Letter to the Editor: Enhanced recovery after caesarean section - a call to action

Guidelines for Vaginal Birth After Previous Caesarean Birth

Guidelines for vaginal birth after previous caesarean birth

Guidelines for Vaginal Birth after Previous Caesarean Birth

Care of Women with Obesity in Pregnancy

Management of Breech Presentation: Green-top Guideline No. 20b.

University of California, San FranciscoProfessorDepartment of AnesthesiaStaffCardiovascular Research Institute University of California, San Francisco San Francisco, Californiaweiskopf@anesthesia.ucsf.eduTHE use of intraoperative erythrocyte salvage has increased substantially during the past decade. Its popularity is likely propelled by a perception of its effectiveness and safety and the desire to avoid potential complications following transfusion of allogeneic blood. However, the risks attendant with the transfusion of allogeneic blood are decreasing. After the current implementation of testing of donor blood with gene amplification techniques, the expected risks of transmission 1of hepatitis B (1/63,000 units) and hepatitis C (1–3/106units) and the human immunodeficiency virus (1 to 2/ 106units) should be less than its current historic lowest levels. 2Other important risks of transfusion are similarly low: fatal hemolytic transfusion reaction (nearly all error induced) of approximately 1 to 2/106units, 3even more rare fatal septicemia, and an uncertain degree of immunomodulation. 4In this issue of Anesthesiology, Waters et al. 5report the effect of washing and filtering material that is aspirated from the surgical field during cesarean section on the reduction of the concentration of amniotic fluid material in the final processed erythrocyte suspension. In 1994, the National Institutes of Health National Heart, Lung, and Blood Institute (Bethesda, Maryland) convened a panel (which included the undersigned) to evaluate autologous transfusion and provide recommendations. This panel endorsed the expanded use of intraoperative erythrocyte salvage 6but did not recommend this practice during cesarean section.This view was prompted by both a concern that an amniotic fluid embolism might result and a lack of data from prospective randomized studies documenting the safety of this practice.As with any therapy, the use of intraoperative erythrocyte salvage during cesarean section should be based on considerations of effectiveness and safety compared with the available alternatives. There are two substantial difficulties in assessing the relative safety of intraoperative erythrocyte salvage during cesarean section. First, the pathophysiologic etiology of amniotic fluid embolism is not clear. The inciting components are not known; thus, studies cannot evaluate whether processing salvaged material from the surgical field reduces the specific component or components of amniotic fluid to concentrations below an unknown pathologic threshold. Second, the incidence of amniotic fluid embolism is low: approximately 1/8,000 to 1/80,000. 7A prospective randomized study with a power of 80% to show that erythrocyte salvage is not likely to increase this incidence by fivefold would require a population of more than 27,000 to approximately 275,000 patients.In the period since the National Heart, Lung, and Blood Institute report, several reports have evaluated the various aspects of the potential use of erythrocyte salvage and processing during cesarean section. Investigators have evaluated the processed material for potentially detrimental components of amniotic fluid or have transfused patients with the processed erythrocytes that were salvaged during cesarean section, or both. Several devices are available for intraoperative erythrocyte salvage that efficiently remove solute in the supernatant. For example, less than 10% of the heparin and free hemoglobin in the material aspirated from a nonobstetric surgical field appears in the processed erythrocytes suspended in 0.9% NaCl. 8,9Therefore, it is reasonable to expect similar elimination rates from aspirated amniotic fluid for solutes or free proteins, such as “tissue factor,” free fetal hemoglobin, and α-fetoprotein, but not for cellular components, such as fetal erythrocytes, fetal squamous cells, and cellular debris. Processing devices differ in ability to eliminate lipids from the final erythrocyte suspension. 10Therefore, elimination of fetal phospholipids contained in amniotic fluid may also vary.Investigations examining the product of erythrocyte salvage and processing during cesarean section generally have produced results consistent with these expectations. Tissue factor, 11free fetal hemoglobin, 12,13and α-fetoprotein 13,14have been reduced or eliminated from the final erythrocyte suspension, whereas substantial concentrations of fetal erythrocytes 5,12,14,15and fetal squamous cells 5,14and lamellar bodies (composed of phospholipids) 5remained.Recently, an attempt to remove fetal squamous cells and debris by filtration of the final processed erythrocyte suspension was not successful. 14As reported in this issue of Anesthesiology, Waters et al. , 5by using a different filter (intended to remove leukocytes from donated blood), nearly eliminated fetal squamous cells from the filtered erythrocyte suspension. The authors’ attribution of their improved results (compared with a previous study 14) to the use of a different filter appears reasonable because before filtration their product contained substantial numbers of fetal squamous cells.Other differences among studies may have resulted from differences among erythrocyte salvage devices, sizes of processing bowls, amounts of saline wash, and degree of technical expertise in device operation. Use of erythrocyte salvage devices using technologies other than a centrifugation-type bowl during cesarean section has not been studied. Many of the reports do not contain sufficient information to evaluate these differences. This is not unexpected because intraoperative erythrocyte salvage in the United States has been a largely unregulated cottage industry. Although devices marketed for the purpose require approval of the US Food and Drug Administration (FDA), their use, the training of the operators, and quality assurance of the product do not. The American Association of Blood Banks is developing “Standards” and “guidance” applicable to intraoperative erythrocyte salvage to ensure the quality of erythrocytes salvaged and processed for transfusion.The literature contains four reports of 174 patients who were underwent transfusion with erythrocytes after salvage during cesarean section and washing. 12,16–18With the exception of one case of heparin overdose, 17those reports contain no other occurrence of adverse events. Although some may regard these results as reassuring, only one of the reports 12was of a prospective randomized study in which a mean ± SD of 363 ± 153 ml (range, 125–800 ml) blood was salvaged, washed, and transfused in 34 patients. The absence of symptoms in 34 patients allows one to state with 95% assurance that those symptoms would not likely occur in more than 8% of a similar population that was given this relatively small amount of salvaged and processed erythrocytes. The value of “lack of symptoms” emanating from a retrospective chart review is less clear. Even if all 174 patients (including those from retrospective chart reviews) truly had no adverse events, the 95% confidence level is approximately 2% for this limited amount of transfused erythrocytes (i.e., up to 2% of the population might have an adverse event). Neither figure approaches the reported incidence for amniotic fluid embolism of 0.01 to 0.001%. In addition, there is a single case report of fatal amniotic fluid embolism after transfusion of erythrocytes salvaged during cesarean section. 19Therefore, it cannot be stated that use of this technique during cesarean section does not add risk of amniotic fluid embolism.A second safety concern for the use of salvaged and washed cells during cesarean section involves the transfusion of fetal erythrocytes to the mother. There is no reason to believe that the devices used for washing salvaged erythrocytes can distinguish between maternal and fetal erythrocytes. Studies that have evaluated the washed cells have found substantial concentrations of fetal cells mixed with the maternal cells in the final product. 5,12,14,15Waters et al. 5confirm these previous findings and note a concentration of fetal hemoglobin approximately four times that measured in maternal blood. Transfusion of erythrocytes salvaged during cesarean section could result in the administration of a substantial additional load of fetal erythrocytes not present in other allogeneic blood. Antigens present on fetal erythrocytes but absent on maternal erythrocytes can result in alloimmunization. Therefore, erythrocytes salvaged during cesarean section must be regarded as allogeneic. In the report by Rainaldi et al. , 12material processed from half the patients was incompatible with the maternal blood. The suggestion of Waters et al. , 5that the quantity of fetal hemoglobin in maternal blood should be measured after the transfusion of salvaged erythrocytes and that immune globulin should be administered as necessary, is appropriate.How are we to determine whether it is safe to use erythrocytes salvaged during cesarean section? The Food and Drug Administration has had to face a similar problem in attempting to assess the “safety” of artificial oxygen carriers (hemoglobin solutions and fluorocarbon emulsions). The approach of the Food and Drug Administration has been to require a prospective, randomized study of 600 patients: 300 each per treatment and control groups. The required number of treated patients was doubled after one study was halted because of an increased incidence of death in the treated group. The absence of an amniotic fluid embolism in a study of this size would indicate, with 95% confidence, that the adverse event probably would not occur in more than 1% of the population, but could not approach that degree of assurance for the far lesser frequency of amniotic fluid embolism, approximately 0.005%.The second issue for consideration of the appropriate use of erythrocytes salvaged during Cesarean section is that of efficacy. Several components of efficacy necessitate consideration. First, what are the circumstances during cesarean section that necessitate the transfusion of the mother with cells from any source? Average maternal blood loss is approximately 600 ml during vaginal delivery, and is approximately 1000 ml during cesarean section, 20a difference of only approximately 400 ml. At term pregnancy, maternal blood volume is increased by approximately 30–40% with return to normal values within 1 week. 21,22Loss of 1,000 ml blood during cesarean section in an average mother, while maintaining isovolemia with an adequate quantity of asanguinous fluid, would decrease maternal hemoglobin concentration from the usual value of approximately 12 g/dl to 10 g/dl immediately after surgery. 23Thereafter, the hemoglobin concentration would increase as maternal blood volume decreased during the ensuing week to the nonpregnant normal state by reduction of plasma volume. In reports that evaluated erythrocyte salvage during cesarean section, material sufficient for analysis could be collected in only 10 of 27 patients. 13In those 10 patients, the average volume of material produced for transfusion was 186 ml at a hematocrit value of 49%13or 91 ml erythrocytes, the amount contained in approximately one half of 1 unit of erythrocytes. Thus, during cesarean section erythrocyte recovery is ordinarily low.More than a decade ago, the National Institutes of Health Consensus Conference on Red Cell Transfusion recommended that erythrocytes not be transfused when the recipient’s hemoglobin concentration is greater than 7 g/dl. 24More recently, the American Society of Anesthesiologists (ASA) approved an ASA Task Force recommendation that for a healthy patient, intraoperative erythrocyte transfusion is not usually needed for hemoglobin concentrations of greater than 6 g/dl. 25Furthermore, a hemoglobin concentration of 5 g/dl does not produce evidence of inadequate systemic oxygen delivery. 26Thus, the usual low blood loss (and erythrocyte recovery) during cesarean section, together with the increased blood volume during pregnancy and the ability of healthy humans to tolerate low hemoglobin concentrations, indicate that it should be very unusual for transfusion to be necessary during cesarean section. This conclusion is supported by the data of Sherman et al. 27Older reports of a greater incidence of transfusion during cesarean section probably resulted from the clinical application of transfusion thresholds that were higher than those that are currently recommended and are physiologically acceptable. Therefore, the routine use of a technology of uncertain safety during cesarean section is not warranted.Nevertheless, for unusual occasions, cesarean section may result in blood loss that is sufficient to necessitate erythrocyte transfusion. Although banked blood might not be available immediately, a similar limitation may exist for salvaged and washed erythrocytes. Several minutes are necessary to set up washing devices. The device, if available, is likely to be stored in a location other than the obstetric suite because the need, and presumably the use, of these expensive devices is unusual in obstetric surgery. Transport of the device and the arrival of a dedicated, trained person to operate the device (as is strongly recommended and may become required) may cause further delay. These delays may be longer than the time to obtain type O or type-specific erythrocytes from the blood bank. Furthermore, if elimination of fetal tissue is an important concern (it may not be), 28,29the use of a leukodepletion filter of the type described by Waters et al. 5substantially decreases the flow rate at which the processed cells can be administered to a rate (approximately 30 ml/min) that is insufficient to maintain isovolemia or to provide substantial augmentation of oxygen-carrying capacity during substantial hemorrhage.The reports published during the past several years have begun the process of evaluating the safety of the use of erythrocyte salvage and processing during cesarean section. However, larger prospective randomized studies are necessary to document the safety of this technique for the occasional obstetric patient for whom it may be efficacious and needed. Until then, the use of this technique during cesarean section should be limited to those times when it is the only way to augment the patient’s oxygen-carrying capacity, when it is necessary to preserve function or life. The need may become more frequent if the predicted shortage of blood in the United States 30becomes a reality.

Background: The rate of multiple cesarean sections is persistently on the rise because of cultural demands for large families, and multiple cesarean sections are an important cause of maternal morbidity and mortality.Objectives: This study was designed to detect the complications associated with higher order compared to lower order cesarean sections.Materials and methods: The hospitals record of women who had a cesarean section performed after three or more previous cesarean sections, and those who had a cesarean section for the second time over 2 years reviewed. Women with ≥3 cesarean sections admitted for elective cesarean section after 38 weeks’ gestation, and those with ≥3 cesarean sections admitted in labor for emergency cesarean section were included in group 1. Women with history of previous one lower segment cesarean section (LSCS), who refused trial of labor and women with one LSCS who had an emergency cesarean section after failed trial of labor (TOL) were included in group 2. Antenatal, intraoperative, and postoperative data were reviewed. Statistical analysis done using SPSS version 20 (Chicago, Illinois, USA), to detect the complications associated with higher order compared to lower order cesarean sections. Primary outcome measures; complications associated with higher order compared to lower order cesarean sections. Secondary outcome measures; intraoperative, and postoperative complications.Results: Four hundred and fifty (450) women undergoing repeat cesarean section studied; 32.2% (145/450) had ≥3 previous cesarean sections (group 1), and 67.8% (305/450) had previous one cesarean section (group 2). In group 1, 77.2% (112/145) had previous three cesarean sections, 12.4% (18/145) had previous four cesarean sections, 9% (13/145) had previous five cesarean sections, and 1.4% (2/145) had previous six cesarean sections. The proportion of unbooked admission, and emergency cesarean sections were significantly high in group 2 compared to group 1 (11.1% (34/305) and 73.1% (223/305) versus 4.83% (7/145) and 40.7% (59/145); respectively) (p<.05, 95% CI; 0.1–0.2) and p<.01, 95% CI; 0.4–11.4; respectively. The risk of dense omental adhesions, and bladder injuries were significantly high in group 1 compared to group 2 (4.14% (6/145) and 1.38% (2/145) versus 0.66% (2/305) and 0% (0/305); respectively), (p=.01 (95% CI; 0.6–1.6) and p=.01 (95% CI; 0.5–5.5); respectively). Logistic regression analysis showed that the bladder injury was 5 times more (odds ratio 5.0 (95% CI; 0.035–711.8)) and the blood transfusion was 4.7 times more (odds ratio 4.7 (95% CI; 0.147–151.5)) in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference p=.52 and .38; respectively).Conclusion: The risk of dense omental adhesions and bladder injury was significantly high in women with previous ≥3 cesarean sections compared to women with previous one cesarean section. Logistic regression analysis showed that the bladder injury was five times more and the blood transfusion was 4.7 times more in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference).

Objectives: To determine the frequency of repeat Cesarean Section in patients with previous one cesarean section To compare the maternal and perinatal outcome in vaginal birth after Cesarean and repeat caesarean section Material and Methods: This Cross sectional study was conducted at Obstetrics &amp; Gynecology unit1 JPMC Karachi from Jan 2020 to31 Dec2020.A total of 137 women with history of previous one cesarean section were included in this study. All patients’ history and examination was taken. The data was collected on a predesigned Performa. Mean and Standard Deviation for quantitative variables and percentage for categorical qualitative variables. Maternal and perinatal outcomes was compared between women who have VBAC and those who have repeat Cesarean section by using chi-square test with P-values less than or equal to 0.05 significant. Results: The average age of the women was 29.88±3.26 years. Frequency of repeat caesarean section in patients with previous one cesarean section was 52.55%. PPH was observed in 37.96% cases while prolong hospital stay in 28.47%. There were 15.33% still birth, Apgar score less than 7 in 42.34% at 1 minute, and NICU admission was observed in 23.38%. Rate of Postpartum hemorrhage and prolong hospital stay was significantly high in repeated caesarean section. Conclusion: All of the maternal and prenatal outcomes were significantly high in repeated Cesarean section as compare to vaginal deliveries. The trial of labor in women with a single previous caesarean delivery can safely reduce rate of caesarean section. Keywords: Caesarean section, vaginal birth after Cesarean, repeats caesarean section

Objectives: To determine the frequency of repeat Cesarean Section in patients with previous one cesarean section To compare the maternal and perinatal outcome in vaginal birth after Cesarean and repeat caesarean section Material and Methods: This Cross sectional study was conducted at Obstetrics &amp; Gynecology unit1 JPMC Karachi from Jan 2020 to31 Dec2020.A total of 137 women with history of previous one cesarean section were included in this study. All patients’ history and examination was taken. The data was collected on a predesigned Performa. Mean and Standard Deviation for quantitative variables and percentage for categorical qualitative variables. Maternal and perinatal outcomes was compared between women who have VBAC and those who have repeat Cesarean section by using chi-square test with P-values less than or equal to 0.05 significant. Results: The average age of the women was 29.88±3.26 years. Frequency of repeat caesarean section in patients with previous one cesarean section was 52.55%. PPH was observed in 37.96% cases while prolong hospital stay in 28.47%. There were 15.33% still birth, Apgar score less than 7 in 42.34% at 1 minute, and NICU admission was observed in 23.38%. Rate of Postpartum hemorrhage and prolong hospital stay was significantly high in repeated caesarean section. Conclusion: All of the maternal and prenatal outcomes were significantly high in repeated Cesarean section as compare to vaginal deliveries. The trial of labor in women with a single previous caesarean delivery can safely reduce rate of caesarean section. Keywords: Caesarean section, vaginal birth after Cesarean, repeats caesarean section

The objective of this retrospective, nationwide Finnish population-based cohort study was to determine whether there is an association between preterm caesarean breech delivery in the first pregnancy and maternal and neonatal morbidity in the subsequent pregnancy and delivery. We identified all singleton preterm breech birth in Finland from 2000 to 2017 (n = 1259) and constructed a data set of the first two deliveries for these women. We compared outcomes of the following pregnancy and delivery among women with a previous preterm caesarean breech section with the outcomes of women with one previous vaginal preterm breech birth. p Value, odds ratio, and adjusted odds ratio were calculated. Neonates of women with a previous caesarean preterm breech delivery had an increased risk for arterial umbilical cord pH below seven (1.2% versus 0%; p value .024) and a higher rate of neonatal intensive care unit admission [22.9% versus 15% adjusted OR 1.57 (1.13–2.18); p value <.001]. The women with a previous caesarean section had a higher rate of uterine rupture (2.3% versus 0%; p value .001). They were also more likely in the subsequent pregnancy to have a planned caesarean section [19.9% versus 4% adjusted OR 8.55 (4.58–15.95), an emergency caesarean section [21.5% versus 9.7% adjusted OR 2.16 (1.28–2.18)], or an instrumental vaginal delivery [9.3% versus 3.8% adjusted OR 2.38 (1.08–5.23)]. IMPACT STATEMENT What is already known on this subject? Vaginal birth after caesarean section is generally known to be associated with a higher risk of maternal and neonatal morbidity. What do the results of this study add? The following birth after previous caesarean preterm breech section is associated with a higher rate of uterine rupture and with a higher rate neonatal admission to the neonatal intensive care unit and more often an arterial umbilical cord pH below seven regardless of the mode of the following delivery, compared to women with a subsequent delivery after a previous vaginal preterm breech birth. What are the implications of these findings for clinical practice and/or further research? Our results must be considered when counselling patients regarding their first preterm breech delivery, as the selected method of delivery also affects the outcomes of subsequent pregnancies and deliveries.

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS. IMPACT STATEMENT What is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors. What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS. What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

Cesarean delivery on maternal request is one of the important public health issues in China. Our study aimed to apply the theory of planned behaviour to comprehensively determine the factors regarding pregnant women's preference for cesarean section and to provide references for establishing measures to reduce cesarean delivery on maternal request. This cross-sectional analysis was conducted in four women's and children's hospitals in China from May to June 2018. Eligible women arriving for routine antenatal visits at these hospitals were recruited to answer a structured questionnaire. A total of 1853 pregnant women consented to participate in the investigation, with a response rate of 88.75%. Finally, 1677 pregnant women (984 nulliparae and 693 multiparae) were involved in the analysis. Descriptive statistics and logistic regression analyses were used. Of the study participants, 20.39% preferred cesarean section. For both nulliparae and multiparae, those who had lower scores of attitudes towards vaginal delivery, lower scores of childbirth self-efficacy and higher scores of subjective norms were more likely to prefer cesarean section. Pregnant women's birth preferences were significantly associated with their attitudes towards the delivery mode, childbirth self-efficacy and subjective norms, which is consistent with the theory of planned behaviour. Interventions to reduce cesarean delivery on maternal request can be developed based on the theory of planned behaviour.

The Over Roofing Rates of Caesarean Section

Cesarean sections at St. Louis Maternity Hospital from 1948 through 1952

Objectives: We analyzed the indications of cesarean section (CS) using Robson Ten-Group. Classification Systems (RTGCS) and comparison between private and public health facilities in Addis Abeba hospitals, Ethiopia, 2017. Methods: Facility-based retrospective cross-sectional study was carried out between January 1 and December 31, 2017, including 2411 mothers who delivered by CS were classified using the RTGCS. Data were entered into SPSS version 20 for cleaning and analyzing. Binary logistic regression and AOR with 95% CI were used to assess the determinants of the CS. Results: The overall CS rate was 41% (34.8% and 66.8% in public &amp; private respectively, p &lt; .0001). The leading contributors for CS rate in the private were Robson groups 5,1,2,3 whereas in the public 5,1,3,2 on descending order. Robson group 1 (nulliparous, cephalic, term, spontaneous labor) and group 3 [Multiparous (excluding previous cesarean section), singleton, cephalic, ≥ 37 weeks’ gestation&amp; spontaneous labor], the CS rate was over two-fold higher in the private than the public sector. Women in Robson groups 1, 2, 5 &amp; 9 are two and more times higher for the absolute contribution of CS in private than public. The top medical indications of CS were non-reassuring fetal status (NRFS, 39.1%) and repeat CS for previous CS scars (39.4%) in public and private respectively. Mothers who delivered by CS in private with history of previous CS scar (AOR 2.9, 95% CI 1.4-6.2), clinical indications of maternal request (AOR 7.7, 95% CI 2.1-27.98) and pregnancy-induced hypertension (AOR 4.2, 95% CI 1.6-10.7), induced labor (AOR 2.5, 95% CI 1.4-4.6) and pre-labored (AOR 2.2, 95% CI 1.6-3.0) were more likely to undergo CS than in public hospital. Conclusion: The prevalence of CS was found to be high, and was significantly higher in private hospitals than in a public hospital. Having CS scar [having previous CS scar, Robson group 5(Previous CS, singleton, cephalic, ≥ 37 weeks’ gestation) and an indication of repeat CS for previous CS scar] is the likely factor that increased the CS rate in private when compared within the public hospital. Recommendation: It is important that efforts to reduce the overall CS rate should focus on reducing the primary CS, encouraging vaginal birth after CS (VBAC). Policies should be directed at the private sector where CS indication seems not to be driven by medical reasons solely.