Elective Lower Segment Caesarean Section Research Articles

Late Presentation of Rheumatic Heart Disease during Pregnancy: A common occurrence in the NT

Rheumatic heart disease remains an undertreated and underdiagnosed entity in Australia. As 98% of acute rheumatic fever and rheumatic heart disease occurs in the Indigenous population and as females represent two thirds of rheumatic heart disease, our most vulnerable population suffers from this disease the most. This is a disease of the socially disadvantaged: social, cultural, physical barriers exist between this population and appropriate prevention, diagnoses and management. We present here 6 years of data, equating to 60 females, diagnosed with rheumatic heart disease during pregnancy. Approximately one third with moderate to severe valvular disease and 20% pulmonary hypertension. This is not uncommon in the Northern Territory. The majority of these cases were diagnosed before admission for birth, however a small number were only diagnosed perinatally. The majority of these cases were able to be managed through normal vaginal delivery or elective lower segment caesarean section without fatal complications. A small number of attempted vaginal deliveries resulted in emergency. We observe the changing physiology within pregnancy trimesters and stages of delivery and the impact this has on valvular gradients and pulmonary hypertension, including the incredible and unexpected physiological reserve many of these females display. We also discuss the various methodology of diagnosis, the medical and social management of such females, including the anaesthetic approach to vaginal delivery or lower segment caesarean section.

Effect of Tranexamic Acid on Blood Loss in Elective Cesarean Delivery

Background: tranexamic acid as an agent given before surgical procedures reduces the blood transfusion risk, mean volume lost, and the requirement for reintervention due to bleeding issues, without raising thrombotic risks. Aim: to evaluate Tranexamic acid agent infusion as regards its efficacy in blood volume loss reduction in practice of elective lower segment cesarean section delivery. Patients and Methods: A double blinded, randomized, controlled research clinical trial. All study subjects have been recruited from the cases scheduled for elective cesarean delivery in the labor ward of Mokattam Insurance Hospital. The study subjects were totally 200 cases allocated in by randomization into 2 research groups. The study research group have been composed of 100 cases that were administered a mixture of tranexamic acid 25mg/kg in 200 ml of normal saline by intravenous drip for 20 minutes before incision, while the control research group contained 100 cases administered a volume of normal saline in accordance to patient’s weight (25 mg/kg) by intravenous drip for 20 minutes before time of incision. Results: Blood loss volume was statistically significantly lower among Tranexamic research group than among placebo research group (p value <0.001). Postoperative hematocrit was statistically significantly higher among Tranexamic research group than among placebo research group (p value =0.020). Hematocrit reduction was statistically significantly lower among Tranexamic research group than among placebo research group (p value <0.001). PPH and blood transfusion were statistically significantly less frequent among Tranexamic research group (p values=0.010, 0.005 consecutively). Conclusions and Recommendation: The administration of tranexamic acid before starting a cesarean section is valuable as a prophylaxis against intra-operative and post-partum bleeding issues. Future research studies are required to consider various variables such as racial and ethnic differences and consider various clinical case scenarios e.g. previous cesarean delivery and categorization of more possible critical indications of cesarean such as second stage cesarean, emergency cesarean section and time interval of decision to incision as those variables could influence blood volume loss indices.

Comparison between Preoperative and Postoperative Sublingual Misoprostol for Prevention of Postpartum Hemorrhage during Cesarean Section: A Randomized Clinical Trial

Background: Blood loss is one of the important complications during cesarean section (CS). Previous reports have shown that misoprostol is effective in reducing blood loss during and after CS. However, the optimum time for its administration to decrease the amount of PPH is still under discussion. Objective: To compare the effect of preoperative and postoperative administration of sublingual misoprostol (400 μg) in reducing the amount of blood loss during and 24 hours after CS. Setting: Obstetrics and Gynecology Department, Faculty of Medicine, Assiut University, Assiut, Egypt, between January 2017 and July 2018. Study Design: A prospective, randomized clinical trial. Methods: Four-hundred thirty women fulfilling the inclusions criteria: elective lower segment CS at term (≥37 weeks) with normal fetal heart tracing who accepted to participate in the study. Patients were divided into two groups; Patients assigned to group 1 received 400 μg sublingual misoprostol immediately after urinary catheterization and before skin incision, while patients assigned to group 2 received sublingual misoprostol immediately after skin closure. The primary outcome was the estimation of intraoperative and postoperative blood loss for 24 hours. Results: There was a significant reduction in the intraoperative blood loss in group 1 compared with group 2 (403.51 ± 72.99 vs. 460.99 ± 74.66 ml, respectively). Also, there was a significant reduction in postoperative blood loss in group 1 compared with group 2 with a statistical significance (169.45 ± 12.03 vs. 195.77 ± 13.34 ml, respectively). Postoperative hemoglobin and Hematocrit values were significantly higher in group 1 compared with group 2. Conclusions: Preoperative administration of sublingual misoprostol (400 μg) during CS is better than postoperative administration as it is associated with a reduction in the amount of intraoperative and postoperative blood loss and drop in hemoglobin level.

The potential value of surrogate performance markers at caesarean section for the assessment of surgical competence

ObjectivesWe hypothsised that surrogate markers of competence (procedure time and estimated surgical blood loss) could be of value when assessing competence for trainees learning to undertake lower segment caesarean section (LSCS). The study aim was to investigate differences in surrogate markers of surgical competence at LSCS between different training grades of primary surgeon and for different grades of surgical assistant; to assess the potential value of using these surrogate markers in overall assessments of surgical competence. Study designOperating records for elective LSCS were reviewed from January 2007 to January 2015. Uncomplicated LSCS where a junior trainee (ST2/ST3) or a senior trainee (ST6+) was the primary surgeon were included. Inclusion criteria were LSCS with body mass index less than 35, singleton pregnancy, greater than 34 weeks’ gestation, no more than one previous caesarean section and no low-lying placenta. Procedure time, estimated blood loss and the effect of the grade of surgical assistant (consultant or trainee) on these were compared overall for all surgeons at ST2 level, ST3 level and senior level (ST6+) using Student’s t test and effect size calculation (Cohen test). ResultsDuring the study period 3099 uncomplicated LSCS were performed by 60 trainees: 1367 by ST2, 1085 by ST3 and 646 by senior trainees (ST6+). Mean procedure times and recorded estimated blood loss decreased significantly for each level of training (p < 0.05). The degree of experience of the surgical assistant was also associated with reduced procedure times and blood loss, this was significant for trainees in ST2 when assisted by a consultant (p < 0.05). ConclusionsTraining progression is associated with a reduction in procedure time and estimated blood loss, which are both surrogate markers of competence at LSCS. Current objective structured assessments of technical competence for trainees (OSATS) do not take these metrics into account when assessing performance. An enhanced assessment of trainees undertaking LSCS is suggested, reviewing both objective structured assessments of technical performance (OSATS) and surrogate markers of performance recorded in a surgical logbook to provide a more comprehensive assessment of overall competence.

Abstract P-352: OUTCOME OF NEONATAL CONGENITAL DIAPHRAGMATIC HERNIA IN A MIDDLE-INCOME COUNTRY

Aims & Objectives: To investigate the outcome of neonates with congenital diaphragmatic hernia (CDH) admitted to the Pediatric Intensive Care Unit (PICU) in University Malaya Medical Center. Methods A retrospective study of unilateral CDH from 2003–2017 was conducted. Results A total of 118 neonates, 58.5% males (n=69) were identified. Antenatal diagnosis of CDH was recognized in 40.7% (n=48) while inborn cases constituted 48.3% (n=57) of the population. The modes of delivery were emergency lower segment caesarean section (LSCS) in 26.3% (n=31), elective LSCS in 11.9% (n=14) and spontaneous vaginal delivery in 61.9% (n=73) of the cases. The 1-minute and 5-minute Apgar scores of >7 were observed in 51.3% (n=58) and 75.2% (n=85) of the population respectively. Stabilization with conventional ventilation including the use of respiratory rates up to 100/minute was preferred and achieved in 50.8% of cases (n=60). Another 27 cases were stabilized with high frequency oscillation. Surgical repair was carried out in 89 patients including 2 cases who did not achieve stabilization pre-operatively, at median age of 8 days (IQ 6–13 days). The other 29 cases died without an operation. Of those who underwent surgical repair, 4 died before 30 days-of-life while another 5 died after 30-days, making the 30-day survival 72% and survival to hospital discharge 67.8%. Factors associated with non-survival were antenatal diagnosis, being inborn, 1 and 5-minute Apgar scores <7, elective LSCS as the mode of delivery and non-stabilization preoperatively. Conclusions Survival to hospital discharge of CDH in our centre is slightly lower than in those with extra-corporeal membrane oxygenation in developed countries.

The effect of rectus muscle re-approximation at cesarean delivery on pain perceived after operation: a randomized control trial

Background: Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section.Objective: The purpose of this study was to assess the effect of rectus muscle reapproximation at cesarean delivery on the postoperative pain.Methods: This study was a prospective, double-blind, randomized controlled trial. It included 280 primigravidas, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group (A): undergoing rectus muscle reapproximation, and Group (B): not undergoing rectus muscle reapproximation. Postoperative pain was assessed by visual analogue scale (VAS) from 0 (no pain) to 100 (maximum pain). Postoperative analgesia, operative time, changes in hemoglobin level, length of hospital stay, and occurrence of postoperative complication were also assessed.Results: Postoperative pain score at the end of the first 24 hours and at the end of the next 24 hours were significantly higher among the group of rectus muscle reapproximation (a difference in VAS pain score of: 5, 95% confidence interval: 0.1–11, p value: .02) and (a difference of 1, 95% confidence interval: 0.1–2.9, p value: .01), respectively. As regards the narcotic use in the first 24 hours after cesarean section, in the form of injections of meperidine 50 mg, it was significantly higher among the group of rectus muscle closure (a difference of 10 mg, 95% confidence interval 3–21.7 mg, p value: .02). While in the next 24 hours, the NSAIDs use, in the form of diclofenac sodium injection, was significantly higher among the group of rectus muscle reapproximation (a difference of 10 mg, 95% confidence interval 3.7–31.7 mg, p value: .02).Conclusions: Rectus muscle reapproximation among women undergoing primary caesarian section is associated with significant increase in the postoperative pain and analgesic requirements.

Comparison of efficacy of different concentration of bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for postoperative pain relief in lower segment cesarean section

Comparison of efficacy of different concentration of bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for postoperative pain relief in lower segment cesarean section

Pregnancy after DHEA-S for low ovarian reserve due to laparoscopic ovarian drilling

A 32-year-old married for three years, who had taken treatment for primary infertility, approached for assisted reproductive techniques (ART) after the failure of 10 cycles of ovulation induction with clomiphene citrate (CC) and laparoscopic ovarian drilling (LOD) two years ago. She was evaluated and found to have anti-Mullerian hormone (AMH) of 0.63 ng/ml and antral follicle count (AFC) of four and was treated with dehydroepiandrosterone sulphate (DHEA-S) for three months. Her AMH increased to 1.2 ng/ml and AFC to seven and she underwent three cycles of ovulation induction and intrauterine insemination (IUI) which was unsuccessful. She conceived naturally after the fourth cycle of ovulation induction with gonadotropins without cycle monitoring. Her Pregnancy was supported with progesterone until 36 weeks, and she underwent elective lower segment Caesarean section (LSCS) for mid-pelvic contraction at 38 weeks of pregnancy. The Caesarean section inspection of the ovaries showed bilateral charring and a few tubo-tubal adhesions. Her postoperative period was normal and mother and baby were discharged on the fifth postnatal day.

Outcome in gestational diabetes mellitus after various treatment modality: A tertiary center experience in North India

Background: Gestational diabetes mellitus (GDM) is a potential risk factor for pregnant women because it leads to various complications during pregnancy and childbirth; thus, GDM directly increases the risk of maternal and neonatal mortality and morbidity. Aim: To estimate the prevalence of GDM and evaluate maternal and fetal outcome in pregnant women with GDM. Materials and Methods: This was a prospective study carried out over a period of 1 year. After informed consent and ethical clearance, a total of 8970 pregnant women were recruited and followed; they underwent universal screening for diabetes as per the Diabetes in Pregnancy Study Group India criteria. Three-hundred and eighty women were diagnosed with diabetes, of this 29 were found to be type 2 diabetes and 351 pregnant women were diagnosed as gestational diabetes. Women with gestational diabetes were followed till 6 weeks of postpartum. After enrollment, 290 women were treated with regular insulin and neutral protamine Hagedorn insulin and only 61 women were kept on medical nutrition therapy. Results: About 76.1% of women underwent cesarean section, whereas 23.9% women delivered vaginally. Elective (LSCS) Lower segment caesarean section was done in 22% of women while emergency cesarean section in 54.1%. Preeclampsia was observed in 13.7%, 45.3% women delivered preterm baby, polyhydramnios was found in 3.41%, and oligohydramnios was found in 2% women. Candida vaginal infection was observed in 2.50% and intrauterine growth restriction present in 11.90% women. 8.3% babies were macrosomic and 3.1% babies were admitted in Neonatal intensive care unit. Stillbirth was noted in 4.3%. Congenital malformation was seen in 1.7% babies of GDM mothers who did not receive any antenatal care. About 26.5% of total GDM cases were unbooked. Conclusion: Gestational diabetes is a rising complication of pregnancy. If women receive proper medical nutritional therapy and insulin therapy during pregnancy, better maternal and fetal outcome could be achieved.

Comparative analysis of duration of postoperative analgesia between levobupivacaine and levobupivacaine with clonidine after ultrasound-guided transversus abdominis plane block in patients undergoing lower segment cesarean section

Background:Transversus abdominis plane (TAP) block in cesarean section is carried out by local anesthetics such as bupivacaine or ropivacaine with a limited duration of analgesia. The addition of adjuvants such as clonidine and dexmedetomidine has increased the duration of postoperative analgesia.Aims, Settings and Design:The aim of this study was to compare the duration of postoperative analgesia between clonidine and levobupivacaine (0.25%) versus levobupivacaine (0.25%) alone in the bilateral TAP block after lower segment cesarean section (LSCS).Materials and Methods:In this prospective randomized double-blind interventional study, 100 parturients undergoing elective LSCS were included in the study. Patients were randomly divided to receive either 20-ml levobupivacaine 0.25% (Group A; n = 50) or 20-mL levobupivacaine (0.25%) +1-μg/kg clonidine bilaterally (Group B; n = 50) in TAP block in a double-blind fashion. The total duration of analgesia, patient satisfaction score, postoperative visual analog scale score, total requirement of analgesics in the first 24 h, and the side effects of clonidine were observed.Statistical Analysis:Statistical tests were conducted using SPSS. P < 0.05 was considered as statistically significant.Results:A total of 92 patients were analyzed. Duration of analgesia was significantly longer in Group B (17.94 ± 0.76 h) compared to Group A (7.16 ± 0.41 h) (P < 0.001). Mean consumption of tramadol was 197.77 ± 14.90 mg and 8.889 ± 28.77 mg in Groups A and B (P < 0.001), respectively. All patients in Group B were extremely satisfied while those in Group A were satisfied (P < 0.01). None of the patients experienced hypotension or bradycardia.Conclusion:The addition of clonidine 1 μg/kg to 20-ml levobupivacaine 0.25% in TAP block bilaterally for cesarean section significantly increases the duration of postoperative analgesia, decreases postoperative rescue analgesic requirement, and increases maternal comfort compared to 20 ml of levobupivacaine 0.25% alone.

Hypoxic-ischemic brain injury: Planned delivery before intrapartum events.

Mothers are increasingly given greater control over many of the choices around birth, although there is little robust evidence to inform these choices. After an infant is born with HIE the question of whether it was predictable, or preventable, is often raised. Intrapartum 'sentinel' events and antenatal predictors of HIE have been well described, however there is little evidence how antenatal and intrapartum factors interact. This is particularly important when elective delivery by lower segment caesarean section (LSCS) has been shown to be beneficial in high risk groups. To develop a clinical risk score to identify women with a higher risk of having an infant with HIE. This study is based on the Avon Longitudinal Study of Parents and Children (ALSPAC). This dataset was split into two halves: with each infant being randomly allocated to either cohort one or two. The first cohort was used for the derivation of the model, while it was tested exclusively on the second. Logistic regression modelling was then performed to develop a predictive model. The final model was used to predict the outcome of infants in the second cohort and infants divided into four risk quartiles. To give some indication of possible avoidable disease, the proportion of infants with HIE, potentially avoided by earlier delivery, was estimated by assuming that medicalized delivery by elective LSCS at 37 weeks would remove intrapartum risk of HIE for those infants undelivered at this point. In the final model seven covariates remained (parity, preeclampsia, polyhydramnios, prelabor rupture of membranes, gender, concerns over fetal growth and prematurity). When applied to the second cohort, a ROC curve for the prediction of developing HIE in the newborn period showed good evidence for association (AUC 0.68 (0.60 to 0.77)) and the risk score derived was strongly associated with the risk of HIE, resuscitation and stillbirth, and neonatal death (all p < 0.05). Elective delivery of high risk infants at 37 weeks gestation could prevent 14% of all HIE, with a NNT of 41. It is possible to combine routine antenatal findings to identify infants at higher risk of neonatal HIE, thereby recognizing those infants who may benefit most from delivery by elective caesarean section. This work suggests a clinical risk score permits antenatal identification of high-risk infants whose outcome may be amenable to changes in clinical practice to potentially reduce HIE rates, and its devastating consequences.

The Case Study of Gestational Diabetes Mellitus (GDM) Underwent Elective Lower Segment Caesarean Section

This case study is written for Family Health Practitioners and Nurse Case managers. To add, reflective critical analysis, frameworks, exploration of advanced role of case manager, ethical and professional issues which contribute enhancing the health and care needs, reflection on roles and responsibilities in relation to interdisciplinary teams is discussed in the report. It is to revitalize health systems in under-developed countries based on the tenets of the Alma Ata Declaration of Health Care, presented by the World Health Organization remains essential for attaining the maternal and child health related Millennium Development Goals (MGDs). Ehiri [1] informed that MGDs have a target date of 2015 and synthesize many of the commitments made in achieving that target.

Efficacy of Intravenous Ondansetron for Prevention of Postspinal Shivering during Lower Segment Cesarean Section: A Double-Blinded Randomized Trial.

Background and Aims:Elective lower segment cesarean section under spinal anesthesia is frequently associated with shivering. Ondansetron has been shown to be effective for postspinal shivering. In the present study, we compare the efficacy of ondansetron to prevent postspinal shivering in parturients undergoing cesarean delivery under spinal anesthesia.Materials and Methods:A total of eighty full-term parturients scheduled for elective lower segment cesarean section under spinal anesthesia were randomly allocated into two groups. Group O received 8 mg/4 ml ondansetron, and Group S received 4 ml normal saline intravenously immediately before induction of spinal anesthesia. The level of sensory block, core body temperature, shivering score, and presence or absence of nausea and vomiting during the perioperative period, 1st and 5th min neonates Apgar scores were recorded. The data analysis was carried out with Z-test and Chi-square test.Results:Ten percent (4/40) of patients in Group O and 42.5% (17/40) of patients in Group S had Grade III shivering during the perioperative period and that was treated with intravenous injection tramadol (P = 0.001). Two patients (5%) in ondansetron and 19 patients (47.5%) in control group had nausea and vomiting (P < 0.001) and was treated with intravenous 10 mg metoclopramide. 1st and 5th min Apgar scores of neonates were not statistically different in the groups.Conclusions:Ondansetron is an effective way to prevent shivering, nausea and vomiting during lower segment cesarean section under spinal anesthesia with no effect on Apgar score.

Combined spinal epidural anaesthesia in a case of primigravida with coarctation of aorta with severe hypertension for elective lower segment caesarean section.

Combined spinal epidural anaesthesia in a case of primigravida with coarctation of aorta with severe hypertension for elective lower segment caesarean section.

Evaluation of the Role of Induced Uterine Contraction on Blood Loss during Caesarean Section under Different Types of Anesthesia: A Double Blind Controlled Study

Background: Delivery by Caesarean section (CS) can cause more complications than normal vaginal delivery and one of its common complications is postpartum bleeding which can be life threatening. To reduce maternal mortality and morbidity caused by bleeding, it is important to reduce the extent of bleeding during and after CS. Objectives: To compare between the efficacy of using prostaglandin F2α under spinal or general anesthesia on decreasing the amount of blood loss during elective caesarean section. Settings and design: A prospective, double blind controlled randomized and comparative study. Methods: 60 patients undergoing elective lower segment caesarean section were divided into two groups: Group A received general anesthesia with subtypes A1 (general anesthesia=control group), and A2 (general anesthesia +prostaglandin F2α) and Group B received spinal anesthesia with subtypes B1 (spinal anesthesia=control group), and B2 (spinal anesthesia+prostaglandin F2α), hemodynamics, total blood loss , Hemoglobin Hb (gm/dl) and hematocrit Hct (%) values were recorded before and after the operation. Results: There was significant difference in total blood loss (ml) between general and spinal anesthesia groups which was 772.333 ± 144.287 in group A and 623.667 ± 119.779 in group B and significant increase in total blood loss in group A1 when compared with other three groups, significant increase in group A2 when compared with B2, insignificant changes between A2 and B1 and significant increase in total blood loss in group B1 when compared with group B2. Also the same manner present in MAP and HR where there was significant difference in MAP and HR in group A1 when compared with other three groups, significant difference in group A2 when compared with B2, insignificant changes between A2 and B1 and significant difference in MAP and HR in group B1 when compared with group B2 at 10 and 20 min but there was insignificant changes at preoperative and immediately postoperative measurements between 4 subgroups. Conclusion: PGF2α under spinal anesthesia decreases the amount of blood loss during cesarean section.

Comparison of fractionated dose versus bolus dose injection in spinal anaesthesia for patients undergoing elective caesarean section: A randomised, double-blind study.

Background and Aims:Spinal anaesthesia (SA) with bolus dose has rapid onset but may precipitate hypotension. When we inject local anaesthetic in fractions with a time gap, it provides a dense block with haemodynamic stability and also prolongs the duration of analgesia. We aimed to compare fractionated dose with bolus dose in SA for haemodynamic stability and duration of analgesia in patients undergoing elective lower segment caesarean section (LSCS).Methods:After clearance from the Institutional Ethics Committee, the study was carried out in sixty patients undergoing elective LSCS. Patients were divided into two groups. Group B patients received single bolus SA with injection bupivacaine heavy (0.5%) and Group F patients fractionated dose with two-third of the total dose of injection bupivacaine heavy (0.5%) given initially followed by one-third dose after 90 s. Time of onset and regression of sensory and motor blockage, intraoperative haemodynamics and duration of analgesia were recorded and analysed with Student's unpaired t-test.Result:All the patients were haemodynamically stable in Group F as compared to Group B. Five patients in Group F and fourteen patients in Group B required vasopressor. Duration of sensory and motor block and duration of analgesia were longer in Group F (273.83 ± 20.62 min) compared to Group B (231.5 ± 31.87 min) P < 0.05.Conclusion:Fractionated dose of SA provides greater haemodynamic stability and longer duration of analgesia compared to bolus dose.

Oh Rh (D)-Negative in vitro fertilization pregnancy: Obstacles surmounted

We report a rare case of Oh (D)-negative female with in vitro fertilization (IVF) pregnancy. Blood grouping was reported as O Rh (D) negative elsewhere and was referred at 28 weeks gestation for anti-D titration to our center. Blood grouping repeated at our laboratory was Oh Rh (D) negative. Owing to the absence of H antigen-negative cells, we did anti-H adsorption studies on the patient serum to look for underlying red cell alloantibodies, which were absent. The Ig (G) anti-H titer was 256, but there were no signs of fetal anemia as seen on the fetal middle cerebral artery (MCA) peak systolic volume studies also. The patient was on follow-up with anti-H titers and fetal MCA-Doppler studies every 2 weeks. The patient was started on oral iron and erythropoietin as hemoglobin was 8.5 g% which then improved to 11.5 g% after two doses of erythropoietin. Owing to risk of bleeding due to low-lying placenta, the treating obstetrician wanted to keep two units of red cell concentrate ready before elective lower segment cesarean section. Hence, close family members of the patient were screened for Oh phenotype, but none of them were found to be of Oh phenotype. Hence, autologous predeposit with fetal monitoring was considered but not implemented owing to legal and patient concerns. Pregnancy was uneventful and a healthy female baby was delivered at term. The baby did not have any signs of hemolytic disease of newborn. Blood grouping of baby was O positive and direct antiglobulin test done at the referring center was negative.

Perfusion index as a predictor of hypotension following spinal anaesthesia in lower segment caesarean section.

Background and Aims:Perfusion index (PI) is a new parameter tried for predicting hypotension during spinal anaesthesia for the lower segment caesarean section (LSCS). This study aimed at investigating the correlation between baseline perfusion index and incidence of hypotension following SAB in LSCS.Methods:In this prospective observational study, 126 parturients were divided into two groups on the basis of baseline PI. Group I included parturients with PI of ≤3.5 and Group II, parturients with PI values >3.5. Spinal anaesthesia was performed with 10 mg of injection bupivacaine 0.5% (hyperbaric) at L3–L4 or L2–L3 interspace. Hypotension was defined as mean arterial pressure <65 mmHg. Statistical analysis was performed using Chi-square test, independent sample t-test and Mann–Whitney U-test. Regression analysis with Spearman's rank correlation coefficient was done to assess the correlation between baseline PI and hypotension. Receiver operating characteristic (ROC) curve was plotted for PI and occurrence of hypotension.Results:The incidence of hypotension in Group I was 10.5% compared to 71.42% in Group II (P < 0.001). There was significant correlation between baseline PI >3.5 and number of episodes of hypotension (rs0.416, P < 0.001) and total dose of ephedrine (rs0.567, P < 0.001). The sensitivity and specificity of baseline PI of 3.5 to predict hypotension was 69.84% and 89.29%, respectively. The area under the ROC curve for PI to predict hypotension was 0.848.Conclusion:Baseline perfusion index >3.5 is associated with a higher incidence of hypotension following spinal anesthesia in elective LSCS.

Blood Transfusion during caesarean delivery

Introduction: Blood transfusion is considered as a life saving measure in obstetrics. However, at present it is not considered safe all the time due to transfusion reactions and infections. The mother is at risk of increased bleeding, because caesarean section may result in twice the blood loss of vaginal delivery (due to placental attachment and two surgical scars). In Sri Lankan setup, grouping and cross matching are done prior to each and every caesarean section without considering the presence or absence of risk factors even with less facilities available. During caesarean section in Sri Lanka blood transfusion to cross matching ratio is considered to be low. Objectives: To determine the proportion of blood transfusions performed among mothers whose blood was grouped and cross-matched for Lower segment caesarean section (LSCS). To find out the indications/ associated factors for blood transfusion in LSCS Method &amp; Materials: A retrospective cross sectional study carried out in Obstetric Units, General Hospital Matara Sri Lanka. Data collected from all the bed head tickets and other records available at Blood Bank General Hospital Matara belong to mothers who underwent elective and emergency caesarean sections from 30th July 2013 to 1st of June 2014 Results: Our sample size was 3174 mothers majority underwent Elective Lower segment caesarean section (EL/LSCS) (57.5%) &amp; 42.5% were Emergency Lower segment caesarean section (EM/LSCS). Only 1.85% of mothers transfused blood during LSCS, as 3.38% during EL/LSCS &amp; 96.6% during EM/LSCS. Lower segment large fibroid (50%) &amp; placenta accreta + past section (50%) were two indications that need blood transfusion during EL/LSCS in our research. Antepartum haemorrhage (APH) (15.78%), pregnancy induced hypertension (PIH) (8.77%), postpartum haemorrhage (26.31%), Anaemia Hb 7.6-8.2g/dl (36.84%), Twin pregnancy (5.26%) &amp; placenta previa were other indication that need blood transfusion in EM/LSCS. Conclusions: This study shows each &amp; every mother who undergo EL/LSCS do not need blood transfusion &amp; cross matching especially in EL/LSCS. According to our study patients with following risk factors need blood grouping &amp; cross matching. APH, PIH, Placental abnormalities, Anaemia (Hb 7.6-8.2g/dl), Twin pregnancy, and pregnancy complicated with abnormal uterine condition eg: - fibroids, placenta accrete.

Evaluation of the effects of prespinal administration of Ondansetron on maternal hemodynamics

Introduction: Spinal anaesthesia is the preferred method of anaesthesia for elective lower segment caesarean section (LSCS). It has a shorter onset time, but is associated with hypotension and bradycardia,which at times may be deleterious to both mother and fetus. Aim of Study: To evaluate the effects of intravenous administration of ondansetron prior to spinal anaesthesia on the hemodynamic responses in the mother specifically hypotension and bradycardia. Materials and Methods: The study was a hospital based prospective, double-blinded, randomized, placebo controlled study in our teaching medical college and hospital over a period of 6 months –February to July 2015.As per inclusion and exclusion criteria of our study, study population ( 72 patients) was identified who were planned for elective LSCS. They were randomly allocated into two groups. 5 minutes prior to spinal anaesthesia, group O (n =36) received 4mg IV Ondansetron and group P (n = 36) received physiological saline. Blood pressure and heart rate were monitored once in 5 minutes for 30 minutes, and requirement of vasopressors was noted. Results: Hypotension was significantly lower in group O when compared to group P. Bradycardia was less in number in group O but it was statistically insignificant. Vasopressor requirement was also lower in group O patients.Conclusion: Intravenous Ondansetron 4mg given 5 minutes prior to spinal anaesthesia significantly reduces the hypotension. The episodes of bradycardia as well as the requirement of vasopressors in parturients were low in ondansetron group, which was found to be statistically insignificant, may be due to less number of study population.