Rate Of Endometritis Research Articles

Effect of prophylactic preoperative nursing interventions on prevention of endometritis among women undergoing elective caesarean delivery

Objective : The single most important risk factor for postpartum endometritis is cesarean delivery. Aim: This study aimed to evaluate the effect of prophylactic preoperative nursing interventions on prevention of endometritis among women undergoing elective caesarean delivery. Methods : Setting: This study was conducted in Operating Rooms, Postnatal Wards and Clinics of the Obstetrics and Gynecology Department at Mansoura University Hospital. Study Design: A randomized controlled clinical trial was utilized. Sample: A purposive sample of 150 parturient women undergoing elective cesarean section were randomly chosen according to inclusion criteria and then divided into three equal groups of 50 parturient women. Group one the control group received routine preoperative abdominal and thigh scrub with 10% Povidone Iodine and taken standard antibiotic regiment. There were two intervention groups; Group two participants received vaginal washing with 0.9% saline solution and group three participants received vaginal washing with 10% Povidone–iodine solution in addition to routine preoperative care. Results : The findings of this study revealed that the risk of developing post-elective caesarean delivery endometritis was significantly lower in the intervention groups compared to the control group ( P < .05). Conclusions : Vaginal washing with Povidone-iodine or saline solution immediately prior cesarean delivery significantly reduces the rate of post-elective caesarean delivery endometritis. Recommendation: Vaginal washing immediately prior to cesarean delivery should be a routine care to reduce the risk of postpartum endometritis.

Adjunctive Azithromycin Prophylaxis for Cesarean Delivery

BackgroundThe addition of azithromycin to standard regimens for antibiotic prophylaxis before cesarean delivery may further reduce the rate of postoperative infection. We evaluated the benefits and safety of azithromycin-based extended-spectrum prophylaxis in women undergoing nonelective cesarean section.MethodsIn this trial conducted at 14 centers in the United States, we studied 2013 women who had a singleton pregnancy with a gestation of 24 weeks or more and who were undergoing cesarean delivery during labor or after membrane rupture. We randomly assigned 1019 to receive 500 mg of intravenous azithromycin and 994 to receive placebo. All the women were also scheduled to receive standard antibiotic prophylaxis. The primary outcome was a composite of endometritis, wound infection, or other infection occurring within 6 weeks.ResultsThe primary outcome occurred in 62 women (6.1%) who received azithromycin and in 119 (12.0%) who received placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). There were significant differences between the azithromycin group and the placebo group in rates of endometritis (3.8% vs. 6.1%, P=0.02), wound infection (2.4% vs. 6.6%, P<0.001), and serious maternal adverse events (1.5% vs. 2.9%, P=0.03). There was no significant between-group difference in a secondary neonatal composite outcome that included neonatal death and serious neonatal complications (14.3% vs. 13.6%, P=0.63).ConclusionsAmong women undergoing nonelective cesarean delivery who were all receiving standard antibiotic prophylaxis, extended-spectrum prophylaxis with adjunctive azithromycin was more effective than placebo in reducing the risk of postoperative infection. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; C/SOAP ClinicalTrials.gov number, NCT01235546.)

Duration of Oxytocin and Rupture of the Membranes Before Diagnosing a Failed Induction of Labor.

To compare maternal and neonatal outcomes based on length of the latent phase during induction with rupture of membranes before 6 cm dilation. This is a retrospective cohort study using data from the Consortium of Safe Labor study, including 9,763 nulliparous and 8,379 multiparous women with singleton, term pregnancies undergoing induction at 2 cm dilation or less with rupture of membranes before 6 cm dilation after which the latent phase ended. Outcomes were evaluated according to duration of oxytocin and rupture of membranes. At time points from 6 to 18 hours of oxytocin and rupture of membranes, the rates of nulliparous women remaining in the latent phase declined (35.9-1.4%) and the rates of vaginal delivery for those remaining in the latent phase at these time periods decreased (54.1-29.9%) Nulliparous women remaining in the latent phase for 12 hours compared with women who had exited the latent phase had significantly increased rates of chorioamnionitis (12.1% compared with 4.1%) and endometritis (3.6% compared with 1.3%) and increased rates of neonatal intensive care unit admission (8.7% compared with 6.3%). Similar patterns were present for multiparous women at 15 hours. Based on when neonatal morbidity increased, in an otherwise uncomplicated induction of labor with rupture of membranes, a latent phase after initiation of oxytocin of at least 12 hours for nulliparous women and 15 hours in multiparous women is a reasonable criterion for diagnosing a failed induction.

A comparison of 3 antibiotic regimens for prevention of postcesarean endometritis: an historical cohort study

Prophylactic antibiotics are of proven value in decreasing the frequency of postcesarean endometritis. The beneficial effect of prophylaxis is enhanced when the antibiotics are administered before the surgical incision as opposed to after the clamping of the umbilical cord. However, the optimal antibiotic regimen for prophylaxis has not been established firmly. The purpose of this study was to compare 3 different antibiotic regimens for the prevention of postcesarean endometritis. This retrospective historical cohort study was conducted at the University of Florida, which is a tertiary care facility that serves a predominantly indigent patient population. In the period January 2003 to December 2007, our standard prophylactic antibiotic regimen for all women who had cesarean delivery was cefazolin (1 g) administered immediately after the baby's umbilical cord was clamped. In November 2008, we began to administer the combined regimen of cefazolin (1 g intravenously) plus azithromycin (500 mg intravenously); both were given 30-60 minutes before the skin incision. In the period of January-December 2014, we continued the dual agent regimen but based the dose of cefazolin on the patient's body mass index: 2 g intravenously if the body mass index was <30 kg/m(2) and 3 g if the body mass index was >30 kg/m(2). The surgical technique was consistent throughout all 3 time periods. Our primary endpoint was the frequency of endometritis in each time period. This diagnosis was based on fever ≥37.5°C, lower abdominal pain and tenderness, the exclusion of other localizing signs of infection, and the requirement for administration of therapeutic antibiotics. In the first year after beginning the new antibiotic regimen, we also monitored the frequency of neonatal sepsis evaluations and compared it with the frequency that was recorded during the year immediately preceding the change in antibiotic regimens. During the entire period 2003-2014, 29,633 women delivered at our institution; 6455 women (22%) had a cesarean delivery. In the period January 2003 to December 2007, 1034 women had a primary or repeat cesarean delivery. One hundred seventy women (16.4%; 95% confidence interval, 14.4-18.4%) developed endometritis. In the period November 2008 to December 2013, 4484 women had a primary or repeat cesarean delivery. Fifty-nine patients (1.3%; 95% confidence interval, 1.0-1.7%) developed endometritis (P < .0001 compared with period1). In the year 2014, 937 women had a cesarean delivery; 22 of them (2.3%, 95% confidence interval, 1.3-3.3%) developed endometritis (P< .0001 compared with period 1 and P > .5 and <.10 compared with period 2). The frequency of evaluations for suspected neonatal sepsis in infants who were delivered to mothers who had cesarean delivery was 17.6% in the period January to December 2007 and 19.3% in the period November 2008 to November 2009 (relative risk, 1.1; 95% confidence interval, 0.7-1.9). One infant had proven sepsis in the former period; 2infants had proven sepsis in the latter period (not significant). When administered before skin incision, the combination of cefazolin plus azithromycin was significantly more effective in the prevention of endometritis than the administration of cefazolin after cord clamping; the rate of endometritis was reduced to a very low level without increasing the rate of neonatal sepsis evaluations.

The association of skin-incision type at cesarean with maternal and neonatal morbidity for women with multiple prior cesarean deliveries

ObjectiveIn women with multiple prior cesarean deliveries (CDs), vertical skin incisions are thought by some to result in better outcomes. The objective of this study was to compare maternal and neonatal outcomes according to the type of skin incisions among women with multiple prior CDs. Study designThis was a secondary analysis of MFMU Cesarean Registry data. Women undergoing repeat CD with a viable singleton gestation and history of ≥2 prior CDs were included in this analysis. Women who had indications for urgent CD (e.g., cord prolapse) or suspected placenta accreta were excluded. Maternal and neonatal outcomes of women with 2, 3 and ≥4 prior CDs were compared by skin-incision type (transverse vs. vertical) using univariable and multivariable analyses. Results5007 women met the inclusion criteria. In univariable analysis, women with 2 prior CDs who had a vertical skin incision had shorter incision-to-delivery intervals (12.9min vs. 14.1min, p<0.001) but also higher rates of endometritis and composite adverse maternal outcomes (4.9% vs. 2.7%, p=0.001, 16.1% vs. 13.4%, p=0.026, respectively). Women with 3 prior CDs also had higher rates of composite adverse maternal outcomes (21.2% vs. 15.8%, p=0.042). In women with ≥4 prior CDs, prolonged hospitalization, composite adverse maternal outcomes, NICU admission and composite adverse neonatal outcomes also were higher with vertical skin incision (23.2% vs. 9.3%, p=0.005, 32.9% vs. 13.7%, p=0.001, 32.1% vs.19.6%, p=0.045, 32.9% vs.19.4%, p=0.024, respectively). In multivariable analyses, vertical skin incision remained associated with prolonged hospitalization and composite adverse maternal outcome among women with ≥4 prior CDs (aOR 3.40, CI 1.11–10.38, aOR=2.37, CI 1.02–5.55, respectively). ConclusionVertical skin incision at the time of multiple repeat CD was not associated with better obstetric or perinatal outcomes and was associated among women with ≥4 prior CDs with a higher frequency of prolonged hospitalization and adverse maternal outcomes.

Antibiotic prophylaxis for term or near-term premature rupture of membranes: metaanalysis of randomized trials

The objective of the study was to evaluate the efficacy of antibiotic prophylaxis in women with term or near-term premature rupture of membranes. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, EMBASE, ScienceDirect.com, MEDSCAPE, and the Cochrane Central Register of Controlled Trials with the use of a combination of key words and text words related to antibiotics, premature rupture of membranes, term, and trials from inception of each database to September 2014. We included all randomized trials of singleton gestations with premature rupture of membranes at 36 weeks or more, who were randomized to antibiotic prophylaxis or control (either placebo or no treatment). The primary outcomes included maternal chorioamnionitis and neonatal sepsis. A subgroup analysis on studies with latency more than 12 hours was planned. Before data extraction, the review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42014013928). The metaanalysis was performed following the Preferred Reporting Item for Systematic Reviews and Meta-analyses statement. Women who received antibiotics had the same rate of chorioamnionitis (2.7% vs 3.7%; relative risk [RR], 0.73, 95% confidence interval [CI], 0.48-1.12), endometritis (0.4% vs 0.9%; RR, 0.44, 95% CI, 0.18-1.10), maternal infection (3.1% vs 4.6%; RR, 0.48, 95% CI, 0.19-1.21), and neonatal sepsis (1.0% vs 1.4%; RR, 0.69, 95% CI, 0.34-1.39). In the planned subgroup analysis, women with latency longer than 12 hours, who received antibiotics, had a lower rate of chorioamnionitis (2.9% vs 6.1%; RR, 0.49, 95% CI, 0.27-0.91) and endometritis (0% vs 2.2%; RR, 0.12, 95% CI, 0.02-0.62) compared with the control group. Antibiotic prophylaxis for term or near-term premature rupture of membranes is not associated with any benefits in either maternal or neonatal outcomes. In women with latency longer than 12 hours, prophylactic antibiotics are associated with significantly lower rates of chorioamnionitis by 51% and endometritis by 88%.

Antibiotic regimens for management of intra-amniotic infection.

Antibiotic regimens for management of intra-amniotic infection.

Blunt versus sharp uterine incision expansion during low transverse cesarean delivery: a metaanalysis

We sought to review and update available evidence regarding outcomes after cesarean delivery (CD) using blunt vs sharp expansion of the uterine incision. We queried the database of PubMed (US National Library of Medicine, 1946 through December 2013), the Cochrane Library Database of Systematic Reviews, ClinicalTrials.gov, and Web of Science. All relevant bibliographies were reviewed. Randomized controlled trials comparing blunt with sharp expansion of the lower segment during CD were evaluated for inclusion and methodological quality. The primary outcome was occurrence of unintended extensions. Secondary outcomes were drop in hematocrit or hemoglobin and estimated maternal blood loss, need for transfusion, operative time, use of uterotonics, rate of endometritis, and neonatal outcomes. Data extraction, analysis, and results were based on the preferred reporting items for systematic review and metaanalysis guidelines. Six randomized controlled trials (2908 patients) were included. Blunt expansion technique was associated with lower drop in postoperative hematocrit (weighted mean difference [WMD], -1.07%; P = .05) and hemoglobin (WMD, -0.64 g/dL; P < .05), lower rate of unintended extensions (pooled relative risk, 0.47; P < .05), and a shorter operative time (WMD, -2 minutes; P < .05). Lower estimated blood loss was also observed but the difference was not significant (WMD, -88.07 mL; P > .05). There were no differences in the rates of blood transfusion, endometritis, use of uterotonics, and neonatal outcomes between both techniques. Blunt expansion of uterine incision during CD is associated with less unintended extensions and favorable maternal outcomes. Although the drop in hemoglobin, hematocrit, and operative times were in favor of blunt expansion, the degree of reduction may not be clinically relevant.

Second-stage vs first-stage caesarean delivery: Comparison of maternal and perinatal outcomes

In this observational study, we investigated the maternal and perinatal complications of caesarean delivery performed in the second stage compared with the first stage of labour at a tertiary hospital in İstanbul. This study was performed from June 2008 to July 2011. Primary maternal outcomes measured included intraoperative surgical complications, surgery duration, need for blood transfusion, endometritis, requirement for hysterectomy, unintended extension and length of hospital stay. Neonatal outcomes included a 5 min Apgar score ≤ 3, admission to a neonatal intensive care unit, fetal injury, septicaemia and neonatal death. In total, 3,817 caesarean deliveries were available for analysis; 3,519 were performed in the first stage, and 298 in the second stage. Caesarean deliveries performed in the second stage were associated with increased intraoperative complications, unintended extensions, need for blood transfusion, higher rates of endometritis and requirement for hysterectomy and were, therefore, associated with longer operation time and hospital stay. Neonatal complications included a significantly low Apgar score at 5 min, increased neonatal death, admission to the neonatal intensive care unit, septicaemia and fetal injury (all p < 0.05). Caesarean deliveries performed in the second stage of labour were associated with higher rates of maternal and neonatal complications, particularly in women who had undergone previous caesarean delivery.

The Association between Endometriosis and Chronic Endometritis

ObjectiveTo evaluate the association between endometriosis and chronic endometritis.MethodsEndometrial specimens were obtained from 71 patients, 34 with endometriosis (endometriosis group) and 37 without endometriosis (non-endometriosis group), who underwent hysterectomy, and the specimens were immunostained for the plasmacyte marker CD138. The rate of chronic endometritis was compared between the endometriosis group and the non-endometriosis group. Furthermore, the 71 patients were also divided into two groups, 28 with chronic endometritis (chronic endometritis group) and 43 without chronic endometritis (non-chronic endometritis group). Logistic regression analysis was performed with variables including age, body mass index (BMI), gravidity and parity, and diagnoses of leiomyoma, adenomyosis, and endometriosis on pathology to examine the independent effect of each variable on chronic endometritis. Patients suffering from cervical invasive carcinoma, endometrial carcinoma, and endometrial polyps or treated with gonadotropin-releasing hormone agonists, progestins, or oral contraceptives before surgery were excluded.ResultsChronic endometritis was identified in 52.94% of the endometriosis group and 27.02% of the non-endometriosis group (p<0.05). Logistic regression analysis revealed that endometriosis was associated with chronic endometritis.ConclusionsThis result suggests a strong association between endometriosis and chronic endometritis.

Estrategia multimodal en la disminución de las endometritis puerperales de parto vaginal

Las infecciones intrahospitalarias suelen ser elevadas cuando no se tiene un control adecuado de los múltiples factores que participan en su presentación. Durante el año 2010 y parte del 2011, la tasa de endometritis puerperales en el parto vaginal llegó a triplicar los estándares nacionales, por lo cual diseñamos una intervención que constó de aplicar la estrategia multimodal de lavado de manos de la Organización Mundial de la Salud (OMS), que consiste en 1) cambio de sistema, 2) educación y entrenamiento, 3) retroalimentación, 4) recordatorios y 5) clima organizacional. Objetivos: Disminuir las tasas de endometritis puerperales en partos vaginales. Diseño: Cuasi experimental, prospectivo y longitudinal. Institución: Hospital Nacional Docente Madre Niño San Bartolomé, Lima, Perú. Participantes: Médicos asistentes, residentes, internos que rotaban en sala de partos. Intervenciones: Intervención en base a la Estrategia Multimodal de lavado de manos de la OMS. Principales medidas de resultados: Tasas de endometritis puerperal. Resultados: Las endometritis puerperales empezaron a disminuir de 1,1% entre 2010 y 2011 a 0,7% 2011 a 2012, y esta última cifra se ha mantenido casi constante por más de cinco meses. El uso de alcohol gel varió de 40 mL por mes a 750 mL por mes. Conclusiones: Con la intervención Estrategia Multimodal de lavado de manos de la OMS se obtuvo disminución de las endometritis puerperales en partos vaginales. Palabras clave: Infecciones intrahospitalarias, endometritis puerperal, parto vaginal, lavado de manos.

Endometritis in Simmental cows: incidence, causes, and therapy options

The objectives of this study were to evaluate endometritis incidence and possible causes, and to assess the different therapy options. From a total of 1300 cows, endometritis was diagnosed in 23.07%, with clinical endometritis in 15.31% and subclinical endometritis in 7.77%. Previous dystocia resulted in 40.59% of the clinical endometritis and 47.52% of the subclinical endometritis (P < 0.05). Placental retention caused clinical and subclinical endometritis in 43.18% and 37.50% of the cows, respectively (P < 0.05). Body condition score 2 resulted in the highest endometritis rate and body condition score 3-4 resulted in the lowest endometritis rate (P < 0.05). Corpus luteum was found in 9.67% of the cows suffering from endometritis, while the rest developed various types of subfertility (P < 0.05). Three groups of cows (A, B, and C) with an almost equal number of clinical and subclinical endometritis diagnoses were formed. All of the groups received prostaglandin analogues (PGF Veyx Forte®, Veyx Pharma) intramuscularly 3 times at 11 day intervals. In group A, only prostaglandins were used; in group B, cephapirin (Metricure®, Intervet Schering-Plough) was administered into the corpus uteri simultaneously with the first 2 doses of prostaglandins; and in group C, the first 2 doses of prostaglandins were followed by the ozone product Riger Spray (Novagen, Italy) applied into the uterus. The criteria applied for the therapy success were the number of cows conceived after the first artificial insemination and the number of days open. The best therapy results were achieved in groups C and B (P < 0.05), with the advantage of no milk and meat withdrawing period in the animals of group C.

558: Cannabidiol enhances placental permeability to xenobiotics throughout direct inhibition of breast cancer resistance protein in the human placental barrier

Bakri balloon. There were no differences between the Bakri and nonBakri groups in maternal age, BMI, parity, plurality, gestational age at delivery, insurance, or comorbidities such as prior cesarean section, hypertension, diabeties or asthma. There were no differences in duration of rupture of membranes, GBS status or intrapartum antibiotics. The Bakri group had more cesarean deliveries and a higher rate of chorioaminoitis (see table). During management of the post-partum hemorrhage, the estimated blood loss, rate of blood transfusion, number of strategies used, length of stay and ICU admissions were higher in the Bakri group (see table). The rate of post-partum endometritis was significantly higher in the Bakri group compared to the non-Bakri group (OR 19.1 CI 5.9, 62.6), as was the rate of maternal sepsis (OR 63.5 CI 5.3, 753.5). On multivariable analysis, use of a Bakri balloon in the management of post-partum hemorrhage remained independently associated with endometritis after controlling for chorioaminoitis, mode of delivery, estimated blood loss, blood transfusion, and number of strategies used. CONCLUSION: Despite the routine use of prophylactic antibiotics, we have demonstrated a significantly increased rate of endometritis with the use of Bakri balloon for postpartum hemorrhage. While this is usually well-tolerated in otherwise healthy women, caution should be exercised in women for whom an infectious complication would lead to significant morbidity and mortality. 558 Cannabidiol enhances placental permeability to xenobiotics throughout direct inhibition of breast cancer resistance protein in the human placental barrier Valeria Feinshtein, Zvi Ben-Zvi, Offer Erez, Tamar Eshkoli, Eyal Sheiner, Gershon Holcberg Ben-Gurion University of the Negev, Pharmacology, Beer-Sheva, Israel, Soroka University Medical Center, Obstetrics and Gynecology, Beer-Sheva, Israel OBJECTIVE: Illicit drugs affect pregnancy outcome, however, the mechanisms in which cannabis exert its effect is not well understood. The aims of our study are to examine the effect of acute exposure (1-2 hours) to cannabidiol (CBD) on human placental Breast Cancer Resistance Protein (BCRP) function in in-vitro and ex-vivo models. STUDY DESIGN: CBD impact on BCRP in BeWo and Jar cells was tested with Mitoxantrone (MX) (BCRP substrate) uptake assay, using Nicardipine (BCRP inhibitor) as a positive control. CBD impact on BCRP function in human placenta was examined by testing Glyburide transport (known BCRP substrate) across term, normal, human cotyledon that was dually perfused for 2 hours, with [CBD group, n 5] or without [control group, n 5] CBD. Glyburide was introduced to maternal (M) and fetal (F) compartments, and F/M ratio of its concentrations was calculated. RESULTS: CBD inhibition of BCRP-dependent MX efflux (measured by elevation of intracellular MX) is concentration dependent in both cell lines; it effect is stronger than that of Nicardipine. [BeWo cells CBD 10 M-25%; CBD 25 M-125%; and Nicardipine 53% (p 0.001); Jar cells CBD 10 M-22%; CBD 25 M-96%; and Nicardipine 65% (p 0.001)]. Similarly, in the perfused term cotyledons, F/M ratios of Glyburide concentrations at 90 and 120min. are significantly higher (by 45%) in the presence of CBD (0.85 in control group vs 1.23 in CBD group) (Figure). CONCLUSION: BCRP is inhibited by acute exposure to CBD in the human placental barrier in in-vitro and ex-vivo models. These findings suggest that marijuana consumption affects the defense mechanisms of the human placenta against xenobiotics. This effect could jeopardize fetal wellbeing, and the safety of drugs that are BCRP substrates (i.e. glyburide, folic acid) which are used in pregnant women, is questionable during cannabis consumption.

Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta‐analysis

BackgroundProphylactic antibiotics reduce infectious morbidity from caesarean section. The timing of their administration, however, is a matter of controversy.ObjectivesTo examine maternal and neonatal infectious morbidity in women receiving preoperative prophylaxis compared with those receiving intraoperative administration.Search strategyMedline, Embase, Current Controlled Trials and Cochrane Central were searched from their inception dates to December 2011.Selection criteriaRandomised controlled trials of a single dose of any antibiotic comparing preoperative with intraoperative administration were selected.Data collection and analysisTrial characteristics, outcomes and quality measures, based on the Cochrane tool for risk of bias, were independently extracted. The random effect model of DerSimonian and Laird to estimate relative risks (RRs) for maternal and neonatal outcomes was used.Main resultsSix trials met the inclusion criteria, reporting on 2313 women and 2345 newborns. Preoperative administration was associated with a significant 41% reduction in the rate of endometritis compared with intraoperative administration (RR 0.59; 95% confidence interval [95% CI] 0.37–0.94; I2 0%). In the preoperative group, there were nonsignificant reductions in the rates of wound infection (RR 0.71; 95% CI 0.44–1.14; I2 0%), maternal febrile morbidity (RR 0.94; 95% CI 0.46–1.95; I2 0%), neonatal sepsis (RR 0.81; 95% CI 0.47–1.41; I2 0%), neonatal septic work-up (RR 0.93; 95% CI 0.71–1.21; I2 0%) and neonatal intensive-care unit admission (RR 0.92; 95% CI 0.65–1.28; I2 0%). There were nonsignificant increases in the rates of maternal pyelonephritis (RR 1.09; 95% CI 0.49–2.43; I2 0%) and neonatal pneumonia (RR 3.36; 95% CI 0.55–20.47; I2 0%).ConclusionsCompared with intraoperative administration, preoperative antibiotics significantly reduce the rate of endometritis. The lack of neonatal adverse effects should be cautiously interpreted given the limited power of the trials to detect such effects.

Does vaginal preparation with povidone–iodine prior to caesarean delivery reduce the risk of endometritis? A randomized controlled trial

Objective: The purpose of the present study was to determine whether the vaginal preparation with povidone–iodine prior to caesarean delivery decreased the incidence of postpartum endometritis. Methods: The present study was a prospective randomized controlled trial in which subjects received a vaginal preparation with povidone–iodine solution immediately prior to caesarean delivery or received no vaginal preparation. The primary outcome measure was the rate of postpartum endometritis. Results: A significant decrease in post-caesarean endometritis was noted in the group that received the povidone–iodine vaginal preparation (n = 334) compared with the control group (n = 336) [6.9 vs. 11.6%; RR = 1.69; 95% CI = 1.03–2.76]. No statistically significant differences in the incidence of endometritis were noted between the experimental and control groups among women who were not in labor at the time of the caesarean delivery [9.2 vs. 8.6%; RR = 1.05; 95% CI = 0.58–1.90], and no differences were found between groups when women with ruptured membranes were excluded from the analysis [9.6 vs. 6.7%; RR = 1.39; 95% CI = 0.78–2.47]. Conclusions: Vaginal preparation with povidone–iodine solution immediately prior to a caesarean delivery reduces the risk of post-operative endometritis. This preemptive measure was only found to be beneficial in women whose membranes had ruptured and those who were in labor prior to caesarean surgery.

Elective repeat cesarean delivery compared with spontaneous trial of labor after a prior cesarean delivery: a propensity score analysis

The purpose of this study was to determine outcomes, after the use of propensity score techniques, to create balanced groups according to whether a woman undergoes elective repeat cesarean delivery (ERCD) or trial of labor (TOL). Women who were eligible for a TOL with 1 previous low transverse incision were categorized according to whether they underwent an ERCD or TOL. A propensity score technique was used to develop ERCD and TOL groups with comparable baseline characteristics. Outcomes were assessed with conditional logistic regression. The rates of endometritis, operative injury, respiratory distress syndrome, and newborn infant infection were lower and the rates of hysterectomy and wound complication were higher in the ERCD group. Propensity score techniques can be used to generate comparable ERCD and TOL groups. Some types of maternal morbidity (such as hysterectomy) are higher; other types (such as operative injury) are lower in the ERCD group. Although the absolute risk is low, neonatal morbidity appears to be lower in the ERCD group.

Remote prognosis after primary cesarean delivery: the association of VBACs and recurrent cesarean deliveries with maternal morbidity.

PurposeTo determine the effects of vaginal birth after cesarean (VBAC) versus repeated cesarean sections (RCS) after a primary cesarean section (CS), on the rate of intraoperative and postpartum maternal morbidity.Patients and methodsThis is a retrospective population-based cohort study. During the study period (1988–2005) there were 200,012 deliveries by 76,985 women at our medical center; 16,365 of them had a primary CS, of which 7429 women delivered a singleton infant after the primary CS, met the inclusion criteria, were included in our study, and were followed for four consecutive deliveries. Patients were divided into three study groups according to the outcome of their consecutive delivery after the primary CS: VBAC (n = 3622), elective CS (n = 1910), or an urgent CS (n = 1897). Survival analysis models were used to investigate the effect of the urgency of CS and the numbers of pregnancy predating the primary CS on peripartum complications.ResultsWomen who failed a trial of labor had a higher rate of uterine rupture than those who had a VBAC. Patients who delivered by CS had a higher rate of endometritis than those giving birth vaginally. The rate of cesarean hysterectomy and transfer to other departments increased significantly at the fourth consecutive surgery (P = 0.02 and P = 0.003, respectively). VBAC was associated with a 55% reduction in the risk of intrapartum complications in comparison to a planned CS (hazard ratio [HR] 0.45; 95% confidence interval [CI]: 0.22–0.89. A greater maternal parity at the time of primary CS was associated with lower intrapartum and postpartum morbidities (HR 0.44; 95% CI: 0.24–0.79; HR 0.54; 95% CI: 0.47–0.62, respectively).Conclusions(1) A successful VBAC is associated with a reduction in the intrapartum complications; and (2) maternal morbidity increases substantially from the fourth consecutive cesarean delivery.

Comparison of uterine exteriorization and in situ repair during cesarean sections

To compare the peri- and postoperative complication rates of two cesarean delivery techniques. Medical records from 1,087 patients who had a cesarean delivery with regional anesthesia between 2008 and 2010 were reviewed retrospectively. Seven hundred and thirty-two patients had an in situ uterine repair, and 355 patients had an exterior uterine repair. Patients who had chorioamnionitis, preeclampsia, a bleeding disorder, or abnormal placentation were excluded from the study. The following outcomes were compared between the two groups: mean operative time, intraoperative blood loss, perioperative nausea, tachycardia, hypotension, hemoglobin level, hematocrit level, the time to the first recognized bowel movement, postoperative analgesic dose, nausea, length of hospital stay, surgical site infection rate and endometritis rate. No clinically significant differences were found between the exteriorization and in situ uterine repair groups for mean hematocrit differences, intraoperative blood loss, perioperative nausea, tachycardia, hypotension and postoperative analgesic doses. However, the mean operative time, time to the first recognized bowel movement, surgical site infection rate and length of hospital stay were significantly lower in the in situ repair group (p < 0.05). Although the techniques are similar in most scenarios, in situ uterine repair during cesarean sections appears to be more advantageous than exteriorization with respect to the mean operative time, time to the first recognized bowel movement, surgical site infection rate and length of hospital stay.

The effect of time of day on outcome of unscheduled cesarean deliveries

Objective. To assess the association between time of day and characteristics and complications rate of cesarean sections.Methods. We conducted a retrospective cohort study of all women who underwent an unscheduled (non-elective) cesarean section (CS) between 1997 and 2007 in a single tertiary medical center. Maternal and neonatal outcome and duration of CS were analyzed according to the work shift. Multivariable logistic regression analysis was used to determine whether shift number is an independent risk factor for maternal or neonatal adverse outcome.Results. There were overall 9944 unscheduled CS during the study period, of them 2995 (30.1%) were operated on the morning shift, 4618 (46.4%) on the evening shift, and 2331 (23.5%) on the night shift. The characteristics of the women in each of the shifts were overall similar. Women who underwent CS during night shift had a higher rate of endometritis and wound infection, postpartum hemorrhage requiring hemotransfusion, and prolonged postoperative hospitalization. The rate of adverse neonatal outcome was similar in the three working shifts. After adjustment for potential confounders by multivariable logistic regression analysis, maternal morbidity was significantly higher for women operated on night shift. The risk of neonatal morbidity was unrelated to the working shift. Overall duration of CS, time required for induction of anesthesia, and net operation time were all significantly higher during the night shift compared with the morning and evening shift.Conclusion. CSs performed during night shift are associated with longer operative time and an increased risk for maternal, but not neonatal, morbidity.

Factors Associated With Cesarean Delivery in Nulliparous Women With Type 1 Diabetes

To identify factors associated with cesarean delivery in nulliparous women with type 1 diabetes mellitus. We performed a nested case-control study within a cohort of nulliparous women with type 1 diabetes mellitus. Independent factors and odds ratios were identified by logistic regression. Among 209 women, a cesarean delivery was performed without labor in 94 women (45%). Gestational weight gain higher than 15 kg (39% compared with 23%; odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.5) and suspected macrosomia (79% compared with 21%; OR, 13.1; 95% CI, 5.3-32.2) were independently associated with cesarean delivery without labor. Among 115 women who underwent a trial of labor, 54 (47%) had a cesarean delivery. Prepregnancy body mass index more than 25 kg/m2 (84% compared with 39%; OR, 7.5; 95% CI, 1.9-29.4) and Bishop score 3 or lower (66% compared with 25%; OR, 5.9; 95% CI, 2.2-16.1) were independently associated with cesarean delivery in labor. Preconception care, presence of a nephropathy, hemoglobin A1C levels during pregnancy, preeclampsia, and preterm delivery were not associated with cesarean delivery. The rates of wound infection and endometritis were 0.7% and 3%, respectively. The rate of cesarean delivery in nulliparous women with type 1 diabetes mellitus is very high. Prepregnancy body weight, gestational weight gain, and accuracy of the prediction of fetal macrosomia are potentially modifiable risk factors for cesarean delivery.