Lower Segment Caesarean Section Research Articles

CHALLENGES IN THE ANESTHETIC MANAGEMENT OF PERIPARTUM CARDIOMYOPATHY UNDERGOING EMERGENCY CESEREAN SECTION

Peripartum cardiomyopathy (PPCM) is an unusual form of dilated cardiomyopathy which manifests as acute heart failure in the last trimester of pregnancy or early postpartum period. Choice of anaesthesia is based on the urgency of lower segment caesarean section and severity of PPCM. Here we report a 31year old female G3P2L2 36weeks + 2days diagnosed as Peripartum Cardiomyopathy came with complaints of leaking per vagina was taken up for emergency caesarean section under general anaesthesia.In this case report,we discuss the anaesthetic management of a case of PPCM posted for emergency caesarean section with intra-operative event of desaturation. Anaesthetic management was directed towards optimization of desaturation,myocardial contractility,preload and after load.No adverse events or complications were observed.

Evaluation of the Effect of Intravenous Dexamethasone on the Duration of Spinal Anaesthesia in Parturients Undergoing Lower Segment Caesarean Section.

Introduction Dexamethasone is shown to prolong the duration of nerve blocks when administered perineurally as well as intravenously. The effect of intravenous dexamethasone on the duration of hyperbaric bupivacaine spinal anesthesia is lesser known. We conducted a randomized control trial to determine the effect of intravenous dexamethasone on the duration of spinal anesthesia in parturients undergoing lower-segment cesarean section (LSCS). Methods Eighty parturients planned for LSCS under spinal anesthesia were randomly allocated to two groups. Patients in group A were administered dexamethasone intravenously, and group B received normal saline intravenously before spinal anesthesia. The primary objective was to determine the effect of intravenous dexamethasone on the duration of sensory and motor block after spinal anesthesia. The secondary objective was to determine the duration of analgesia and complications in both groups. Result The total duration of the sensory and motor blocks in group A was 118.38 ± 19.88 minutes and 95.63 ± 19.91 minutes, respectively. The entire sensory and motor blockade duration in group B was 116.88 ± 13.48 minutes and 97.63 ± 15.15 minutes, respectively. The difference between the groups was found to be statistically insignificant. Conclusion Intravenous 8 mg dexamethasone in patients planned for LSCS under hyperbaric spinal anesthesia does not prolong the sensory or motor block duration compared to placebo.

Management of Intra Uterine Growth Restriction with Month wise Ksheera Kashaya

Intrauterine Growth Restriction (IUGR) is a main health condition affecting pregnant women and its outcomes are perinatal mortality and morbidity. In the prevailing case a 38 year-old Multi gravida who undergone regular ante natal check-up was detected with Intrauterine Growth restriction at 21 weeks of gestation. The estimated weight of the foetus was found less than 19 percentile and there has been oligohydramnios, pleural effusion and increased pericardial fluid to the foetus on additional evaluation. She was given allopathic control initially; however, the circumstance remains unchanged. She turned into Ayurveda and was handled with the treatment principles of Garbhasosha (foetal emaciation). She was managed by month wise medicated Ksheera kashaya (milk decoction) for Brimhana (nourishing) and pacifying Vata. She delivered a full term healthy female baby of weight 2.57kg through a Lower Segment Caesarean Section. The prognosis by the allopathic system was poor in this case and there are no interventions in their system to improve placental perfusion. In this case the condition was achieved through month wise treatment and specification of Ayurvedic formulations. Completed in a brief span of time, thereby stopping the want for early delivery and the persisted until 39 weeks of gestation. Being a term delivery, the need for neonatal extensive care was no longer arising. The cutting-edge method shows that Ayurveda is tremendously powerful in intra uterine growth restriction and its complications. This case opens the scope for additional studies within the region of Intrauterine Growth Restriction with Ayurvedic drug treatments.

EFFECTS OF DEXAMETHASONE AS AN ADJUVANT TO ROPIVACAINE ON DURATION AND QUALITY OF POST-OPERATIVE ANALGESIA IN ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK IN PATIENTS UNDERGOING LOWER-SEGMENT CESAREAN SECTION

Aim: The aim of this study was to measure the effect of adding dexamethasone to ropivacaine on the duration and quality of post-operative analgesia in patients undergoing lower-segment caesarean section (LSCS) who are receiving ultrasound-guided transverse abdominal plane (TAP) blocks. Methods: An interventional, prospective, randomized, and double-blind trial was conducted at a hospital. Before beginning the investigation, the Institutional Ethics Committee permission was acquired. The patient characteristics were analyzed using the Students t-test for continuous variables and the Chi-square test for categorical variables. A total of 60 patients were randomly split into two groups of 30 each. Results: Time to first rescue analgesia was significantly shorter in Group R (11.62±3.80 h) than the Group D (19.04±4.20 h) (p<0.001). The total tramadol requirement in post-operative period was significantly higher in Group R (86.67±30.55 mg) than the Group D (35.56±39.54 mg) (p<0.001). Conclusion: The use of dexamethasone along with 0.1% ropivacaine prolongs the analgesic duration of TAP block in patients undergoing LSCS.

A Case of Jehovah's Witness for Emergency Lower Segment Caesarean Section with Global Left Ventricular Hypokinesia

A Case of Jehovah's Witness for Emergency Lower Segment Caesarean Section with Global Left Ventricular Hypokinesia

An analytical study on increasing number of cesarean section in a tertiary care hospital

Background: One of the most common surgeries performed worldwide is cesarean section (CS). The World Health Organization has identified an ideal CS rate for a nation of around 10–15%. In recent times, the proportion of delivery conducted by CS has increased. However, it can lead to significant increase in maternal and infant morbidity and mortality. Aims and Objectives: This study aims to analyze determine rate of CS and factors that lead to increased number of CS in a tertiary care hospital. Materials and Methods: This analytical prospective study has been carried out on pregnant women undergoing CS in Calcutta National Medical College and Hospital from March 2019 to February 2020. Total 1000 cases undergoing emergency CS during study period were included in the study. Template was generated and analysis was done on SPSS software. Results: In this study, lower segment CS (LSCS) rate is highest in age group of 20–25 years (47.2%), followed by <19 years age group (24%) and lowest LSCS rates seen in >35 years age group. Relationship between parity and LSCS rate is also considered in the present study. Primipara contributes around 76% LSCS rate, where multipara shows only 24% of total LSCS in this study. In respect to total number of LSCS in this study, Robson Group 2B is maximum contributor (37.4%), followed by 2A (14.4%), 4B (13.2%), and Group 6 (7.6%). Conclusion: The LSCS rate in the present study is far higher than standards which are statistically significant also. Hence, it is mandatory to assess risk and benefit ratio of mother and fetus before taking any measure to reduce LSCS rate.

A TRIAL TO INVESTIGATE THE CORRELATION BETWEEN THE SPINAL COLUMN LENGTH AND ABDOMINAL GIRTH, AND THE LEVEL OF SENSORY BLOCKADE IN SUBARACHNOID BLOCK IN PARTURIENTS REQUIRING SPINAL ANAESTHESIA FOR LOWER SEGMENT CAESAREAN SECTION.

Introduction Spinal anaesthesia (SA) is a type of regional anaesthesia which obstructs nerve roots coursing through the subarachnoid space. It is a reliable technique that has become a preferred technique in lower segment caesarean section. Sensory blocking up to T4 dermatome level is required during Caesarean section, as this not only suppresses somatic sensations but also removes visceral discomfort caused by peritoneum manipulation. However, because of this, the nal extent of anesthesia remains unpredictable which may cause inadequate local anaesthesia or excessive block which may increase hemodynamic instability and be hazardous to the patients. Hence, predicting and controlling the spread of local anaesthesia in the cerebrospinal uid is crucial which can be achieved by studying the factors that inuence the extent of spinal anaesthesia. Such factors include the patient's general features, the characteristics of the injected solution, the clinical technique used and so on. The current study was undertaken to investigate the correlation between patient's general features such as the spinal column length and abdominal girth, and the level of sensory blockade in subarachnoid block for a given amount of local anaesthetic. The current prospective study cohort includes 100 parturients who rece Methods ived 2mL of 0.5% hyperbaric bupivacaine for subarachnoid block. Height, weight, spinal column length, and abdominal girth were measured and recorded. Sensory level of blockade achieved was noted at 3 minutes and 25 minutes. The data was recorded in Microsoft excel and the analysis was done using SPSS version 20. Results Analysis indicated a negative association between abdominal girth and thoracic dermatome levels at 3 minutes (r-value=-0.042) and this association was found statistically insignicant (p-value=0.410>0.05). Similarly, at 25 minutes, there was a negative association between abdominal girth and thoracic dermatome levels (r-value=-0.201), however, this association was statistically signicant (p-value=0.017<0.05). The spinal column length and thoracic dermatome levels showed negative association that was statistically insignicant at both the 3 (r-value=- 0.409, p-value = 0.673>0.05) and 25-minute (r-value=-0.148, p-value=0.530>0.05) time points. From o Conclusion ur study we concluded that spinal column length was not a contributing factor to the level of blockade either at the onset of blockade or the nal spread. However, abdominal girth did have an inuence on the level of blockade. In order to conrm these results and reach a more satisfactory conclusion, studies in larger population need to be conducted.

Preoperative Diagnostic Dilemma of Diaphragmatic Eventration

Background: Diaphragmatic eventration is an abnormal elevation of the dome of the diaphragm into the thoracic cavity. Neonatal respiratory distress is the most common clinical presentation of diaphragmatic eventration. Direct abdominal organ compression on the lung or lung hypoplasia is the cause of this symptom. Preoperative radiological imaging is important to diagnose diaphragmatic eventration. Chest radiographs, ultrasound, CT scans and MRI can be used to evaluate the anatomy of the diaphragm. In complicated condition, video-assisted thoracoscopy (VATS) play a role as a diagnostic and therapeutic tool to diagnose and manage diaphragmatic eventration. Case presentation: We presented a case of a full-term unfortunate baby delivered via emergency lower segment caesarean section due to bleeding of the placenta previa type III. Immediately post-delivery, the patient had respiratory distress with an episode of desaturation. CT scan showed a focal right hemi-diaphragmatic bulge with liver tissue within. Video-assisted thoracoscopy (VATS) was performed and the diagnosis of right diaphragmatic eventration had been established. Diaphragmatic plication was done via a VATS-assisted thoracotomy approach. Conclusion: Video-assisted thoracoscopy (VATS) plays a role as a diagnostic tool and even as a therapeutic tool to diagnose and manage diaphragmatic eventration. The capability of VATS to provide direct visualization intrathoracically has a great advantage in managing a such case.

Impact of Umbilical Cord Milking and Delayed Cord Clamping on Hematological Parameters in Term Neonates: A Case Control Study

Introduction Placental transfusion is additional volume of blood transferred to the baby during birth. A newborn who receives placental transfusion at birth obtains 30% more blood volume than the newborn whose cord is cut immediately. Receiving an adequate blood volume from placental transfusion at birth may be protective for the distressed neonates. It provides sufficient iron reserves for the first 3 to 6 months of life there by preventing or delaying iron deficiency anemia until the use of iron fortified food is implemented. There are 2 ways of placental transfusion, they are delayed cord clamping and umbilical cord milking. Delayed cord clamping (defined as clamping till cessation of pulsations or up to 60-180 s) leads to improvement in levels of hemoglobin and hematocrit at 6 weeks of age. However, universal application is limited due to concerns for the risk of hypothermia, and delay in initiation of resuscitation if required. Umbilical cord milking involves milking the entire contents of the umbilical cord towards the baby with in 20 s. Umbilical cord milking can be used in deliveries where delayed cord clamping is not feasible. Objective Comparison of hematological parameters (cord hemoglobin at birth, hemoglobin, hematocrit, and bilirubin levels in term neonates at 48 h with umbilical cord milking and delayed cord clamping). Methods and Analysis In this study all the term neonates delivered by vaginal delivery and lower segment caesarean section born to nonanemic mothers were considered eligible. All newborns with no risk factors underwent delayed cord clamping (n = 148) and those term neonates in whom delayed cord clamping was not feasible and/or currently WHO guidelines recommend for immediate cord clamping were allocated for umbilical cord milking (n = 121). Cord hemoglobin at birth, hemoglobin, hematocrit, and bilirubin (direct and indirect) were sent at 48 h. These parameters were compared between 2 groups. Results At birth cord hemoglobin was 15.36 and 15.46 (mean difference = 0.1) in DCC and UCM, respectively. At 48 hours, mean hemoglobin was 18.73 and 18.95 (mean difference = 0.22, P = .3591). Mean hematocrit was 52.22 and 53.28 (mean difference = 1.06, P = .0989), and mean total bilirubin levels was 11.24 and 10.56 (mean difference = 0.69, P = .466). Conclusion There were no statistically significant differences in the hematological parameters in full term neonates at 48 h, between delayed cord clamping and umbilical cord milking groups.

Interventions required and outcome in pregnancy induced hypertension patients in Intensive Care Unit: An observational study

Hypertensive disorders of pregnancy, particularly preeclampsia, eclampsia remain one of the leading causes of maternal morbidity and mortality worldwide. We studied the association between the risk factors, interventions required, diagnosis and outcome in these patients admitted to the Intensive Care Unit (ICU).: We conducted a prospective, observational study after the Institutional Scientific and Ethics committee approval. The Institutional record was taken to identify 70 women with Pregnancy Induced Hypertension (PIH) admitted to ICU after meeting the inclusion and exclusion criteria. Socio-demographic details, indication and timing of ICU admission were noted. On ICU admission; baseline vitals, detailed history, duration of complications, therapeutic interventions, laboratory parameters and imaging were compiled. Maternal outcome was assessed in terms of interventions needed, complications encountered and mortality or discharge and follow up was done up to 6 weeks postpartum. Fetal outcome was assessed in terms of live births or Intrauterine fetal death (IUFD), Apgar score, term/preterm and followed up to 7 postnatal days.: It was observed that out of 70 women enrolled in our study, 48 women were diagnosed with preeclampsia, 54 belonged to the age group of 21-30 years, 61 were unregistered for antenatal checkup, 46 had term gestation, 52 were nulliparous and 64 underwent Lower segment caesarean section (LSCS). 60 of them had postpartum ICU admission, all of them had significant rise in blood pressure. Most common interventions were transfusion of blood products (n=30) and mechanical ventilation (n=6). HELLP syndrome was the most common complication (n=7). Maternal mortality was seen in 6 women. 35 neonates had low birth weight, 6 had intra uterine growth retardation (IUGR), 19 were preterm and Apgar score was significant at 5 minutes.: From our observations, it can be concluded that majority of the women were diagnosed with preeclampsia, were relatively of younger age group, nulliparous with no antenatal checkup, underwent LSCS and were admitted postpartum to ICU. Transfusion of blood products was the most common intervention & HELLP syndrome was most common complication. Maternal mortality was higher in women with preeclampsia although overall mortality was low. The incidence of low birth weight, IUGR and preterm neonates was more in eclamptic women. Neonatal mortality was more in preeclamptic women.

A Study to Assess the Effectiveness of Pre Operative Teaching on Knowledge Regarding Postnatal Care among Mothers Undergoing Elective Lower Segment Cesarean Section (LSCS) at Shri Vinoba Bhave Civil Hospital, Silvassa, Dadra and Nagar Haveli

Knowledge regarding the pregnancy, labor and postnatal care has the positive influence on the mothers, Knowledge about what to expect during the postnatal period is one of the best ways to improve the health of mother and baby and prevent the complications, with a view to this, the study was conducted to assess the effectiveness of pre operative teaching on knowledge regarding postnatal care among mothers undergoing elective cesarean section at Shri Vinoba bhave Civil Hospital, Silvassa. Evaluate the effectiveness of pre operative teaching on postnatal care among mothers undergoing elective lower segment cesarean section. Associate the pre-test level of knowledge regarding postnatal care among mothers undergoing elective lower segment caesarean section with selected socio-demographic variables. Quasi experimental, pre-test-post-test control group research design with non probability, purposive sampling technique was used to selected 60 elective caesarean section mothers falls in inclusion criteria, Interview schedule consist of two section such as Socio-demographic variables, Structured knowledge questionnaire (30 items). Validity and reliability were established. Pre-test was conducted followed by pre operative teaching regarding postnatal care and after 7 days post test was conducted. The data obtained were analysed using descriptive and inferential statistics. Overall the calculated “t” value was (25.76), mean difference was (11.47), p-value was less than 0.05 which shows highly significant. Association was assessed by chi-square which it shows there was significant association between educational status of mother (ꭓ2(5,0.05)=19.084, 0.00185; p<0.05), educational qualification of husband (ꭓ2(6,0.05)=14.186, 0.0276; p<0.05) and religion (ꭓ2(3,0.05)=12.347, 0.0062; p<0.05). Present study shows that pre operative teaching regarding postnatal care among mothers undergoing elective caesarean section was effective method for increasing the knowledge regarding postnatal care.

Effect of Intrathecal Fentanyl on Haemodynamic Changes in Lower Segment Caesarean Section

Effect of Intrathecal Fentanyl on Haemodynamic Changes in Lower Segment Caesarean Section

A Longitudinal Analytical Study on Umbilical Cord Coiling Index as a Predictor of Pregnancy Outcome.

Background The umbilical cord coiling index (UCI) is usually measured sonographically during antenatal follow-up and can be used to determine the fetuses at risk of adverse outcomes. Methodology UCI measured antenatally and postnatally whose correlation is studied along with the association of abnormal UCI with the adverse outcomes in terms of gestational age, intrauterine growth restriction (IUGR), intra-uterine death, birth weight, sex, neonatal intensive care unit (NICU) admission, the color of the liquor, Amniotic Fluid Index (AFI), Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score at one min and five mins and mode of delivery. All parameters are tested for significant differences among UCI and a p-value < 0.05 is considered significant. The correlation of UCI measured antenatally and postnatally is tested using the spearman correlation coefficient. Results A strong correlation is found between antenatal UCI and postnatal UCI with rs 0.9. The majority of the population had normo coiling. Hyper and hypo coiling are associated risks of emergency lower segment cesarean section (LSCS). Low birth weight is seen in 88.89% of hypo coiled patients with a p-value < 0.01. The coiling index among sex is found to be insignificant with a p-value of 0.81. Meconium-Stained Liquor (MSL) is seen in 78.5% of hyper coiled patients. IUGR is found to be associated with hypo coiling as seen in 59.2% of patients with significant p-value (< 0.01). Age, gestational age, and birth weight are found to be statistically significant between various coiling indexes with p-value < 0.05. Conclusion Antenatal UCI correlates with postnatal UCI and any abnormal index found can be used as a predictor of adverse perinatal outcomes and help obstetricians to monitor continuously and put the patients at risk on prophylactic measures.

Comment on 'Hypertension and tachycardia following high spinal anaesthesia during lower segment caesarean section: An unusual presentation'.

Comment on 'Hypertension and tachycardia following high spinal anaesthesia during lower segment caesarean section: An unusual presentation'.

Efficacy of intravenous dexamethasone for post-operative pain relief in elective cesarean section

Background: Various additives have been evaluated for the purpose of enhancing quality of analgesia and prolonging duration of spinal anesthesia. Aims and Objectives: This randomized study was conducted to evaluate the efficacy of intravenous dexamethasone in spinal anesthesia. Materials and Methods: A total of 100 patients scheduled for lower segment cesarean section under spinal anesthesia were randomly allocated into two groups, Group-1 and Group-2, including 50 patients each. All the patients received injection bupivacaine 0.5% heavy 10 mg for spinal anesthesia. Group-1 received injection dexamethasone 8 mg intravenously, and Group-2 received injection normal saline 2 cc immediately after spinal anesthesia. Duration of sensory and motor block, post-operative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia, total analgesic requirement in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded. Results: The mean duration of sensory block (min) in Group-1 and Group-2 was 162.50 and 106.17, respectively. Time to the requirement of first rescue analgesia was 8.67 h in Group-1 and 4.40 h in Group-2. Significant changes seen in VAS score in post-operative period after 1 h of surgery in Group-1 and Group-2. Group-1 had more duration of sensory block, prolonged requirement of first rescue analgesia. Duration of motor block and intra- and post-operative hemodynamic parameters was comparable in both the groups. No side effects were recorded in both the groups. Conclusion: We conclude that administration of dexamethasone 8 mg intravenously prolongs the duration of post-operative analgesia and sensory block in patients undergoing lower segment cesarean section under spinal anesthesia.

Oxytocin induced itching in a 37 week primigravida with meconium stained liquor

Introduction: Oxytocin is the most frequently used medication for labour augmentation in obstetrics. One of the known benefits of its use is the improvement of uterine contractions. An injectable form of oxytocin is administered intravenously as an infusion. Adverse drug reactions at this stage may distress the baby and worsen the outcome of the pregnancy.&#x0D; Case details: A 19-year-old female with a history of nine months gestation presented in labour. She was administered oxytocin infusion in ringer lactate to augment labor. She developed itching all over her body and was immediately administered Inj. hydrocortisone intravenously. As the foetus was in distress, she was taken for an emergency lower segment cesarean section (LSCS).&#x0D; Conclusion: The administration of IV oxytocin was considered the possible cause of the development of rashes in this case. We suggest adopting preventive strategies to avoid ADRs in emergencies to avoid deleterious consequences. The preventive strategies may include screening in the antenatal period for previous history of sensitivity to oxytocin, latex, etc. In addition, other strategies are discussed in this article.

Shiv-mix for perioperative hemodynamic stability and analgesia: A new paradigm for limited resource centres

Dear editor, A very interesting article has been published in your esteemed journal titled “Effect of pre-emptive intravenous paracetamol, magnesium sulfate, and lignocaine on hemodynamic variables during perioperative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia: A prospective randomized study” by Kothari et al., (December 2022|Vol 13|Issue 12). Research is not complete unless it reaches to its potential audience. We, firstly, would like to congratulate the authors and the journal for publishing their research on such a very important topic. Authors have described their findings in a clear and scientific manner. Randomized and double-blinded studies provide inferences which are considered more authentic. Authors in this study used envelop method for allocating patient in the two groups; the intervention and the control. Findings of this study will definitely help readers and practitioners in providing safe and stable anesthesia to their patients. In this prospective randomized study, authors concluded that combination of paracetamol, magnesium sulfate, and lignocaine is effective in attenuating hemodynamic responses to laryngoscopy and intubation. They also found better hemodynamic stability during intraoperative and post-operative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia. Finally, they opined that when paracetamol, magnesium sulfate, and lignocaine are given together effective and prolonged post-operative analgesia can be obtained. Authors discussed efficacy and safety of various medications (Lignocaine, fentanyl, esmolol, and magnesium sulfate) comparing with placebo and different combinations used to attenuate laryngoscopy and intubation response. However, in last paragraph of introduction and in discussion, authors wrote that they could not find any single study using all three drugs (intravenous paracetamol, magnesium sulfate, and lignocaine) simultaneously for attenuation of hemodynamic changes during laryngoscopy and intubation. We would like to draw your kind attention published work that have utilized the same combination with similar effects and this study support the conclusions of those studies. We do agree that these were nor RCTs but case series. Two related articles are discussed here. Khan and Singh in their narrative review described efficacy, safety, and patient satisfaction of various combinations of paracetamol, tramadol, magnesium sulfate, and lignocaine (Shiv-mix 1, 2, and 3). Authors found the described opioid free anesthesia (OFA) regimen (Shiv-mix) very effective in attenuating laryngoscopic and intubation response. In their case series, they also found stable intraoperative hemodynamics and absence of some commonly seen post-operative complications such as PONV and shivering. In another case series by Ansari et al., using similar OFA describing ten cases of laparoscopic cholecystectomy, the authors found that OFA using Shiv-Mix (A combination of paracetamol, tramadol, magnesium sulfate, and lignocaine) infusion preoperatively was a safe, opioid‑sparing, and feasible option that provide good perioperative analgesia, stable hemodynamics, and an uneventful recovery profile. We again support the findings of the study by Kothari et al. We hope that this discussion will help researchers and practitioners to provide effective and safe perioperative course of their patients and opening new horizons for multimodal analgesia.

MATERNAL AND FETAL OUTCOMES IN PATIENTS WITH PREVIOUS CAESAREAN SECTION UNDERGOING TRIAL OF VAGINAL BIRTH

Background: Vaginal birth after cesarean section (VBAC) is one of the strategies developed to control the rising rate of cesarean sections (CSs). It is a trial of vaginal delivery in selected cases of a previous CS in a well-equipped hospital. In 1916, Cragin popularized the dictum, once a caesarean section, always a caesarean section. That was the era of the classical CS. In the present era of lower segment caesarean section (LSCS), cesarean-related morbidity and mortality are significantly reduced. The dictum now is once a caesarean section, always an institutional delivery in a well-equipped hospital. The reasons which led to the reversal of the old dictum are based upon the newer concepts of the assessment of scar integrity, fetal well-being, and improved facilities of emergency Cesarean Section. Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation.Nevertheless, a previous CS does cast a shadow over the outcome of future pregnancies. With present techniques and skill, the incidence of cesarean scar rupture in subsequent pregnancies is very low. The strength of the uterine scar and its capacity to withstand the stress of subsequent pregnancy and labor cannot be completely assessed or guaranteed in advance. These cases require the assessment and supervision of a senior obstetrician during labor. Hence, the present study is undertaken to assess the success and safety of VBAC in selected cases of one previous LSCS and to evaluate the maternal and fetal outcome in these cases. Methods:This prospective observational study was conducted over a period of 18 months from 1st August 2019 to 28th February 2021 at the department of obstetrics and Gynaecology, tertiary care hospital Pune, Maharashtra, India. After achieving ethic committee approval, informed consent of patients enrolled for the study taken, a thorough history and physical examination was done as per proforma. Cases were evaluated thoroughly to collect maternal age, gestational age at admission, association of success rate of VBAC and Parity, Mode of delivery, whether instrumentation was required, indication of previous LSCS, indication of caesarean section in repeat emergency caesarean section, history of prior vaginal delivery, interpregnancy interval. Maternal and fetal outcomes in both successful VBAC and emergency caesarean section were observed.Data collected in structured pro-forma, entered in Microsoft Office Excel format, and statistical analysis was performed using SPSS software. The data so collected was presented with graphical representation. Results: Out of 65 patients undergoing TOLAC, a total of 51 patients had successful vaginal birth and for 14 patients emergency caesarean section was needed. Therefore, the success rate of VBAC in this study in 78%. The most common indication of failed TOLAC was fetal distress. Factors affecting success of TOLAC seen in the study were inter-pregnancy interval, fetal weight and previous caesarean section done for non-recurrent indications. No significant fetal or maternal morbidity was observed in this study. There was no fetal and maternal mortality. Conclusion:Trial of labor after one caesarean section should be undertaken in selected patients in well-equipped hospitals where facilities to deal with emergencies are available.Despite the risks, trial of labor after caesarean remains safer option for many patients as there are fewer complications with less maternal morbidity and will lead to a successful outcome in a high percentage of cases.

Effect of position on incidence of post-dural puncture headache in patients undergoing caesarean section: A comparative study

Background: Postdural puncture headache (PDPH) is an expected complication after lumbar puncture (LP). Spinal anaesthesia (SA) is given to a patient in lateral decubitus or in the sitting position. Our aim is to compare the incidence of PDPH between sitting and lateral decubitus position among patients scheduled for LSCS. Methods: This is a kind of comparative study done on 200 pregnant women scheduled for elective lower segment caesarean section at our tertiary care centre named NRI Institute of Medical Sciences, Chinakakani Andhra Pradesh, India. Patients were randomized into two groups as per the position used for spinal anaesthesia. Group S(sitting) included 100 patients and group D (lateral decubitus) included 100 patients. Results: There is no significant difference in the mean age, mean BMI and ASA grade of patients in both groups. The incidence of post-dural puncture headache was more common in sitting group patients on a postoperative day 1 compared to lateral decubitus group patients. The intensity of headache was more in sitting group patients from days 1 to 3 postoperatively. There is no significant difference in postoperative nausea and vomiting between two groups. Conclusion: The incidence of post-dural puncture headache is more common among patients in the sitting group compared to patients kept in lateral decubitus position. Also, the intensity of headache is more in the sitting group among pregnant women who were scheduled for elective lower segment caesarean section.

High glucose induced HIF-1α/TREK1 expression and myometrium relaxation during pregnancy.

The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. GDM patients have a significantly higher rate of cesarean section and postpartum hemorrhage, suggesting changes in uterine contractility. TWIK-1-related potassium channel (TREK1) expressed in the pregnant uterus and its role in uterine contraction. In this study, we examined the expression of HIF-1α and TREK1 proteins in GDM uterine and investigated whether high glucose levels are involved in the regulation of human uterine smooth muscle cells (HUSMCs) contraction through TREK1, and verified the role of HIF-1α in this process. Compared the uterine contractility between GDM and normal patients undergoing elective lower segment cesarean section. The HUSMCs were divided into normal glucose group, high glucose group, normal glucose with CoCl2 group, CoCl2 with echinomycin/L-Methionine group, and high glucose with echinomycin/L-Methionine group; Compare the cell contractility of each group. Compared the expression of hypoxia-inducible factor-1α (HIF-1α) and TREK1 protein in each group. The contractility of human uterine strips induced by both KCl and oxytocin was significantly lower in patients with GDM compared with that in normal individuals, with increased TREK1 and HIF-1α protein expression. The contractility of cultured HUSMCs was significantly decreased under high glucose levels, which was consistent with increased expression of HIF-1α and TREK1 proteins. The contractility of HUSMCs was decreased when hypoxia was induced by CoCl2 and increased when hypoxia was inhibited by echinomycin. The TREK1 inhibitor L-methionine also recovered the decreased contractility of HUSMCs under high glucose levels or hypoxia. The high glucose levels decreased the contractility of the myometrium, and increased expression of HIF-1a and TREK1 proteins play a role in changes in uterus contractility.