A comparison of acute pain management strategies after cesarean delivery.

BACKGROUND: There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. OBJECTIVE: To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain. STUDY DESIGN: This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. RESULTS: During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). CONCLUSION: Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

A comparison of an interactive computer-based method with a conventional reading approach for learning pelvic anatomy.

OBJECTIVE: This study was undertaken to assess the impact of interactive, computer-based versus conventional, paper-based format in student, resident, and fellow learning and retention of anatomy knowledge. STUDY DESIGN: Randomized longitudinal cohort design with scores repeated as pre-, post-, and follow-up tests. Subjects were randomly assigned to an anatomy module in computer-based (CD-ROM) format and 1 in paper-based format. A follow-up examination was administered 3 weeks after the posttest to evaluate retention of knowledge. Tests results were analyzed by using Student t tests and analysis of variance. RESULTS: Thirty-nine subjects completed all testing. Regardless of instructional method, pretest to posttest scores improved (P < .01), and posttest to follow-up test scores decreased among all levels of training (P < .01). Student satisfaction was highest with CD-ROM format. CONCLUSION: Improvement and retention of anatomy knowledge was not significantly different when comparing a new CD-ROM interactive approach with a traditional paper-based method.

Urine screening for Chlamydia trachomatis during pregnancy.

OBJECTIVE: To compare the rates of Chlamydia trachomatis detection using urine and cervical secretions from pregnant women at our institution. METHODS: A large cross-sectional sample of pregnant women (N=2,018) at 35-37 weeks of gestation were tested for C trachomatis with both endocervical and urine sampling using the Aptima Combo 2 Assay. RESULTS: A prevalence of 4.3% and 4.1% were found for Chlamydia endocervical and urine samples, respectively. There was no difference between the two tests by McNemar's test (-0.02%, 0.32%; P=.083). There was excellent correlation between the tests found by the κ statistic (0.982 [0.961-1.000]). CONCLUSION: Urine sampling for C trachomatis is equivalent to endocervical sampling in pregnancy using the Aptima 2 Combo Assay. LEVEL OF EVIDENCE: II.

Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life.

OBJECTIVE: The purpose of this study was to estimate the prevalence and impact upon quality of life of anal incontinence (AI) in women aged 18 to 65. STUDY DESIGN: Consecutive women presenting for general gynecologic care were given a bowel function questionnaire. Women with AI were prompted to complete the Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The cohort was composed of 457 women with a mean age of 39.9 +/- 11 years. AI prevalence was 28.4% (95% CI 24.4-32.8). After logistic regression, IBS (OR 3.22, 1.75-5.93), constipation (OR 2.11, 1.22-3.63), age (OR 1.05, 1.03-1.07), and BMI (OR 1.04, 1.01-1.08) remained significant risk factors. The mean FISI score was 20.4 +/- 12.4. Women with only flatal incontinence scored higher, and women with liquid loss scored lower on all 4 scales of the FIQL. CONCLUSION: AI is prevalent in women seeking benign gynecologic care, and liquid stool incontinence has the greatest impact upon quality of life.