Lower Segment Cesarean Delivery Research Articles

Vaginal Birth after Caesarean Section: A Study of 60 Patients with Spontaneous Onset of Labor Pain

Background: Most women with a singleton pregnancy of cephalic presentation at 37+ weeks or later who have had a single prior lower segment cesarean delivery, with or without a history of prior vaginal birth, are candidates for planned VBAC and may be offered it for a trial of VBAC. Objective: The objective of this study is to determine the outcome of vaginal birth after caesarean section (VBAC) in a tertiary care hospital in Sylhet. Methods: This prospective study took place between April 2022 and February 2023 and lasted for a total of eleven months. A total of sixty patients were hospitalized in the gynecology and obstetrics department at North East Medical College, all of whom had a history of either one or two previous cesarean sections and were experiencing labor pain. 43 of these patients had their deliveries through the vaginal route. The remainder of the patients had cesarean sections because of fetal distress, scar tenderness, and the patient's wish during 1st stage of labor. Results: The VBAC success rate in this study was 71.67%. Among the 43 patients, the highest number of patients, 51.2%, came from the age range of 28-37 years, followed by 21 patients (48.8%), who were in the age category of 18-27 years. The majority of the patients (24, 55.82%) were in their second pregnancy, with 10 (23.25%) in their third pregnancy and 9 (20.93%) in their more than third pregnancy. Among the 43 patients, 42 (97.7%) had a previous caesarean section, while the remaining 1 patient (2.3%) had two previous caesarean sections. Most patients (58.14%) were admitted to the hospital between 35 and 38 weeks of pregnancy. Among the participants, 97.7% had normal placenta size, 88.4% had average bleeding, 79.1% had clear liquor and 97.7% had no scar rapture. The study shows an extremely low level of complication in VBAC. Conclusion: This study identified that, the success rate of vaginal birth after one caesarean section is very high. An evidence-based systematic review suggested that planned VBAC is a safe and appropriate mode of delivery for the majority of pregnant women with a single previous lower-segment caesarean delivery.

Comparison of Intraoperative Hemorrhage by Blunt Versus Sharp Expansion of Uterine Incision at Lower Segment Cesaeren Delivery

Objectives: To compare the intraoperative hemorrhage between blunt and sharp expansion of uterine incision at lower segment caesarean delivery. Study Design: Randomized controlled trial. Study Duration: 03-02-2022 to 02-08-2022 (6 months) Setting: Department of Obstetrics and Gynecology, D.G Khan Hospital D. G Khan Material and methods: Total 74 patients undergoing C-section, age range 20-40 years, with singleton pregnancy and patients with >37 weeks gestation. (on ultrasound) were included. Intraoperative blood loss was compared between blunt and sharp group. Results: Mean age was 32.31 ± 6.246 years, in Blunt and Sharp group, mean age was 35.70 ± 4.122 years and 28.92 ± 6.202 years. In Blunt group, mean blood loss was 201.62 ± 60.794 ml while in sharp group was 782.03 ± 153.819 ml. Difference of mean blood loss between Blunt and Sharp group was significant (P= 0.000). Conclusion: Results of present study reflects that there is significant difference of intraoperative mean blood loss between blunt and sharp groups. Most of the patients were between 31-40 years of age. After stratification of age, gestational age, parity and type of C-section, it was found that there is significantly low mean blood loss in blunt group as compared to sharp group. Keywords: Blood loss, C-section, Blunt, intraoperative haemorrhage,

Maternal and neonatal outcomes of trial of labor compared with elective cesarean delivery according to predicted likelihood of vaginal delivery

Objective The vaginal birth after cesarean (VBAC) calculator developed by the Maternal-Fetal Medicine Units Network (MFMU) helps to identify the likelihood of VBAC. We sought to compare adverse maternal and neonatal outcomes of trial of labor after cesarean (TOLAC) to those of elective cesarean delivery after stratifying by VBAC likelihood. Study design This was a retrospective cohort study of all women whose primary low transverse segment cesarean delivery and subsequent singleton term delivery with vertex presentation occurred at an academic center from January 2009 to June 2018. Only data from the second pregnancy were analyzed. The final analysis included 835 women. The MFMU VBAC calculator was used to assess the likelihood of VBAC. The two primary outcomes were composite adverse maternal (death or severe maternal complications) and neonatal outcomes (perinatal death or severe neonatal complications). The analyses were stratified based on the VBAC likelihood (less than 60% and 60–100%). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI), controlling for predefined covariates. Results Among women with VBAC likelihood less than 60%, TOLAC compared with elective cesarean was associated with increased odds of the primary adverse maternal outcome (16.4% vs. 4.2%; adjusted OR 4.60 [95%CI 1.48–14.35]) and the primary adverse neonatal outcome (17.8% vs. 6.3%; adjusted OR 3.93 [95%CI 1.31–11.75]). Among women with VBAC likelihood of 60–100%, TOLAC compared with elective cesarean was associated with decreased odds of the primary adverse maternal outcome (6.4% vs. 11%; adjusted OR 0.47 [95%CI 0.25–0.89]) and similar odds of the primary adverse neonatal outcome (6.7% vs. 8.3%; adjusted OR 0.98 [95%CI 0.52–1.84]). Conclusions Among women with a history of a primary low transverse cesarean delivery, those who underwent TOLAC compared to those who had elective cesarean had increased odds of adverse maternal and neonatal outcomes when VBAC likelihood was less than 60%.

Vaginal delivery after previous one lower segment caesarean section at a tertiary care hospital

Aims & Objectives: To find out the predictors of spontaneous term vaginal birth after a previous one lower segment caesarean delivery. Materials & Methods: A prospective study was conducted in the Department of Obstetrics & Gynecology, SMS Medical College, and Jaipur from March 2015 to October 2016. 120 pregnant women with a history of one previous Lower segment caesarean section (LSCS) were enrolled in the study. Results: In our study, 60% cases had a successful Vaginal birth after caesarean section (VBAC) and 40% underwent a repeat emergency LSCS for failed trial of labour after caesarean section. Anterior position of cervix, cervical dilatation ≥ 3cm, effacement ≥ 60-70%, vertex position at or below the ischial spine at the time of admission in labour room were significant factor in favoring a successful VBAC. The incidence of scar dehiscence was 5.83%. There was no maternal or neonatal mortality. Conclusion: Trial of labour after caesarean section (TOLAC) can be given in selected cases with good monitoring of Fetal heart sound (FHS) and progress of labour under supervision of trained staff at a tertiary care hospital.

Tranexamic Acid and Ethamsylate for Reducing Blood Loss in Patient Undergoing Lower Segment Cesarean Section at High Risk for Post-Partum Hemorrhage: A Pilot Study

Objective: To assess the efficacy of intravenous tranexamic acid and ethamsylate in reducing blood loss during and after elective lower segment cesarean delivery in patients at high risk for postpartum hemorrhage. Methods: A double-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term pregnancy at high risk for postpartum hemorrhage at Ain Sham University Maternity Hospital in Cairo, Egypt, between January 2019 and October 2019. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1 g tranexamic acid and 1 gm ethamsylate or 5% glucose (placebo) just after delivery of the fetus. Prophylactic oxytocin was administered to all women. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during the cesarean, which was the primary outcome. Results: Analyses included 32 women in each group. Our results showed that tranexamic acid and ethamsylate significantly reduced bleeding during and after cesarean delivery. The study group’s total blood loss (149.22 ± 54.74 ml) was significantly less than the control group (353.75 ± 115.56 ml) (p the control group (p the control group (p Conclusion: The use of tranexamic acid and ethamsylate during cesarean delivery can significantly reduce blood loss during and after cesarean delivery.

593: Neonatal outcomes of trial of labor after cesarean delivery compared with elective cesarean

The vaginal birth after cesarean (VBAC) calculator developed by the Maternal-Fetal Medicine Units (MFMU) Network helps to predict the likelihood of VBAC. It is not clear whether the decision of undergoing a trial of labor after cesarean (TOLAC) is associated with adverse neonatal outcomes when the VBAC likelihood is low. We sought to compare neonatal outcomes of TOLAC to those of elective repeat cesarean after stratifying by VBAC likelihood. This was a retrospective cohort study of all women whose primary low transverse segment cesarean delivery and subsequent singleton delivery occurred at our academic center. Only data from the second pregnancy were analyzed. Women with preterm delivery prior to 37 weeks’ gestation, multiple gestation, malpresentation, abnormal placentation, fetal anomaly, and stillbirth were excluded. The MFMU VBAC calculator was used to assess the likelihood of VBAC. Women were categorized into two groups based on the VBAC likelihood (less than 60% and 60-100%). The primary outcome was a composite of perinatal death or severe neonatal complications. Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI), controlling for predefined covariates. Of 843 women, 625 (74%) and 218 (26%) had VBAC likelihood of 60-100% and less than 60%, respectively. In women with VBAC likelihood of 60-100%, women who underwent TOLAC compared with those who had elective cesarean had a similar rate of the primary outcome (7.0% vs. 8.5%; adjusted OR 0.95 [95%CI 0.51-1.75]). In women with VBAC likelihood less than 60%, women who underwent TOLAC compared with those who had elective cesarean had increased odds of the primary outcome (17.8% vs. 6.2%; adjusted OR 3.89 [95%CI 1.42-10.63]). Among women with a history of a primary low transverse segment cesarean delivery, women who underwent TOLAC compared to those who had elective cesarean had increased odds of neonatal complications when VBAC likelihood was less than 60%.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Effect of Omission of the Bladder Flap Formation at Lower Segment Cesarean Delivery: A Randomized Controlled Trial

Background: This study aims to evaluate the effects of omission of the bladder flap formation at primary and repeat lower segment CS. Patients and Methods: The current study was randomized controlled trial conducted in Women Health Hospital, Assiut University, Egypt between March 2017 and May 2018 (ClinicalTrial.gov NCT03016273). Patients were divided into: Non bladder flap group: Uterine incision made 1 cm above the vesico-uterine reflection without incision and dissection of the bladder peritoneum and bladder flap group: Standard cesarean section technique with incision and dissection of a bladder flap prior to uterine incision. Results: The study included 150 patients (75 in each arm). The most common indication for CS in both groups was repeated CS. Non-bladder flap group, compared with flap group, showed shorter skin-incision to delivery time and total operative time, and significantly lower mean estimated blood loss and postoperative pain score. Non-bladder flap group, compared with flap group, was more likely to show postoperative microhematuria. The two groups required approximately the same time for post-operative defecation. Conclusion: Omission of bladder flap formation during CS is associated with shorter operative time, less blood loss, less postoperative pain and lower incidence of postoperative hematuria.

A Rare Case of an Arteriovenous Malformation Scar Pregnancy Treated With a Combined and Conservative Approach

A Rare Case of an Arteriovenous Malformation Scar Pregnancy Treated With a Combined and Conservative Approach

Risk factors for surgical site infection after cesarean delivery: A case-control study

The cesarean delivery (CD) rate is increasing worldwide. Surgical site infection (SSI) incidence is likely to follow an upward trajectory. We examined the incidence and risk factors for SSI after CD. A case-control study of women who had a lower-segment CD during the study period was performed at Ireland's Cork University Maternity Hospital. Cases were patients who presented to the hospital with SSI and who met the criteria of the U.S. Centers for Disease Control and Prevention. Controls were randomly selected from the discharge register of CDs at a ratio of 2:1. Data were extracted from the medical records. A multivariable stepwise logistic regression model approach was used, and the results were expressed as adjusted odds ratios (aORs). The SSI rate was 2%. The greatest contribution to risk of SSI was associated with maternal obesity (aOR, 4.76; 95% confidence interval [CI], 2.00-11.32) and hypertensive disorders (aOR, 6.67; 95% CI, 1.54-28.99]. There was also an increased risk for women who underwent an emergency CD (aOR, 3.50; 95% CI, 1.09-11.30), for women who had ≥5 vaginal examinations (aOR, 3.24; 95% CI, 0.92-11.41), and for women without hypertensive disorders who delivered a baby weighing <3,500 g (aOR, 2.18; 95% CI, 1.08-4.37). Obesity, hypertensive disorders, emergency CD, and multiple vaginal examinations were independent risk factors for SSI after CD.

Case 3: Term Neonate with Tachycardia

A male infant is born at 39 weeks to a 27-year-old, gravida 3, para 1, blood group B–negative woman with an uneventful antenatal period and good antenatal care. The birth was via emergency lower-segment cesarean delivery, in view of breech presentation during labor and a birthweight of 3,100 g (appropriate for gestational age). The infant is born with no respiratory effort and bradycardia at birth requiring positive pressure ventilation. He is noticed to have micrognathia and glossoptosis causing airway obstruction and respiratory distress, with associated cleft palate (Figs 1 and 2), suggestive of Pierre Robin sequence. The infant’s 1-minute Apgar score is 4, and he develops stridor and respiratory distress soon after birth. A nasopharyngeal airway is inserted to relieve the respiratory distress. His 5-minute Apgar score improves to 7, and he is moved to the NICU for observation. He has no other obvious congenital anomaly. His chest radiograph is essentially normal. Approximately 1 hour after birth, he starts having tachycardia, with a heart rate of about 250 beats/minute, and …

Case 2: Neonate with an Eye Mask

A male infant (weight 2,340 g) is born to a 39-year-old gravida 2 woman with previously diagnosed systemic lupus erythematosus and a history of 1 preterm intrauterine fetal demise, at 34 weeks of gestation. The mother had been taking oral steroids, azathioprine, and hydroxychloroquine for the last 14 years. She had positive antinuclear antibodies and anti–double-stranded DNA antibodies with biopsy-proven class III lupus nephritis, which worsened during pregnancy with increasing proteinuria. The pregnancy was terminated at 34 weeks through elective lower segment cesarean delivery. During pregnancy, the mother had regular antenatal follow-up visits and underwent investigations including maternal anti-Ro/La antibodies, which were negative, and fetal echocardiography, which had normal findings. At the …

Case 2: Unexplained Hypercarbia in a Neonate in the Neonatal Intensive Care Unit

A male infant is delivered at term via lower-segment cesarean delivery with a birthweight of 3.5 kg to a 25-year-old gravida 2 woman. The mother did not have any significant events during the antenatal period but was noted to have polyhydramnios (amniotic fluid index, 33) during the third trimester. There is no history of consanguinity or sibling death. The infant cried after birth, with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The infant is transferred to the postnatal ward and begins breastfeeding. He develops central cyanosis 3 hours after birth and is admitted in the NICU. His vital signs at the time of admission are as follows: temperature, 97.8°F (36.6°C); heart rate, 128 beats/min; respiratory rate, 36 breaths/min; capillary refill time, 2 seconds; peripheral pulses, palpable; and oxygen saturation, 72% in room air, which improved with oxygen supplementation. The infant is limp at the time of admission, but improves after oxygen administration. The infant has intermittent stridor. He has repeated episodes of apnea on day 2 after birth, for which he was given pressure-synchronized intermittent mandatory ventilation with minimal settings. Antibiotics are started and a blood sample is sent for culture. Venous blood gas before intubation is suggestive of respiratory acidosis with normoxemia (pH 6.86, partial pressure of carbon dioxide [Pco2] 144 mm Hg [19.15 kPa], partial pressure of oxygen [Po2] 54 mm Hg [7.18 kPa], lactate 3.5 mg/dL [0.39 mmol/L]), which improves within 1 hour of ventilation (pH 7.34, Pco2 36.4 mm Hg [4.8 kPa], Po2 88 mm Hg [11.7 kPa], lactate 3.5 mg/dL [0.39 mmol/]). Clinical possibilities considered include early-onset sepsis, pneumonia, perinatal asphyxia, meningitis, congenital heart disease; congenital anomalies like esophageal atresia with/without tracheoesophageal fistula; airway anomalies; vocal cord palsy; subglottic stenosis; …

Case 1: Intramuscular Hematoma in a Neonate in the Nursery

A very preterm (29 2/7 weeks) male infant with a birthweight of 998 g is delivered by lower segment cesarean delivery (for transverse presentation with spontaneous leaking). The mother is a 25-year-old gravida 2 woman with no history of consanguinity. There is a history of intrauterine death in a previous pregnancy (at 6 months of gestation) 2 years prior. The neonate does not cry after birth. The Apgar scores are 2 and 5 at 1 and 5 minutes, respectively. The neonate undergoes intubation and is transferred to the nursery for further management in view of ongoing poor respiratory efforts. Clinical evaluation suggests multiple bruises over the left forearm, left leg, and right leg at birth. Early rescue (bovine) surfactant is administered 45 minutes after birth, ventilator settings are gradually lowered, and the neonate undergoes extubation and receives nasal continuous positive airway pressure (CPAP) 24 hours after birth. The neonate is given nothing by mouth for 24 hours, after which orogastric feeding is initiated (20 mL/kg per day) and then increased as per protocol. Treatment with caffeine (intravenous loading followed by oral) and vitamin A (injectable 5,000 IU alternate days, 3 days a week) is initiated. Respiratory distress worsens 72 hours after birth, requiring increased CPAP support. Radiologic evaluation suggests infiltrates in both the lung fields, and treatment with antibiotics (piperacillin and tazobactam with amikacin) is initiated. Respiratory distress gradually improves, antibiotics are stopped after 10 days, and the neonate is weaned to room air on day 12 after birth. The neonate regains his birthweight on day 18 after birth. The neonate is breathing room air with no respiratory distress and receiving full gavage feeds (180 mL/kg per day) till day 21, when he has 4 …

Comparison of four methods of blood loss estimation after cesarean delivery

ObjectiveTo assess agreement between four different methods of blood loss estimation after lower-segment cesarean delivery (LSCD). MethodsA secondary analysis was undertaken of a randomized controlled trial of three timings of cord clamping during LSCD performed at a center in Sri Lanka between January 21 and April 30, 2013. Eligible women underwent prepartum LSCD at 37–39weeks of pregnancy. Estimated blood loss (EBL) was assessed by a combined method (direct measurements of spilled blood and sucker bottle volumes, and weighing of surgical towels and drapes before and after use), according to visual assessments by the surgeon and by anesthesiologists, and by measurement of preoperative and postoperative hemoglobin levels. ResultsAmong 156 participants, mean EBL was 502mL (95% CI 370–618) from the combined method, 506mL (412–643) calculated from hemoglobin levels, 484mL (367–621) by the surgeon’s estimation, and 491mL (361–612) by anesthesiologists’ estimation (P=0.32). Visual assessment of EBL by anesthesiologists had the best intraclass correlation (0.713) and limits of agreement with the combined method. There were no significant differences between the proportion of cases in which anesthesiologists and the surgeon underestimated or overestimated the EBL when compared with the combined method. ConclusionEBL should be ideally obtained by the combined method.

A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery.

To study the efficacy and safety of preoperative intravenous tranexamic acid to reduce blood loss during and after elective lower-segment cesarean delivery. A single-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term singleton pregnancy at a center in Cairo, Egypt, between November 2013 and November 2014. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1g tranexamic acid or 5% glucose 15 minutes before surgery. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during cesarean, which was the primary outcome. Analyses included women who received their assigned treatment, whose surgery was 90 minutes or less, and who completed follow-up. Analyses included 100 women in each group. Mean EBL was significantly higher in the placebo group (700.3 ± 143.9 mL) than in the tranexamic acid group (459.4 ±7 5.4 mL; P<0.001). Only six women, all in the placebo group, experienced an EBL of more than 1000 mL. There were no reports of thromboembolic events up to 4 weeks postoperatively. Preoperative administration of tranexamic acid safely reduces blood loss during elective lower-segment cesarean delivery. Australian New Zealand Clinical Trials Registry:ACTRN12615000312549.

Neonate With Persistent Hydrops

A female neonate was born to a primigravid mother by emergency lower segment cesarean delivery at 33 weeks’ gestation and noted to have generalized edema, bradycardia, ascites, and hepatosplenomegaly. In view of respiratory embarrassment, the ascitic abdomen was tapped within the first few minutes after delivery. The infant’s appearance and the fluid obtained are shown in Fig 1. Figure 1. A hydropic newborn with abdominal distension and fluid from the ascitic tap (done in view of respiratory distress). The infant was admitted to the neonatal intensive care unit and given fluids and respiratory support. On examination, the newborn was edematous, with a heart rate of 50 beats per minute, respiratory rate of 70 breaths …

Misoprostol versus Foley catheter insertion for induction of labor in pregnancies affected by fetal growth restriction

ObjectiveTo compare 25μg of vaginal misoprostol with a Foley catheter for induction of labor (IOL) for fetal growth restriction. MethodsA randomized controlled trial was conducted in a tertiary center in South India. Women with fetal growth restriction (n=100) were randomized to be induced with three doses of vaginal misoprostol (25μg) every 6hours or with an intracervical Foley catheter, inserted 12hours before rupture of membranes, and oxytocin if needed. The primary outcome was uterine tachysystole with fetal cardiotocography abnormalities. Secondary outcomes pertained to effectiveness, complications, and patient satisfaction. ResultsOne woman in the misoprostol group and none in the Foley catheter group had uterine tachysystole. The duration of labor from IOL to delivery was similar in both groups (P=0.416). More women in the misoprostol group had a vaginal delivery within 12hours (26.1% versus 5.6%; P=0.005). Women induced with misoprostol were less likely to deliver by lower-segment cesarean delivery (15.2% versus 29.6%; P=0.168) and to require oxytocin augmentation (60.9% versus 85.2%; P=0.007). Complications were few in both group. ConclusionFew women had uterine tachysystole with cardiotocography abnormalities. Vaginal misoprostol at 25μg was more effective than a Foley catheter for IOL in fetal growth restriction. Clinical Trials Registry India: CTRI/2014/02/004411.

Diagnosis and Management of Cervical Pregnancy

Abstract Background: Cervical pregnancy is one of the rarest ectopic pregnancies, and it is often diagnosed as intrauterine pregnancy if careful examination is not undertaken. Termination of pregnancy can be hazardous, leading to hemorrhage when diagnosis is missed. Case: A 25-year-old woman, gravida 2, with a previous history of lower-segment cesarean delivery (LSCD) underwent medical termination of pregnancy (MTP) at 2 months of pregnancy, by pharmaceutical methods followed by dilatation and curettage. She did not undergo ultrasound examination prior to the procedure. She had continuous bleeding from her vagina for 25 days, and a transvaginal examination at the Jawaharlal Institute of Postgraduate Medical Education and Research showed an irregular gestational sac in the cervix below the internal os. Her β–human chorionic gonadotropin (β-hCG) was 146.2 (mIU)/mL, and she was treated with a variable dose of methotrexate. Results: This patient responded well to one course of methotrexate and her β-hCG norma...

Factors affecting success of trial of labour afterprevious one lower segment Caesarean section

Objective: The aim was to analyze the different factors associated with successful trial of labor after previous one lower segment cesarean delivery in our institution. Patients and methods: A Prospective case-series study was done at Al-Batool Maternity Teaching Hospital, Mosul on 476 women with previous one lower segment Caesarean delivery subjected to trial of labour between January 2009 and mid June 2009. Results: Successful trial of labour and vaginal delivery was reported in 82%. The factors that were found to be significantly associated with successful trial of labour are: parity of 2-4, history of previous vaginal delivery and particularly history of vaginal birth after Caesarean, fetal malpresentation as the indication of previous Caesarean, inter-pregnancy interval longer than 12 months, gestational age ≤ 40 weeks, cervical dilation ≥4 cm, cervical effacement ≥50%, station lower than –1 and intact membrane at time of admission, clear liquor and neonatal weight < 4000 grams. Conclusions: The factors present in woman's obstetric history and during her intrapartum course in the current pregnancy and birth weight that had significant differences in this study can be used as predictor of successful trial of labour and will help obstetrician to identify women who are more likely to attempt trial of labor and have a successful vaginal birth after previous one lower segment Caesarean delivery.

A Comparison of the Inhibitory Effects of Bupivacaine and Levobupivacaine on Isolated Human Pregnant Myometrium Contractility

Fanning, R. A.; Campion, D. P.; Collins, C. B.; Keely, S.; Briggs, L. P.; O'Connor, J. J.; Carey, M. F. Author Information