes of the due time. The intraclass correlation coefficient was approximately 0.11, showing that there were small systematic differences among patients. There likewise were small to no systematic differences in lateness based on concurrent administrations of acetaminophen and ibuprofen or ketorolac, time of the day that medications were due, weekday, year, or number of medications to be administered among all such patients within 15 minutes. DISCUSSION: Other hospitals should check the lateness of medication administration when that would change their ability to perform or apply the results of analgesic clinical trials (e.g., simultaneous versus alternating administration).

Pharmacologic Analgesia for Cesarean Section: An Update in 2024.

PURPOSE OF THE REVIEW: With the increasing prevalence of cesarean section globally, the importance of perioperative analgesia for cesarean section is becoming increasingly evident. This article provides an overview and update on the current status of cesarean section worldwide and associated analgesic regimens. RECENT FINDINGS: Some recent studies unveiled potential association of neuraxial analgesia might be associated with children's autism, pharmacologic analgesia in obstetric will potentially gain some more attention. Various commonly used techniques and medications for analgesia in cesarean section are highlighted. While neuraxial administration of opioid remains the most classic method, the use of multimodal analgesia, particularly integration of nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks has provided additional and better options for patients who are not suitable for intrathecal and neuraxial techniques and those experiencing severe pain postoperatively. Optimal pain management is crucial for achieving better clinical outcomes and optimal recovery, and with the continuous development of medications, more and better pharmacologic regimen will be available in the future.

A Retrospective Exploration of Pre-operative Antibiotic Prophylaxis with Cefazolin in Cesarean Sections: Implications for Obstetrics and Gynecologic Surgery.

Background: Post-partum infection is a major contributor to maternal mortality and is responsible for approximately 10% of maternal fatalities worldwide. The risk of infection is substantially higher in cesarean section procedures. Approximately 8% of women who undergo cesarean sections are susceptible to infection. Although the body of evidence supporting the regular pre-operative utilization of prophylactic antibiotic treatment is steadily expanding, its usefulness in cesarean sections has not yet been standardized, and post-partum infection is still a serious medical challenge. We aimed to retrospectively assess the prophylactic effectiveness of cefazolin in combination with other antibiotic agents in cesarean sections. Materials and Methods: Both uni-variable and multi-variable analyses were conducted to identify factors that may affect cefazolin pre-operative antibiotic prophylaxis in elective cesarean section operations. The uni-variable analysis included timing of administration, operation duration, body mass index (BMI), and wound type. A multi-variable logistic regression model was then created to determine which variables provide independent information in the context of other variables. Results: Time of administration did not affect prophylactic cefazolin efficacy. However, prophylactic cefazolin was 1.43 and 1.77 times more effective when the operation lasted for 45 minutes or more, compared with operations that were shorter than 45 minutes. Patients with a BMI ranging from 18 to 29 kg/m2 showed increased efficacy of prophylactic cefazolin compared with obese patients with a BMI exceeding 30 kg/m2. The effectiveness of prophylactic cefazolin decreased by 95% in patients with clean-contaminated surgical incisions compared with those with clean surgical incisions. Conclusions: Our findings demonstrate that administering pre-operative prophylactic antibiotic agents to women undergoing cesarean section resulted in a reduction in post-partum infections, thereby reducing maternal mortality. Furthermore, optimal timing of administration, re-dosing if necessary, length of prophylactic medication, and dosing adjustments for obese patients are crucial factors in preventing surgical site infections and promoting antimicrobial stewardship.

Effects of epidural analgesia at 1 cm cervical dilatation on multiparae: A retrospective cohort study using propensity score-matching.

OBJECTIVE: The aim of the present study was to investigate the effects of epidural analgesia (EA) administered at cervical dilatation of 1 cm on multiparae who underwent vaginal delivery. METHODS: This propensity score-matched retrospective cohort research was conducted between 2021 and 2022. All the singleton multiparae who had previous successful vaginal deliveries and epidural analgesia during this delivery were screened for eligibility. The primary outcome was the effect of EA on the duration of labor. The main secondary outcomes included the incidence of cesarean delivery and umbilical arterial pH. RESULTS: This study incorporated 686 multiparae who were divided into two cohorts: EA 1 (cervical dilatation = 1 cm, n = 166) and EA 2 (cervical dilatation >1 cm, n = 520). In the propensity score-matched cohort (including 164 women in each group), there were no statistically significant differences in the incidence of cesarean delivery (4 [2.4%] vs 4 [2.4%], P = 1.000), umbilical arterial pH (7.28 ± 0.06 vs 7.28 ± 0.07, P = 0.550) and other secondary outcomes between the two groups. Based on a comparative assessment of the women who delivered vaginally to the Kaplan-Meier curves and propensity score-matching (including 160 women in each group), there was no statistical significance in the duration of the first, second and third stages of labor (log rank P, P = 0.811; P = 0.413; P = 0.773, respectively). CONCLUSION: Initiation of epidural analgesia at cervical dilatation of 1 cm in multiparae did not cause adverse effects with regard to the duration of labor, increased cesarean deliveries, and bad neonatal outcomes.

Effect of anesthesia on the success rate of external cephalic version: GRADE- assessed systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: External cephalic version (ECV) is a medical procedure in which an extracorporeal manipulation is performed to render the breech presentation (BP) fetus in the cephalic position. The use of anesthesia to facilitate repositioning has been evaluated in various randomized clinical trials (RCTs), but its potential effectiveness remains controversial. METHODS: A systematic literature search was carried out in 8 electronic databases. In the meta-analysis, a random effects model was used to calculate the pooled relative risk (RR) and its 95% confidence interval (CI), and the pooled standardized mean difference (SMD) and its 95% CI, in order to systematically assess the effect of anesthesia on the success rates of ECV, vaginal delivery, cesarean delivery as well as other outcomes. Relevant subgroup analyses, publication bias test and sensitivity analyses were also conducted. RESULTS: This review included 17 RCTs. Women who received anesthesia had a significantly higher incidence of successful ECV (RR: 1.37, 95% CIs: 1.19-1.58) and vaginal delivery (RR: 1.23, 95% CIs: 1.03-1.47), and a significantly lower incidence of cesarean delivery (RR: 0.69, 95% CIs: 0.53-0.91), compared with those who did not. CONCLUSION: The administration of anesthesia not only significantly reduces maternal pain but also significantly increases the success rate of ECV in women with malpresentation at term, leading to a significant rise in the incidence of vaginal delivery. However, it may increase the incidence of maternal hypotension. SYSTEMATIC REVIEW REGISTRATION: The protocol was prospectively registered with PROSPERO, registration CRD42022381552.

Heart Rate Variability Biofeedback Training Reduces Early Maternal Stress, Anxiety, and Depression in Women Undergoing Cesarean Delivery: A Randomized Controlled Trial.

Women who undergo cesarean delivery have reported experiencing mood distress related to the surgery and postoperative pain. Heart rate variability biofeedback (HRVB) training is known to have positive effects on mental health, but its effects on women undergoing cesarean delivery have not yet been determined. This study evaluated the effects of an HRVB training intervention on stress, anxiety, and depression in women undergoing cesarean delivery. We hypothesized that 10 sessions of HRVB training could cumulatively improve emotion regulation in participants. This study was designed as a double-blinded randomized controlled trial involving a total of 86 enrolled women who were then divided into two groups: intervention and control. During their hospitalization, the intervention group underwent HRVB training daily, while both groups received standard perinatal care. Heart rate variability (HRV) was assessed using root mean square of successive differences (RMSSD), standard deviation of normal-to-normal intervals (SDNN), high-frequency power (HF) and low-frequency power (LF). HRV parameters, stress, anxiety, and depression were evaluated at baseline and on the fifth day after childbirth. Intention-to-treat (ITT) analyses examined change over time between groups. Although no significant effects were found for the RMSSD and HF, a significant increase was observed in SDNN (F = 13.43, p = < 0.001, ƞ2 = 0.14), and LF at post-assessment (F = 4.26, p = .04, ƞ2 = 0.05) compared to the control group. Except for the depression variable, stress (F = 6.11, p = .02, ƞ2 = 0.07) and anxiety (F = 8.78, p = .004, ƞ2 = 0.10) significantly decreased compared to the control group on the fifth postpartum day. Furthermore, post-hoc analysis showed that HRVB was more effective in decreasing mild to severe depressive symptoms (F = 7.60, p = .001, ƞ2 = 0.27). The intervention program successfully decreased self-perceived stress and anxiety in the postpartum period and relieved symptoms in more severely depressed participants. Our findings suggest that this program is suitable and beneficial for application in women during the early postpartum period following cesarean delivery.