Cases Of Cesarean Delivery Research Articles

Prophylactic phenylephrine infusion versus treatment with vasopressor bolus as needed during non-urgent cesarean delivery and neonatal acidemia: a retrospective cohort study (2016–2021)

IntroductionProphylactic vasopressor administration reduces spinal hypotension during cesarean delivery, however the effects of vasopressor administration on neonatal acidemia remain uncertain. We examined the occurrence of neonatal acidemia in the setting of non-urgent cesarean delivery and compared outcomes between cases receiving prophylactic phenylephrine infusion versus cases treated with boluses of phenylephrine. MethodsRetrospective cohort study with ethical approval, comparing non-urgent cesarean delivery cases performed under spinal anesthesia (2016 to 2021), receiving either prophylactic phenylephrine infusion or boluses as needed.Data were collected from anesthesia and labor ward electronic medical records. Records with missing pH or missing blood pressure data were excluded. The independent variable was prophylactic phenylephrine administration, a strategy implemented following international recommendations in 2018. The main outcome was neonatal acidemia, defined as umbilical artery pH < 7.1. The secondary outcome was maternal hypotension, defined as at least one systolic blood pressure (SBP) measurement below 100 mmHg or below 80% baseline. ResultsA total of 4392 patients were included in the final analysis; 1318 (30.0%) received prophylactic phenylephrine infusion. Neonatal acidemia (umbilical artery pH < 7.1) occurred in 28 (2.1%) cases receiving prophylactic phenylephrine versus 50 (1.6%) treated with boluses as needed (p = 0.188). Prophylactic phenylephrine infusion was not associated with occurrence of neonatal acidemia (aOR 0.83; 95% CI 0.52 to 1.33, p = 0.435). Prophylactic phenylephrine infusion was associated with a reduced spinal hypotension rate when defined as SBP < 100 mmHg (OR 0.47; 95% CI 0.37 to 0.57; p < 0.001), with similar results when hypotension was defined as a drop below 80% or 90% of baseline SBP. ConclusionIn this pragmatic study, prophylactic phenylephrine infusion was associated with a reduction in maternal spinal hypotension, but not reduced neonatal acidemia.

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

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. Weexamined the "lateness" of analgesic dose administration times, the positive difference ifadministered late, and the negative value ifearly. 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. 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 ±30minutes 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 ofacetaminophen 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. 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).

The association between decision and incision time by race and ethnicity.

Identifying and reducing inequities in the delivery of care is crucial to improving health disparities in obstetric outcomes. This study sought to evaluate the effect of race and ethnicity on time from decision for cesarean delivery to incision following implementation of a case classification system. A retrospective cohort study was performed to identify women who had cesarean deliveries from October 1, 2020, to March 31, 2021, at a single, tertiary care institution. Medical records were reviewed for demographics and cesarean delivery case classification. Case classification was divided into STAT cesarean delivery (within 10 minutes), level A (within 30 minutes), level B (within 60 minutes), or scheduled/unscheduled other. The "decision to incision time" was determined from the time the case surgical order was placed to the case start time. There were 565 eligible individuals who had a cesarean delivery during the study period, with 13.6% identifying as Black/African American, 29.0% as Hispanic/Latina, and 57.3% as White. Hispanic women were more likely to need interpreter services than other race/ethnicity groups. There was no statistically significant difference in "decision to incision time" by race/ethnicity. Within the total cohort, 51.8% of cesarean delivery cases went within the goal time according to case classification, which also did not differ by race/ethnicity. Race and ethnicity do not impact cesarean delivery "decision to incision time" or case classification. Only half of cesarean deliveries went within the goal time, so further evaluation to improve workflow and improve this metric for all patients is needed.

Unintended Consequences: Exploring Iatrogenic Injuries in Cesarean Section Deliveries

Cesarean delivery (CD), or C-section, which prevents injury and death in mothers and babies at higher risk of complicated deliveries, like any surgery, does carry a risk of complications. By reviewing the medical literature and analyzing documented CD cases, we examined the spectrum of iatrogenic injuries, including unintentional injuries, affecting both maternal and neonatal outcomes. This case report describes iatrogenic bladder damage after CD in a 31-year-old woman who had a previous emergency CD two years ago. This case calls for a comprehensive approach to minimize iatrogenic risks and optimize maternal and neonatal well-being during repeat СD.

Effect of vaginal delivery on adverse pregnancy outcomes after cesarean section in scar uterus

ABSTRACT The purpose of this study was to investigate the impact of vaginal delivery on adverse pregnancy outcomes after cesarean section for the cicatricial uterus. Eighty patients with scarred uterus after cesarean section admitted to our hospital from October 2019 to May 2021 were selected for the study. Among them, 44 cases were eligible for vaginal delivery. Thirty-eight cases of cesarean delivery were selected as the control group and 42 cases of vaginal delivery were selected as the observation group according to the mode of delivery. Baseline data, 24-h blood loss, length of hospital stay, hospital costs, 5-minute Apger score, and adverse pregnancy outcomes were compared between the two groups. When comparing the age, gestational age, number of pregnancies, and duration of cesarean delivery between the two groups (t = 1.333, 0.989, 0.597, 0.752, P > 0.05), the scar thickness in the observation group was higher than that in the control group. The 24-h postpartum bleeding and hospitalization cost was lower in the observation group than in the control group, the hospitalization time was shorter than in the control group, and the 5-minute Apger score was higher than in the control group (t = 21.744, 15.029, 11.524, 7.342, P < 0.05). The incidence of maternal and neonatal complications was compared between the two groups (23.68% vs 7.14%, 7.89% vs 0.00%, correction 2 = 1.083, 1.605, P > 0.05). The incidence of adverse pregnancy outcomes was 7.14% in the observation group, which was significantly lower than the 31.57% in the control group. The difference was statistically significant (correction 2 = 4.060, P < 0.05).

Do significant adverse reactions to labor epidural anesthesia affect interval to delivery?

Epidural anesthesia during labor may lead to maternal hypotension and changes in fetal heart rate (FHR). We have evaluated whether occurrence of such adverse reactions affect the interval to delivery after anesthesia. Cohort study of all laboring women who underwent epidural anesthesia during labor for the period October 1, 2020-December 31, 2020. Excluded were cases of elective CD, non-cephalic presentation, twins or multiples, fetal death, and gestational age < 37.0 weeks. Significant adverse reactions included severe maternal hypotension (defined as systolic blood pressure < 100 mm Hg in the 60 minutes after epidural or decreasing by >20% compared with before epidural) or presence of severe (prolonged or recurrent late) decelerations in the 60 minutes after epidural. Occurrence of any significant adverse reaction was related to the interval-to-delivery after completion of epidural anesthesia using linear regression analysis (SPSS 28). Among the 438 women in the cohort, significant adverse reactions to epidural occurred in 172 (39.2%), including severe maternal hypotension in 149 (34%) and severe FHR decelerations in 50 (11.4%). Interval-to-delivery after labor epidural anesthesia was associated with maternal age (P=0.007), body mass index (P< 0.001), cervical dilation at epidural (P< 0.001) as well as occurrence of severe adverse reactions to epidural (P=0.019), cesarean delivery (CD) (P< 0.001) and CD for non-reassuring FHR (P=0.009). Linear regression demonstrated that only cervical dilation at epidural (P< 0.001) and CD (P< 0.001) were related to interval-to-delivery after epidural, whereas adverse reactions to epidural were not (P=0.22). Although significant adverse reactions to labor anesthesia were not uncommon in our cohort, they did not independently affect interval-to-delivery after completion of anesthesia.

Risk-factor model for postpartum hemorrhage after cesarean delivery: a retrospective study based on 3498 patients

This study aimed to investigate the risk factors of patients with postpartum hemorrhage (PPH) after cesarean delivery (CD) and to develop a risk-factor model for PPH after CD. Patients were selected from seven affiliated medical institutions of Chongqing Medical University from January 1st, 2015, to January 1st, 2020. Continuous and categorical variables were obtained from the hospital’s electronic medical record systems. Independent risk factors were identified by univariate analysis, least absolute shrinkage and selection operator and logistic regression. Furthermore, logistic, extreme gradient boosting, random forest, classification and regression trees, as well as an artificial neural network, were used to build the risk-factor model. A total of 701 PPH cases after CD and 2797 cases of CD without PPH met the inclusion criteria. Univariate analysis screened 28 differential indices. Multi-variable analysis screened 10 risk factors, including placenta previa, gestational age, prothrombin time, thrombin time, fibrinogen, anemia before delivery, placenta accreta, uterine atony, placental abruption and pregnancy with uterine fibroids. Areas under the curve by random forest for the training and test sets were 0.957 and 0.893, respectively. The F1 scores in the random forest training and test sets were 0.708. In conclusion, the risk factors for PPH after CD were identified, and a relatively stable risk-factor model was built.

Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020

The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8–16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2–21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.

Discuss the Application of Data Services in Data Health Management of High-Risk Pregnant and Lying-In Women in Smart Medical Care.

Objective In order to improve the refined management of hospitals, promote the scientific development of smart hospitals in medical institutions, and solve the problem of data filling and reporting that is increasing year by year in the country, province, and city. Methods A total of 84 high-risk pregnant women admitted to our hospital from January 2020 to October 2021 were selected and screened for high-risk pregnant women. Risk pregnant women were divided into a routine intervention group and a DS medical group, with 42 cases in each group. High-risk pregnant women in the routine intervention group received routine intervention, and the DS medical group applied data to serve smart medical services on the basis of routine intervention. The scores of self-care, anxiety, and depression were compared between the two groups, the coping styles were analyzed, the satisfaction rate and incidence of adverse conditions of the high-risk puerperae were recorded, and the delivery methods of the two groups were compared. Results After the intervention, the activities of daily living, follow-up, fetal monitoring, and self-protection behaviors in the DS medical group were higher than those in the routine intervention group, and the difference was statistically significant (P < 0.05). The scores of anxiety and depression in the group were lower, with statistical significance (P < 0.05); after the intervention, the scores of negative coping styles in the DS medical group were lower than those in the conventional intervention group, while the scores for positive coping styles were higher than those in the conventional intervention group; the DS medical group had higher risk. The satisfaction of pregnant women was significantly higher than that of the routine intervention group, and the difference was statistically significant (P < 0.05); the overall incidence of adverse maternal outcomes among high-risk pregnant women in the DS medical group was lower than that of the routine intervention group, and the difference was not statistically significant (P > 0.05). Compared with the routine group, the DS medical group had a higher number of vaginal deliveries and a lower number of cesarean deliveries, and the difference was statistically significant (P < 0.05). Conclusion The application of data services in a smart medical high-risk maternity-related data management platform enables the promotion of high-risk pregnant women's self-care behaviors and improves negative emotions, enables them to cooperate in delivery with positive behaviors, and reduces the number of cases of cesarean delivery.

Clinical Effect of Intrauterine 3-Dimensional Ultrasound on the Function of the Intrauterine Cavity of Puerpera With Intrauterine Adhesions and Safety of Pregnancy.

This study aimed to analyze the diagnostic value of intrauterine 3-dimensional ultrasound and the functional characteristics of the intrauterine cavity for puerpera with intrauterine adhesions, and to explore the safety of pregnancy after treatment. A total of 102 puerperas with intrauterine adhesions were randomly selected, and intrauterine 3-dimensional ultrasound and 2-dimensional ultrasound were performed, respectively. Patients were followed up for 3 years to observe the pregnancy outcome and safety. The overall accuracy of diagnosing intrauterine adhesions through intrauterine 3-dimensional ultrasound was significantly higher than that through 2-dimensional ultrasound, and the accuracy of detecting mild intrauterine adhesions was significantly higher than that through 2-dimensional ultrasound, with statistically significant difference ( P < 0.05). There was no significant difference in the accuracy between intrauterine 3-dimensional and 2-dimensional ultrasound in detecting moderate and severe intrauterine adhesions ( P > 0.05). The difference in missed diagnosis and misdiagnosis rates between the 2 methods was statistically significant ( P < 0.05). All patients received hysteroscopic surgery, and 78 cases (76.47%) were naturally fertilized during postoperative follow-up, including 24 cases of mature delivery, 45 cases of cesarean delivery, and 9 cases of spontaneous abortion. The intrauterine 3-dimensional ultrasound examination of the intrauterine cavity will provide intuitive and comprehensive diagnostic information for a parturient with intrauterine adhesion. Its detection accuracy is higher, and the clinical application is noninvasive and safe, which has certain guiding significance for treatment.

Trial of labor of vertex-nonvertex twins following a previous cesarean delivery

Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor. To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation. A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥320/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores. Our data show thattrial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery.Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis.

Estimates for the incidence of difficult intubation in the obstetric population vary widely, although previous studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples. The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery. This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database. The study population included women aged 15 to 44 yr undergoing general anesthesia for cesarean delivery between 2004 and 2019 at 1 of 45 medical centers. Coprimary outcomes included the frequencies of difficult and failed intubation. Difficult intubation was defined as Cormack-Lehane view of 3 or greater, three or more intubation attempts, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway. Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement. The rates of difficult and failed intubation were assessed. Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation. This study identified 14,748 cases of cesarean delivery performed under general anesthesia. There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI, 1:55 to 1:44; n = 14,531). There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI, 1:1,276 to 1:511; n = 14,537). Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid-to-mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations. In this large, multicenter, contemporary study of more than 14,000 general anesthetics for cesarean delivery, an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808 were observed. Most risk factors for difficult intubation were nonobstetric in nature. These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.

Trends, characteristics, and outcomes of conservative management for placenta percreta.

To examine trends, characteristics, and outcomes of women with placenta percreta who had conservative management at cesarean delivery (CD) without hysterectomy. This is a retrospective cohort study querying the National Inpatient Sample. The Study population was comprised of women with diagnosis of placenta percreta who underwent CD from 10/2015-12/2018. Characteristics and surgical outcome of women who had hysterectomy at time of CD were compared to those who did not (conservative management) in multivariable analysis. A total of 1055 cases were examined, of which 790 (74.9%) received hysterectomy at CD and the remaining 265 (25.1%) had conservative management without hysterectomy. During the study period, performance of hysterectomy at CD increased from 71.4% to 93.8% (P < 0.001). In multivariable analysis, more recent cases of CD for placenta percreta were less likely to have conservative management [adjusted-odds ratio (aOR) per year-quarter 0.93, 95% confidence interval (CI) 0.89-0.97]. In contrast, hospitals with small-medium bed capacity (aOR 1.72, 95% CI 1.18-2.51), non-urban teaching setting (aOR 1.76, 95% CI 1.14-2.70), and located in the Midwest (aOR 2.55, 95% CI 1.56-4.17) were more likely to offer conservative management at CD. Later gestational age was also associated with a higher likelihood of conservative management (median gestational age, 36 versus 34weeks, P < 0.001). Women in the conservative management group experienced lower measured surgical morbidity during the admission compared to those in the cesarean hysterectomy group (47.2% versus 75.9%, aOR 0.35, 95% CI 0.26-0.48). The clinical practice for placenta percreta appears to be shifting toupfront hysterectomy at the time of CD.

Total breech extraction of the second twin in trial of labor after cesarean

Maternal and neonatl outcomes in trial of labor after cesarean (TOLAC) deliveries of twins are similar to singleton TOLACs. We examined whether internal podalic version and total breech extraction of the second twin adversely impacts outcome. A retrospective multicenter study was conducted including data on deliveries occurring between 2005-2020. We included TOLACs only, at 320/7 gestational weeks and on, of twin gestations with a vertex presenting first twin upon labor admission. The exposed group was defined as deliveries with a non-vertex second twin at admission to labor, while the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of pre-labor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. Two hundred thirty-six twin TOLACs were included, of whom 128 presented with a non-vertex second twin, and 108 presented with a second vertex twin. There was no difference in the primary outcome of uterine rupture (1/128, 0.9% vs. 1/108, 0.8%, p=1.000) (Table 1). Successful TOLAC of both twins occurred in 76.6% of the exposed group vs. 81.5% in the comparison group, while cesarean delivery (CD) of both twins was performed in 21.9% of the exposed group vs. 17.6% of the comparison group (p=0.418, OR=1.32, CI 0.7-2.5). There were 2 cases of CD for the second twin in the exposed group and one case in the comparison group (1.6% vs. 0.9%, respectively, p=1.000) (Table 2). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, etc. (Table 1). Neonatal outcomes were also comparable between the groups. Non-cephalic second twin in TOLAC deliveries results in favorable maternal and neonatal outcomes, comparable with vertex-vertex TOLACs. Second twin non-cephalic presentation should not discourage parturients and caregivers from considering TOLAC if desired.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Cesarean Delivery in the Bronchoscopy Suite in a Patient with an Anterior Mediastinal Mass

Mediastinal masses pose a significant challenge for anesthesiologists due to the risk of cardiorespiratory collapse. Pregnancy in of itself causes multiple detrimental changes to respiratory physiology. We present a case of cesarean delivery performed in the bronchoscopy suite followed by bronchoscopic airway evaluation in a patient at 33 weeks gestation with symptomatic anterior mediastinal mass. We discuss the multidisciplinary approach and anaesthetic management of this complicated case.

Reported case numbers and variability in delivery route and volume by obstetrics and gynecology residents from 2003 to 2019

The obstetrical landscape in the United States has changed over the past several decades, during which there has been a decline in the number of operative vaginal deliveries performed. Procedural cases of obstetrics and gynecology residents are tracked in the Accreditation Council for Graduate Medical Education database, with a minimum requirement of 15 operative vaginal deliveries before graduation. Nowadays, it is unknown whether the decreasing numbers of operative vaginal deliveries are affecting the delivery case volume and experience of obstetrics and gynecology residents. This study aimed to analyze the trends in the number and route of obstetrical deliveries, including operative vaginal deliveries, performed by graduating obstetrics and gynecology residents in the United States as logged within the Accreditation Council for Graduate Medical Education database. The Accreditation Council for Graduate Medical Education case log data were examined for graduating obstetrics and gynecology residents between 2003 and 2019. Delivery case volume numbers for spontaneous vaginal delivery, cesarean delivery, forceps-assisted vaginal delivery, and vacuum-assisted vaginal delivery were extracted and analyzed over time using linear regression. To compare the variability in logged cases, residents at the 70th percentile for number of cases logged were compared with residents at the 30th percentile for number of cases logged for each delivery type (spontaneous vaginal delivery, cesarean delivery, forceps-assisted vaginal delivery, and vacuum-assisted vaginal delivery). Overall, obstetrical delivery data for 20,268 obstetrics and gynecology residents were collected from 2003 to 2019. Over this period, the mean number of spontaneous vaginal deliveries significantly decreased over time by 20% from 320.8±138.7 to 256.1±75.6 (slope, -2.6; P<.001); however, no significant difference was noted in the reported cesarean delivery cases, with an 8% increase from 191.8±80.1 to 206.8±69.7 per graduating resident (slope, 0.136; P=.873). Notably, the mean reported cases of forceps-assisted vaginal deliveries decreased by 75% from 23.8±21.9 to 6±6.8 per graduating resident (slope, -0.851; P<.001). Similarly, the mean logs of vacuum-assisted vaginal delivery decreased by 37% from 23.8±17.1 to 15±9.5 (slope, -0.542; P<.001). The ratio of reported resident case logs comparing the volume at the 70th percentile with the volume at the 30th percentile demonstrated a significant decrease over time for spontaneous vaginal delivery (slope, -0.015; P<.001), cesarean delivery (slope, -0.015; P<.001), and vacuum-assisted vaginal delivery (slope, -0.033; P<.001) but was significantly increased for forceps-assisted vaginal delivery (slope, 0.07, P=.0065). In the reported Accreditation Council for Graduate Medical Education case logs, we identified that the reported number of obstetrical deliveries performed by obstetrics and gynecology residents in the United States is changing, with a significant decline recognized from 2003 to 2019 in logged numbers of spontaneous vaginal deliveries, vacuum-assisted vaginal deliveries, and forceps-assisted vaginal deliveries, without a difference in reported cesarean delivery cases per graduating resident. Furthermore, substantial variation is seen among resident volume nationwide, with the difference in high- and low-volume resident forceps-assisted vaginal delivery experience increasing over time. Awareness of these data should notify the Accreditation Council for Graduate Medical Education and educators about reasonable targets, increased need for simulation, and new ways to teach all modes of deliveries effectively in all residency programs.

Cesarean Delivery in the Management of Pregnancy Complicated by Burn Injuries.

Two cases of cesarean delivery in the management of burn injuries in 2 pregnant patients are presented to illustrate current utilization of cesarean delivery for infant rescue in maternal burn care.

Ethnic disparities in postpartum hemorrhage after cesarean delivery: a retrospective case\u2013control study

PurposeTo explore the relationship of ethnicity and postpartum hemorrhage (PPH) for women who underwent cesarean delivery (CD) and examine the risk factors for PPH in distinct ethnic groups in China.MethodsWe conducted case–control studies with the maternity data from the 11,778 CD cases, in Xinjiang Uygur Autonomous Region. Initially, multivariable logistic regression was used to estimate the disparity of race-ethnicity on the risk of PPH in ethnic Han, Uygur, Hui and Kazakh. Then, we performed case–control studies within two major ethnic groups, identifying the specific risk factors for PPH.ResultsEthnic Uygur were associated with a statistically significant increased odds [adjusted odds ratios (aOR) 2.05; 95% confidence interval (CI) 1.26–3.33] of PPH compared with ethnic Han. For subgroup analyses, in Uygur subgroup, general anesthesia (aOR 7.78; 95% CI 2.31–26.20); placenta previa (aOR 11.18; 95% CI 3.09–40.45); prenatal anemia (aOR 4.84; 95% CI 2.44–9.60); emergency surgery (aOR 4.22; 95% CI 1.95–9.13) were independently associated with PPH. In Han subgroup, general anesthesia (aOR 5.70; 95% CI 1.89–17.26); placenta previa (aOR 20.08; 95% CI 6.35–63.46); multiple pregnancy (aOR 7.21; 95% CI 1.61–32.37); body mass index (aOR 1.19; 95% CI 1.07–1.31) were the risk factors to PPH.ConclusionUygur have more tendency to PPH compared to Han, and risk factors for PPH in Uygur and Han groups may differ. Knowing these differences may be meaningful when planning interventions and resources for high-risk patients undergoing cesarean delivery, and we need more research aimed at risk factors for PPH.

Effect of a stepwise opioid-sparing analgesic protocol on in-hospital oxycodone use and discharge prescription after cesarean delivery

IntroductionOpioid exposure during hospitalization for cesarean delivery increases the risk of new persistent opioid use. We studied the effectiveness of stepwise multimodal opioid-sparing analgesia in reducing oxycodone use during cesarean...

Placenta percreta - a management dilemma: an institutional experience and review of the literature

Objective:Placenta percreta is an extremely high-risk obstetric condition often associated with significant maternal morbidity and mortality. To date, there is no consensus on its management. This article aimed to identify an optimum management option to improve maternal outcomes in patients with placenta percreta.Material and Methods:This was an observational study conducted at a tertiary care institute from October 2019 to June 2020. A well-defined plan of preoperative, bilateral, uterine artery catheter placement, cesarean delivery (CD) of the baby followed by uterine artery embolization (UAE), and elective delayed hysterectomy after 2-4 weeks, was made by a multidisciplinary team. Demographic variables such as age, parity, period of gestation, presenting complaints, imaging findings, mode of management, intraoperative findings, blood loss, the requirement for blood and blood products, and complications were noted.Results:We encountered seven cases of placenta percreta over a period of nine months. UAE was performed in 6/7 patients. UAE was not performed in one patient as she presented to the emergency department in shock. Elective delayed hysterectomy was performed after 2-4 weeks in three patients, three patients required emergency hysterectomy (two during CD and one on the seventh postoperative day) and one patient was managed conservatively by leaving the placenta in situ after CD and UAE. Patients who underwent UAE had notably less intraoperative blood loss and requirement of blood and blood products than the patient who could not receive UAE. During cesarean hysterectomy, blood loss was 1,700 mL in embolized (case 4) vs 3,000 mL in unembolized patient (case 7). In embolized patients, the median blood loss during CD (case 1,2,3,5,6) was 200 mL (interquartile range: 165-200 mL) and during delayed elective hysterectomy (case 1,3,5) was 150 mL (range: 125-225 mL). Blood loss in case 2 was 1,000 mL during emergency hysterectomy on the 7th day of CD and UAE. The blood loss was appreciably higher in patients who underwent immediate cesarean hysterectomy rather than elective delayed hysterectomy.Conclusion:Placenta percreta, if not managed in a preplanned manner, may lead to disastrous maternal outcomes. Prophylactic devascularization during CD and leaving the placenta in situ followed by elective delayed hysterectomy, might be a reasonable management option in most severe cases of placenta percreta.