Lower Segment Caesarean Section Research Articles

813 Management of Massive Air Leak with Persistent Pneumothorax and Pneumoperitoneum in a 1.2kg Preterm Neonate – a Case Report

Abstract Pneumothorax is a life-threatening condition with potential iatrogenic causes which can extend to pneumomediastinum and pneumoperitoneum. Risk factors of spontaneous pneumothorax include prematurity, low birthweight, low APGAR scores and caesarean-section delivery. A 1255 grams preterm boy (Twin-2) was born at 28+3 weeks of gestation by emergency lower segment caesarean section. He showed signs of respiratory distress after uncomplicated endotracheal tube insertion which was required due to apnoeic episodes during continuous positive airway pressure ventilation. Recurring tube thoracocentesis and high frequency oscillatory ventilation (HFOV) treated persistent right-sided pneumothorax and nonsurgical pneumoperitoneum, with improvement on day-10, gradual removal of five chest drains by day-19 and extubation on day-24. Transillumination and chest radiography were main diagnostic investigations. Laryngotracheobronchoscopy on day-16 identified erythema and possible old injury at the carina. He was also treated for hypotension, suspected sepsis and pulmonary hypertension and was discharged home on day-66. Identifying pneumothorax promptly is essential to reduce morbidity and mortality. Lung ultrasound would improve diagnosis and monitoring. Management is patient-specific and includes needle and tube thoracocentesis and HFOV. Use of blood patch, fibrin glue or chemical agents, selective bronchial ventilation have been reported. Surgery is usually applied in unstable patients where bridging the defect is not feasible. nonsurgical pneumoperitoneum should be considered in ventilated neonates and those with airway injury to avoid exploratory laparotomy. Our case demonstrates challenges of managing a massive air leak in a premature newborn, who with adequate tube thoracocentesis and HFOV, successfully recovered from presumed iatrogenic persistent pneumothorax and pneumoperitoneum with conservative management.

Comparison of Clinical and Radiological Findings for the Prediction of Scar Integrity in Women With Previous Lower Segment Cesarean Sections.

We aimed to compare the clinical and radiological findings to predict scar integrity in term antenatal mothers with a previous lower segment cesarean section (LSCS). This prospective study was conducted in the obstetrics and gynecology department of LN Medical College, Bhopal, India, from August 2020 to August 2021. We included all pregnant women with term gestation (37+0 to 42+0 weeks) who were admitted either for elective repeat LSCS or for emergency LSCS and had a history of a previous LSCS. A detailed history and clinical examinations were performed. We noted the presence of scar tenderness and conducted transabdominal ultrasound (USG) to assess the integrity of the uterine scar in all women. During surgery, the surgeon identified the lower uterine segment scar and graded it as normal, thinned-out, dehiscent, or ruptured. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for both clinical findings (scar tenderness) and ultrasound findings as predictors of scar integrity. A total of 60 pregnant women were included in the study. During a repeat cesarean section, we found a thinned-out scar in 26 women out of 60 (43.3%). Out of 60 women, 13 had scar tenderness, and among these 13 women, 12 had thinned-out scars intraoperatively. Forty-seven women had no scar tenderness; 14 had thinned-out scars intraoperatively. The sensitivity of scar tenderness as a predictor of a thinned-out scar was 46.2%, specificity was 97.1%, PPV was 92.3%, and NPV was 70.2%. Whereas the sensitivity of ultrasound scar thickness as a predictor of a thinned-out scar was only 19.2%, with a specificity of 94.1%, a PPV of 71.4%, and an NPVof 60.4%. Thus, we documented a significant correlation between intraoperative and clinical findings (κ = 0.46; p<0.05), but no agreement could be found between ultrasound and intraoperative findings (p>0.05). Clinically evident scar tenderness continues to be a useful parameter to predict intraoperative scar status.

Intraoperative Direct Vision of Transversus Abdominis Plane (TAP) Block versus Ultrasound Guided Transversus Abdominis Plane (TAP) Block for Pain Control after Caesarean Section (CS). A Randomized Controlled Clinical Trial

Background Adequate postoperative analgesia following CS hastens post-operative mobilization, decreases maternal morbidity and facilitates bonding with the newborn. Aim of the Work to assess pain scores at (rest and movement), and need for opioids in women receiving intraoperative direct vision of transversus abdominis plane (TAP) Block versus women receiving ultrasound guided transversus abdominis plane (TAP) Block following cesarean section in first 24H. Study Design Randomized controlled clinical trial was conducted on Patients undergoing lower segment Cesarean section under spinal anesthesia with intra thecal hyper baric bupivacaine 0.5%. Patients were randomized to study group that received intraoperative direct vision transversus abdominis plane (TAP) Block and control group received ultrasound guided transversus abdominis plane (TAP) Block. Postoperative pain score was recorded using visual analog scale (VAS) score and analgesic consumption recorded from patient medication chart. Result A total of 220 eligible women planned to undergo elective lower segment caesarean section were recruited in the current trial, and were randomly allocated into one of the two groups, there were no significant differences between women of both groups regarding age, parity or BMI. No significant differences between the studied group regarding patient pain perception (VAS Score) during rest and movement at different times of follow up (6,8,12,24 H) postoperatively. The dose and the first time of analgesic requirement was non-significantly different among studied groups. Conclusion USG and surgical TAP blocks were safe and had similar efficacy in providing postoperative analgesia in pregnant women following cesarean section under spinal analgesia. Surgical TAP block is an efficacious, safe and rapid technique, particularly in patients in whom USG TAP block is technically challenging (obese women), and where the ultrasound isn’t available in operative theater.

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache in Patients Undergoing Lower Abdominal Surgeries

Abstract Background Postdural puncture headache (PDPH) is a complication of spinal anesthesia or lumbar puncture and is an unpleasant experience for the patient as well as the anesthetist. It is thought to result from meningeal traction related to low cerebrospinal fluid (CSF) pressure or cerebral vasodilation as an indirect effect of decreased CSF pressure. Neostigmine is a reversible inhibitor of the enzyme cholinesterase, which results in an increased concentration of the neurotransmitter acetylcholine. It produces cholinergic-mediated analgesia and has been used as an adjunct analgesic postoperatively. Neostigmine can pass through the choroid plexus but not the blood–brain barrier, the central effect of both neostigmine and atropine influence both CSF secretion and cerebral vascular tone which are the primary pathophysiological changes in PDPH. Objective Assess the effectiveness of postdural anesthesia with addition of Neostigmine and Atropine versus conventional postdural anesthesia. Patients and Methods A 90 patients were included in our prospective randomized controlled double-blind study that was conducted at Ain Shams University Hospitals for 4 months on patients who fulfilled the inclusion criteria: patients with ASA Grade I &amp; II, aged from (18 to 40) years old and scheduled for cesarean section. All patients aged &amp;gt;18 or &amp;lt;40, body weight &amp;gt;50, ASA III, IV, patients with uncontrolled chronic diseases such as hypertension, cardiac, renal, hepatic, cerebral diseases and peripheral vascular diseases, patients with history of PDPH, chronic headache, cluster headache, migraine, convulsions, cerebrovascular accident, signs of meningismus, preeclampsia, eclampsia coagulopathy, and previous neurological diseases and patients with history of bronchial asthma were excluded. Patients were divided into 2 groups: Group I (experimental group): neostigmine and atropine and Group II (placebo group): Saline placebo. Results The results of this study showed that incidence of postoperative headache was significantly lower among the intervention group, furthermore, VAS was significantly lower in the experimental arm versus placebo one. However, there was no significant difference regarding demographic, vital signs, and need for post-operative analgesia. The presented study showed that there is statistically non-significant difference between the studied groups regarding age, weight, and height and body mass index. There is statistically non-significant difference between the studied groups regarding duration of surgery. Conclusion After demonstrating many management options for post dural puncture headache (PDPH), in this study, we tried to prove the value of the use of neostigmine as a new management option that looks promising to alleviate the symptoms of such distressing condition. The current study results proved that the drug reduced the number of cases that experienced (PDPH) after spinal anesthesia for lower segment caesarean section, and how it prevent &amp;control headache. A combination of neostigmine and atropine are effective in managing PDPH by reducing the associated VAS score and preventing persistence of headache.

Effect of Rectus Muscle Re-approximation and Postoperative Pain in Women with Previous Cesarean Delivery: A Randomized Controlled Trial

Background Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section. Rectus muscle reapproximation at cesarean delivery (CD) is performed frequently by some obstetricians; however, the effect on postoperative pain is unclear. To this end, we investigated whether rectus muscle reapproximation increases postoperative pain. Objective In women with previous cesarean delivery, the aim of this prospective double blind randomized controlled trial is to assess the effect of rectus muscle approximation on postoperative pain. Patients and Methods This study was a prospective, doubleblind, randomized controlled trial. It included 340 women with previous cesarean delivery, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group I (study group) in which rectus muscle approximation were done (surgeons were instructed to place three vertical midline loose interrupted sutures to re-approximate the rectus muscles by using Vicryl 0 suture) while in Group II (control group) rectus muscle approximation not done. Intra- and postoperative pain management was standardized within the study protocol. Results Both groups were comparable in age, body mass index (BMI), parity, gestational age (GA), sub-rectus hematoma, surgical site infection and subsequent hospital stay. While study group had significantly longer operation duration, significantly higher pain score from first day of operation and up to 6 weeks postoperative and significantly higher NSAID dose and opioid requirements at first and second day postoperative. Conclusion Our results suggest that rectus muscle reapproximation increases operative time &amp; postoperative pain and subsequently associated with higher short-term postoperative opioid use among women undergoing cesarean section (CS). Surgical complications do not appear to be impacted by rectus muscle reapproximation. So, the benefits described with rectus muscle reapproximation such as less adhesions, should be weighed against the potential for a modest increased postoperative pain and corresponding opioid use.

307 Intraluminal Migration of Gossypiboma and rectal expulsion an unusual Case- Case Report

Abstract Background Gossypiboma refers to foreign body retained in the body at the end of operation and can be in the form of gauze, sponge or any form of textile resulting in grave consequences for both the patient and the surgeon. Case Summary A 23-year-old female presented with complain of generalized abdominal pain along with non-bilious vomiting since 10 days. She also had relative constipation since four days. Her past surgical history was unremarkable except for three elective lower segment caesarean sections at another hospital. Upon abdominal examination, she had a scar of pfannenstiel incision along with 3x4 cm swelling in umbilical region with positive cough impulse. Her bowel sounds were exaggerated. DRE was unyielding. Clinical diagnosis of subacute intestinal obstruction was made and she was managed conservatively. Ultrasound abdomen showed dilated gut loops with hyperperistalsis. It also revealed a defect measuring 8.5 cm in the supraumbilical region of anterior abdominal wall through which fat content was seen protruding. She was advised contrast enhanced CT abdomen, developed diarrhoea and later on expelled the surgical sponge per rectally. After passage of surgical sponge, condition of patient improved and symptoms resolved. Discussion Diligent efforts are required to prevent this human error by ensuring meticulous sponge count, use of radio-opaque sponges, adjunctive use of WHO safety checklist and introduction of new advancements like tagging system in our healthcare system. Conclusion Gossypiboma is under-reported due to reluctance of institutions to report it to governing body. Reporting of such dreadful complications of surgery and analysis of their root cause should be done to prevent such events from happening.

Maternal and Fetal Outcome Following Post In vitro Fertilization and Embryo Transfer Pregnancy: A Prospective Observational Study

Abstract Background: While the majority of in vitro fertilization (IVF)-conceived children are healthy, IVF has been associated with an increased risk of adverse obstetric and perinatal outcomes including hypertensive disorders of pregnancy, preterm labor and preterm delivery, and low birth weight (LBW). Objective: The objective of the study is to assess pregnancy, maternal, and perinatal outcomes in patients undergoing IVF embryo transfer (IVF-ET) at tertiary care center in North India. Methodology: It was a prospective observational study carried out for duration of 20 months among women who conceived following an IVF-ET. The sample size was 107 consecutive mothers and data were collected using a predesigned semi-structured study pro forma. Detailed menstrual, obstetric, and medical histories of each patient were noted. Findings of the general, physical, systemic, and obstetrical and gynecological examination were noted for all patients. Results: One hundred and seven mothers who fulfilled the study criteria were included. Of these, 4 had an abortion. Rest of the 103 mothers were included in the final analysis. The mean age of the mothers was 30.39 ± 4.7, ranging from 22 to 50 years. Twin pregnancy rate was 45.7%. All were dichorionic-diamniotic twins. Based on gestational age, 5% were extreme preterm births, 14% were very preterm births, 32% were late preterm births, and 48% were early-term births. Normal vaginal delivery (NVD) occurred in 26.2% of the mothers, elective lower-segment cesarean section (LSCS) in 21.4%, emergency LSCS in 51.4%, and one case had vacuum delivery. Hence, NVD occurred in 27% and 73% had LSCS. With respect to neonates born to study participants, 8% were extremely LBW, 7.3% were very LBW, 46% were LBW, and the rest 38.7% weighed 2.5 kg or more at birth. Conclusion: IVF-ET is a safe and highly successful treatment for infertility. Many of adverse outcomes are largely due to an increased risk of multiple gestations in IVF. Patients with infertility are likely to be older and have preexisting comorbid conditions such as hypertension, diabetes, insulin resistance, or other endocrinopathies which may predispose them to adverse obstetric and perinatal outcomes. It is also recommended that patients should be given adequate preconception counseling regarding increased maternal as well as neonatal risk.

The Incidence of Obstetrics and Gynecology Cases Returning to Operation Theater due to Postoperative Complications in a Tertiary Care Hospital

Introduction: Unexpected return to operation theater carries high rate of morbidity and mortality for patients, in addition to increased hospital stay. A close look at such cases would help in identifying high-risk patients thus improving outcome. The aim of the study was to evaluate the incidence of Obs/Gyn cases returning to OT due to postoperative complications in a tertiary care hospital. Methods: It was a retrospective observational study done at tertiary care hospital settings affiliated with academic center in the UAE. The records of patients were scrutinized, and all booked and non-booked pregnant patients of any age undergoing emergency or elective obstetrics or gynecological procedure from January 1, 2016 to December 31, 2020 were enrolled in the study. Relaparotomy was defined as cases opened within same admission and causally associated with previous primary obstetrics or gynecological operation. Result: A total of 21,276 operations were performed from 2016 to 2020. In these 4 years, 33 patients had unexpected return to operation theater making the incidence of re-exploration to 0.15% (33/21,276). There were 16 (48.48%) emergency operations and 17 (51.52%) elective operations previously done on these patients. The most common primary procedure for which re-exploration was done was lower segment caesarean section done in 11 (33.3%) of cases followed by laparoscopic adhesiolysis and myomectomy. Hematoma in the pelvic region and ooze from raw area were the most common per-operative finding in 48.48% of cases. There was no mortality in the abovementioned cases; however, 2 (6.06%) had early acute kidney injury and both recovered from it. Discussion: The incidence of relaparotomy in our hospital is comparable to international literature. Most patients returned to OT within 48 h. Bleeding was the most common indication for laparotomy, and lower segment cesarean section was most common primary operation. This study underscores the need for meticulous hemostasis before closing to avoid return to OT. Conclusion: Return to OT for the right indication saves life. Mortality in such cases may be reduced by earlier detection and treatment of postoperative problems, consideration of relaparotomy, active ICU monitoring, and postoperative care.

FETOMATERNAL OUTCOME OF GESTATIONAL DIABETES MELLITUS IN PRIMIGRAVIDA DELIVERED AT TERTIARY CARE HOSPITAL

Objective: To determine the Prevalence of gestational diabetes mellitus (GDM) in primigravida and their feto-maternal outcome who delivered at tertiary care hospital in western Rajasthan. Methods: A retrospective chart review study will be conducted on primigravida delivered at the department of Obstetrics and Gynaecology, MDM Hospital Dr. S. N. Medical College, Jodhpur, Rajasthan, India from May 2022 to December 2022. Results: The prevalence of GDM in primigravida was 6.42%, maximum occurrence between 34 and 36 weeks of gestation (53.3%). 8.8% of GDM patients had a preterm delivery, out of these 8 women polyhydramnios were seen in 4 women. 49% had lower segment cesarean section and 3% had instrument delivery. preeclampsia was seen in 25.56%, urinary tract infection in 10%, preterm labor was seen in 8.89%, premature rupture of membrane was seen in 5.56% of the study population. 10% of babies were low birth weight. The incidence of congenital anomalies was seen in 6.6%. Intrauterine death was seen in 2 babies who had congenital anomalies. Conclusion: GDM is associated with adverse complications in both the mother and fetus.

A comparative study for feto-maternal outcome of trial of labour after caesarean: spontaneous versus induction

Objective The purpose of this study was to compare the foeto-maternal outcome of trial of labour after previous one lower segment caesarean section in spontaneous and induced labour and to ascertain the success rate of VBAC.(Vaginal birth after cesarean section) Methods It was a prospective study conducted from May2019-November2020.The pregnant women admitted in BPSGMC (BPS Government Medical College), labour ward who had previous one caesarean section undergoing trial of labour after either spontaneous onset or induction of labour, were included in the study. Results Total patients were 130, [65 each, in group I(spontaneous) and group II (induced)]. Successful TOLAC (Trial of labour after cesarean section) happened in 80% in spontaneous labour (gp I) patients and 66.2 % women in induced patients (group II), (p value-0.075). There was no significant difference in age, parity and gestational age (p value &gt;0.05), APGAR score and NICU (Neonatal intensive care unit) admissions in both spontaneous labour(gp I) and induced patients (gp II). There incidence of fetal distress was not statistically significant in spontaneous (group I) and induced patients (group II), (p value-0.744). Indication of primary LSCS (Lower segment cesarean section) showed no significant effect on outcome of TOLAC in spontaneous and induced group patients. History of prior vaginal delivery had more chances of VBAC. Hospital stay and PPH was more in induced patients(group II). The dfference of scar dehiscence in group I(spontaneous) and II (induced) were not statistically significant (p value=0.721). There were no cases of scar rupture in both the groups. Conclusion Induction of labour and spontaneous labour both have almost similar VBAC success rates. Also with fewer scar dehiscence and no rupture, IOL (Induction of labour) is a good option in previous one cesarean patients.

Study of maternal and neonatal outcome in women with one previous lower segment caesarean scar in Raja Isteri Pengiran Anak Saleha Hospital (RIPAS)

Background: The rate of primary caesarean section (CS) is on the rise; it was 30.8% for primiparous women and 11.5% for multiparous women. A trial of vaginal delivery can prevent the risk of repeat CS. Aim: The study was to determine the success rate, and also maternal and neonatal implications of VBAC (Vaginal Birth after Caesarean), attempted in women with one previous lower segment caesarean section (LSCS). Materials and Methods: The retrospective and descriptive study was carried out in a tertiary care hospital, RIPAS Hospital, Brunei Darussalam, over a period of three months (from February 2010 to May 2010). All women with prior LSCS who are suitable for a trial of labour after the previous caesarean (TOLAC) were included in our study. Sixty-one pregnant women with a history of one previous LSCS were enrolled in the study. Results: In our study (38/61) 62.3% of patients had a successful VBAC, and (23/61) 37.7% had undergone a repeat emergency LSCS. In those who had the previous VBAC, cervical dilatation of &gt;4 cm at the time of admission and those who had the previous VBAC are significant factors for a successful VBAC. Conclusion: The trial of VBAC in selected cases has great importance in the present era of the rising rate of primary CS, as it has a considerable success rate and is not associated with serious maternal and foetal morbidity and mortality.

The Correlation between Maternal Factors and Infants Lower Birth Weight

Background: Low birth weight (LBW) continues to remain a major public health problem worldwide. There are numerous factors contributing to LBW both maternal and fetal. The mortality of low birth weight can be reduced if the risk factors are detected early and managed by simple techniques. Objective: In this study our main goal is to assess the correlation between maternal factors and infants lower birth weight. Method: This research was conducted as a cross- sectional analysis at a tertiary care medical facility between January 2022 and January 2023. Where a convenience sample of 100 moms aged 11–19 who were hospitalized throughout the research period was chosen. Ultrasound and other diagnostic procedures verified the pregnancy. Results: During the study, the average age of the participants in the study group was 18.02±05 years, and only 19% of the patients visited the antenatal care facility more than four times. Among the study group, 34% of the participants had anemia, followed by 20% with premature rupture of membranes (PROM), 6% with preterm premature rupture of membranes (PPROM), 11% with mild eclampsia, 7% with severe eclampsia, 5% with gestational hypertension, and 6% with gestational diabetes. In terms of delivery methods, 40% had normal spontaneous vaginal delivery (NSVD), 28% had emergency lower segment cesarean section (LSCS), 17% had planned LSCS, and 13% underwent instrumental delivery. Regarding postpartum complications, 5% of the study group experienced postpartum hemorrhage (PPH), 2% had uterine atony, 3% had wound disruption, 1% had perineal tear, and 1% of the cases resulted in maternal death. Adverse neonatal outcomes were also observed, with 15% of the newborns having a body weight of less than 2500 grams, 11% having low APGAR scores, 12% developing neonatal jaundice, 2% experiencing intrauterine growth restriction (IUGR), 2% being stillborn, 1% having congenital anomalies, and 1% suffering from respiratory distress syndrome. ...

Pregnancy and assisted reproductive technology use in Australian female transfusion-dependent haemoglobinopathy patients: a 20-year retrospective analysis.

In the last few decades, the life expectancy of patients with transfusion-dependent thalassaemia (TDT) and sickle cell disease (SCD) has improved significantly, in part because of improved iron chelation. Fertility challenges and pregnancy complications have historically limited reproductive options in this group; however, improved multi-disciplinary care has made infertility a chronic disease complication requiring attention. Despite this, there are very few reports and no Australian data describing fertility and pregnancy outcomes in this population. To identify the rate of assisted reproductive technologies (ART) utilisation in our female transfusion-dependent haemoglobinopathy patients and to establish the nature of maternal and neonatal complications in this cohort. A 20-year retrospective analysis (1997-2017) at an Australian centre captured data on conception rates, use of assisted reproductive techniques (ART), and pregnancy and neonatal outcomes in female transfusion-dependent haemoglobinopathy patients. Conception was attempted in 14 women (11 TDT and three SCD) during the study period. A total of 28 pregnancies resulting in 25 live births were recorded. ART supported 13 conceptions. A positive association was not identified between elevated mean serum ferritin and ART use; however, all patients with an established diagnosis of hypogonadotropic hypogonadism (HH) required ART. Maternal complications included gestational diabetes mellitus and post-partum haemorrhage. There were no cardiac complications. Two-thirds of women underwent lower segment caesarean section, with prematurity complicating 20% of births. There were no neonatal or maternal deaths. Pregnancy is an achievable goal for women with transfusion-dependent haemoglobinopathies, although the support of ART may be required in a subset of patients.

Efficacy of intravenous ketamine as premedicant for prevention of intraoperative hypotension after spinal anesthesia in parturients posted for elective cesarean section

Background: Hypotension following spinal anesthesia (SA) in lower segment cesarean section can be deleterious to the parturient and to fetus. Ketamine acts by stimulating the cardiovascular system leading to high blood pressure and increase in heart rate (HR) and cardiac output. Aims and Objectives: This study aimed to assess the efficacy of 15 mg of prophylactic intravenous ketamine in elective cesarean section for prevention of hypotension after SA. Materials and Methods: This double-blinded randomized controlled study was conducted on 98 participating parturients who were American Society of Anesthesiologists term pregnant women. The parturients were randomly divided into two groups (n=49 in each). All the parturients received SA. Ketamine group - Group K received 15 mg of ketamine IV bolus in 3 mL saline and control group - Group C received the same volume of normal saline IV bolus. HR and systolic blood pressure (SBP) were recorded at baseline at 5, 10, 15, and 20 min after the injection and then every 15 min till the end of the operation. Incidences of hypotension were recorded. The total number dose of ephedrine used, APGAR score, and Visual Analog Scale scores were recorded. The Ramsay Sedation Score was also recorded at baseline, then 5, 10, 15, 30, and 45 min after injection, and then at the end of the operation. Results: This study showed a statistically significant increase in the incidence of hypotension and higher use of intravenous ephedrine 6 mg boluses in the control group when compared to the ketamine group. Forty-two parturients in the control group developed hypotension compared to 23 parturients in the ketamine group with P&lt;0.001. The total ephedrine dose was significantly lower among the ketamine group. Sedation was observed for the first 15 min intraoperatively in the ketamine group with P=0.001. There was no statistically significant difference in APGAR score between the two groups. Conclusion: There was significantly higher hemodynamic stability in the ketamine group with regard to SBP, diastolic blood pressure, and HR. Hence, low-dose ketamine, when used as a premedicant, is an effective agent that can be used in preventing post-spinal intraoperative hypotension in parturients undergoing cesarean section delivery.

Using days alive and out of hospital to measure surgical outcomes in New Zealand: a cross-sectional study

ObjectivesTo measure differences at various deciles in days alive and out of hospital to 90 days (DAOH90) and explore its utility for identifying outliers of performance among district health boards...

An Intrauterine Complete Perineal Tear in a Female Neonate, A Rare Birth Injury Related to Breech Presentation: A Case Report

Birth injuries are wounds that a newborn receives when being delivered, whether vaginally or via lower segment caesarean section. It is a case of a 39-week pregnant female with foetal distress and breech presentation in labour who was received in the emergency labour room as a referral case after multiple per vaginal examinations done by a staff nurse at a peripheral hospital, with a complaint of leaking and bleeding per vaginum since then. Her emergency LSCS was done in view of foetal distress with breech presentation. A female baby was extracted and found to have a complete perineal tear in an otherwise healthy neonate. Her paediatric surgeon's opinion wassought, and a complete perineal tear was done in layers with Vicryl 3-0 sutures. On follow-up, the female neonate was continent and thriving well. Unintended vaginal examinations during breech presentation could result in an intrauterine complete perineal tear if the examiner is untrained. If these injuries are identified immediately and prompt management is done, it may lead to lesser morbidity and a better quality of life.

The association between trial of labor after cesarean in obese patients and adverse maternal outcomes.

We hypothesized that among obese patients with a history of cesarean birth, a TOLAC is associated with decreased composite maternal adverse outcomes (CMAO) compared to planned repeat low transverse cesarean section (RLTCS). In this population-based cross-sectional study using the National Birth Certificate database from 2016 to 2020, we compared obese patients who attempted TOLAC at term (≥ 37weeks estimated gestational age) to planned RLTCS. The primary outcome was a CMAO, defined as delivery complications, including intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or maternal blood transfusion. Overall, 794,278 patients met inclusion criteria for the study; 126,809 underwent a TOLAC, and 667,469 had a planned RLTCS. The overall CMAO was significantly higher for patients undergoing TOLAC (9.0 per 1000 live births) compared to RLTCS (5.3 per 1000 live births; aRR 1.64, 95% CI 1.53-1.75). This data demonstrate that in obese patients with prior cesarean birth, a trial of labor is associated with increased maternal morbidity when compared to a planned repeat cesarean birth.

Ketamine as a pre-emptive analgesia in patients undergoing caesarean delivery under spinal anesthesia

BACKGROUND &amp; OBJECTIVES: Lower segment caesarean section (LSCS) leads to moderate to severe pain in the patient. Pain severity is directly proportional to the functional limitations and depression in the postpartum period, making it essential to provide good pain relief after surgery. Maternal wellbeing and better nursing care of newborn requires good postoperative analgesia with minimal side effects. The main objective of the study was to evaluate the analgesic effect of intravenous low-dose ketamine, when administered pre-emptively, in patients undergoing caesarean delivery under spinal anesthesia.&#x0D; METHODOLOGY: Two groups were made, each with 50 full-term pregnant females with a plan of caesarean section under spinal anesthesia. Group-A received spinal anesthesia with bupivacaine 0.5% along with intravenous placebo of 2cc normal saline, whereas group-B received 0.5mg/kg ketamine intravenously after administration of spinal anesthesia but before the start of surgical incision. Pain intensity was monitored using a visual rating pain scale (VRS), till the need for the first analgesic dose postoperatively.&#x0D; RESULTS: Both groups were comparable in terms of age and weight. Analgesia was markedly prolonged, and postoperative pain scores were significantly less in Group-B (ketamine group) as compared to Group-A; with p-value&lt; 0.001, demonstrating analgesic properties of ketamine when administered pre-emptively as an intravenous dose.&#x0D; CONCLUSION: Our study concluded that pre-emptive analgesic dose of ketamine (administered before surgical incision), leads to prolong analgesia in post-operative period in patients who underwent LSCS under spinal anesthesia.

Socio-Demographics and Contraceptive Acceptance of Women of Reproductive Age in Peshawar Pakistan: A Cross-sectional Study

Background: Delaying in the initiation of effective contraception in postpartum period and during lactation puts a woman at risk of rapid, repeat, and unintended pregnancy. Postpartum Intrauterine Contraceptive Device (PPIUD) insertion during a Caesarean section allows obstetrician to insert it under vision thus excluding any fear of perforating the uterus with major side effects that is bleeding and abdominal cramps being masked in the puerperium. The aim of the currents study was to investigate knowledge, attitude, and acceptance trends of contraception practices among women from Peshawar Pakistan. Methods: Current six-month duration (January 1,2019 to June 30, 2019) based cross-sectional study was conducted at Obstetrics and Gynecology Unit B, Lady Reading Hospital, Peshawar by following non-probability purposive sampling approach. Detailed socio-demographic and obstetric history was obtained from 316 women who were admitted for elective lower segment Caesarean section by informed ethical concern. The major socio-demographic details collected from the study participants may include age, education level and number of total pregnancies conceived. Further, profession and duration from last childbirth related factor were compared with the knowledge and acceptance rates of intra-uterine postpartum contraception by using Chi-Square test. Further data analysis was made by using SPSS v. 20 and Microsoft office 2010 different tools. Results: Out of 316 participants, only 22 (6.96%) women accepted PPIUCD during Caesarean section. The mean age of participants was 33.26 ± 5.1 SD. About 243 (76.89%) cases had no normal schooling, 15 (4.7%) had primary education, 57 (18%) had secondary and only 1 (0.3%) had higher education. Similarly, 294 (93%) were housewives while only 22 (7%) were employed at work., no significant difference was noted among the acceptance of the different age groups. Conclusion: The uptake of PPIUCD is very low as observed in this study. To improve the situation, health authorities should be encouraged to provide counseling on postpartum contraceptive methods during ante- and post-partum care visits.

Anticipated vs. Experienced Pain at Site of Spinal Needle Insertion in Patients Undergoing Elective Lower Segment Caesarean Section: Perspective from Resource-Limited Region.

Despite significant advantages, approximately 20% of pregnant patients refuse spinal anaesthesia in caesarean section due to fear of spinal needle prick. Studies have shown that the patient's expectation of pain is higher than what they experience in real. The objective was to evaluate the difference between anticipated and actually experienced pain at the spinal needle insertion site in spinal anaesthesia for pregnant women undergoing elective lower segment caesarean section (ELSCS). The cross-sectional study was conducted in a labour room suite of a tertiary care hospital. A total of 50 patients scheduled for ELSCS were included. The median experienced pain at the site of spinal needle insertion was significantly low as compared to anticipated pain (P value < 0.01). For the identification of predictors impacting the anticipated and experienced pain, univariate and multivariate regression models were applied. Amsterdam Preoperative Anxiety and Information Scale ≥11 for anticipated pain showed a statistically significant positive correlation in univariate (coefficient: 2.59; 95% CI: 1.49 to 3.68; P value < 0.001) and multivariable analyses (coefficient: 2.51; 95% CI: 1.36 to 3.67; P value < 0.001). Thus, anxiety was associated with statistically significant higher anticipated pain. In conclusion, there is a remarkable difference in the obstetric population between anticipated and actually experienced pain at the site of spinal needle insertion in ELSCS.