Non-elective Cesarean Delivery Research Articles

Mode of delivery and behavioral and neuropsychological outcomes in children at 10 years of age.

Previous studies have reported that mode of delivery, particularly cesarean delivery (CD), is associated with neurodevelopmental outcomes in children. This study evaluates behavioral and neuropsychological test scores in children based on mode of delivery. Children enrolled in the Raine Study from Western Australia, born between 1989 and 1992 by instrumental vaginal delivery (IVD), elective CD, and non-elective CD, were compared to those with spontaneous vaginal delivery (SVD). The primary outcome was the Child Behavior Checklist (CBCL) administered at age 10. Secondary outcomes included evaluations of language, motor function, cognition, and autistic traits. Multivariable linear regression was used to evaluate score differences by mode of delivery adjusted for sociodemographic and clinical characteristics, and Poisson regression was used to evaluate for increased risk of clinical deficit. Of 2,855 children, 1770 (62.0 %) were delivered via SVD, 480 (16.8 %) via IVD, 346 (12.1 %) via elective CD, and 259 (9.1 %) via non-elective CD. Non-elective CD was associated with higher (worse) CBCL Internalizing (+2.09; 95 % CI 0.49, 3.96; p=0.01) scores, and elective CD was associated with lower (worse) McCarron Assessment of Neuromuscular Development (MAND) (-3.48; 95 % CI-5.61,-1.35; p=0.001) scores. Differences were not seen in other outcomes, and increased risk of clinical deficit was not observed with either the CBCL Internalizing or MAND scores. Differences in behavior and motor function were observed in children delivered by CD, but given that score differences were not associated with increased incidence of clinical deficit, clinical significance may be limited.

Neonatal outcomes in term and preterm infants following adjunctive azithromycin antibiotic prophylaxis for non-elective cesarean delivery

Objective It is currently unknown whether adjunctive azithromycin prophylaxis at the time of non-elective cesarean has differential effects on neonatal outcomes in the context of prematurity. The objective of this study was to compare whether neonatal outcomes differ in term and preterm infants exposed to adjunctive azithromycin prophylaxis before non-elective cesarean delivery. Study Design A planned secondary analysis of a multi-center randomized controlled trial that enrolled women with singleton pregnancies ≥24 weeks gestation undergoing non-elective cesarean delivery (during labor or ≥4 h after membrane rupture). Women received standard antibiotic prophylaxis and were randomized to either adjunctive azithromycin (500 mg) or placebo. The primary composite outcome was neonatal death, suspected or confirmed neonatal sepsis, and serious neonatal morbidities (NEC, PVL, IVH, BPD). Secondary outcomes included NICU admission, neonatal readmission, culture positive infections and prevalence of resistant organisms. Odds ratios (OR) for the effect of azithromycin versus placebo were compared between gestational age strata (preterm [less than 37 weeks] versus term [37 weeks or greater]). Tests of interaction examined homogeneity of treatment effect with gestational age. Results The analysis includes 2,013 infants, 226 preterm (11.2%) and 1,787 term. Mean gestational ages were 34 and 39.5 weeks, respectively. Within term and preterm strata, maternal and delivery characteristics were similar between the azithromycin and placebo groups. There was no difference in the odds of composite neonatal outcome between those exposed to azithromycin versus placebo in preterm neonates (OR 0.82, 95% CI 0.48-1.41) and in term neonates (OR 1.06, 95% CI 0.77-1.46), with no difference between gestational age strata (p = 0.42). Analysis of secondary outcomes also revealed no differences in treatment effects within or between gestational age strata. Conclusion Exposure to adjunctive azithromycin antibiotic prophylaxis for non-elective cesarean delivery does not increase neonatal morbidity or mortality in term or preterm infants. Clinical Trial Registration https://clinicaltrials.gov, NCT 01235546

Delayed umbilical cord clamping in elective and nonelective term Cesarean delivery

BackgroundDelayed cord clamping (DCC) is recommended for preterm and term neonates, regardless of delivery mode. After impression of increased maternal blood loss following DCC implementation during Cesarean delivery (CD) concerns arose about maternal safety, particularly in term CDs. Materials and methodsWe conducted a retrospective cohort study by reviewing birth records from our tertiary hospital in Kuopio, Finland including 914 women with singleton term CD and recorded estimated blood loss. Early cord clamping (ECC) occurred from January 2016 to December 2019, while DCC (30–60 s) from January 2020 to December 2020. We evaluated maternal and neonatal outcomes for ECC vs. DCC and assessed severe postpartum hemorrhage (PPH) (≥1500 ml) and its potential clinical risk factors. ResultsIn total, 914 women were included (DCC N = 152; ECC N = 762). Estimated mean maternal blood loss showed no significant difference between DCC and ECC groups (697 ml vs. 750 ml, p < 0.96). Severe PPH was less frequent in the DCC group (4.6% vs. 10.5 %, p < 0.024). Neonatal outcomes were similar between groups. Multivariable analysis revealed that women with placenta previa (OR 5.63, p < 0.001), macrosomic neonate (OR 2.75, p < 0.001), and intrapartum infection (OR 2.00, p < 0.057) had an increased risk for severe PPH. Earlier CD was associated with less severe PPH (OR 0.36, p < 0.001). ConclusionsDCC (30–60 s) during term CD did not increase maternal blood loss in singleton pregnancies and demonstrated no short-term adverse effects on neonates. Our findings support the general practice of DCC during both elective and nonelective term CD.

Uptake of postplacental intrauterine device placement at cesarean delivery

Several studies have investigated the effectiveness of intrauterine device placement at cesarean delivery as a contraceptive method. However, national-level use and outcomes of a postplacental intrauterine device at cesarean delivery are currently understudied in the United States. This study aimed to examine the trends, characteristics, and outcomes of patients who received a postplacental intrauterine device at cesarean delivery. This retrospective cohort study used the National Inpatient Sample. The study cohort included patients who underwent cesarean delivery from October 2015 to December 2018. The exclusion criteria included hemorrhage, chorioamnionitis, uterine anomaly, hysterectomy, and permanent surgical sterilization. Eligible cases were grouped on the basis of the use of a postplacental intrauterine device at cesarean delivery. The primary outcome measures were temporal trends and characteristics associated with the use of a postplacental intrauterine device at cesarean delivery, assessed using the generalized estimating equation model in multivariable analysis. The secondary outcome measure was perioperative morbidity (leukocytosis, endometritis, myometritis, and sepsis). Propensity score matching was used to balance the baseline characteristics. Among 2,983,978 patients who met the inclusion criteria, 10,145 patients (0.3%) received a postplacental intrauterine device at cesarean delivery. The use of a postplacental intrauterine device increased from 0.1% in the fourth quarter of 2015 to 0.6% in the fourth quarter of 2018 (P<.001). In a multivariable analysis, the use of a postplacental intrauterine device increased by 14% every quarter-year (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.15). In addition, (1) patient characteristics of young age, non-White race, obesity, tobacco use, lowest quartile median household income, and insured with Medicaid; (2) hospital characteristics of large bed capacity and urban teaching setting in Northeast region; and (3) pregnancy characteristics of early gestational age at cesarean delivery, hypertensive disease, previous cesarean delivery, multifetal pregnancy, grand multiparity, placenta previa, and nonelective cesarean delivery represented the independent characteristics associated with the use of a postplacental intrauterine device (all P<.05). A regression tree model identified 35 discrete patterns of the use of a postplacental intrauterine device based on 8 factors (time, race or ethnicity, primary expected payer, obesity, hospital bed capacity, hospital teaching status, hospital region, and previous cesarean delivery). There were 9 patterns, representing 8.8% of the study population, exhibiting a use rate of ≥1.0%, whereas there were 7 patterns, representing 16.0% of the study population, exhibiting no use of a postplacental intrauterine device (absolute rate difference from the highest group to the lowest group, 4.7%). In a propensity score-matched model, postplacental intrauterine device placement at cesarean delivery was not associated with increased risk of measured morbidity (any, 1.8% vs 1.7%; odds ratio, 1.06; 95% confidence interval, 0.66-1.69; P=.812), including postpartum endometritis (1.2% vs 1.0%; odds ratio, 1.19; 95% confidence interval, 0.67-2.14; P=.554). The use of a postplacental intrauterine device at cesarean delivery increased significantly in recent years in the United States.

Assessment of compliance with a color code protocol for non-elective cesarean section and its impact on time to delivery interval and neonatal outcomes

IntroductionWe set out to assess the compliance with a cesarean section color code protocol and its impact on maternal and neonatal outcomes since its implementation in our maternity ward. MethodsThis was a retrospective study including a sample of 200 patients per year who underwent a non-elective cesarean section delivery in Rennes University Hospital from January 1, 2015 to December 31, 2018. Patients were grouped by year and by color code (red, orange or green). The main outcome was compliance with the protocol (color code in accordance with indication for cesarean section) and compliance with the corresponding decision-delivery interval. Secondary outcomes were maternal and neonatal outcomes. ResultsEight hundred patients were included during the study period. There was no significant difference in patient characteristics over the years. There was a significant improvement in protocol compliance: full compliance increased from 22.4% in 2015 to 76.5% in 2018 (p < 0.0001). The respect of the 15 min decision-delivery interval in red code protocol increased between 2015 and 2018 (p = 0.0020). ConclusionWe observed a significant improvement in compliance with the color code protocol between 2015 and 2018 and in the 15 min decision-delivery deadline for the red code.

Validation of translated Obstetric Quality of Recovery (ObsQoR-10A) score after nonelective cesarean delivery (CD) in an Arabic-speaking population.

The ObsQoR-11 is a validated scale that assesses recovery after cesarean delivery (CD). This observational study aimed to evaluate the psychometric properties of its Arabic version. The original ObsQoR-11 was translated into an Arabic version (ObsQoR-10A). All participants completed the ObsQoR-10A at 24 h and 48 h postoperatively after CD. Validity, reliability, responsiveness, and feasibility were assessed. The ObsQoR-10A correlated with Global Health Numerical Rating Scale (NRS) at 24 h (R = 0.68, 95% CI: 0.56-0.80, P < 0.001) and at 48 h (R = 0.66, 95% CI: 0.54-0.78, P < 0.001) and differentiated between good and poor recovery (median scores at 24 h 88 vs. 71, P < 0.001; at 48 h 95.5 vs. 70, P < 0.001). ObsQoR-10A correlated with hospital length of stay at 24 h (R = -0.21, 95% CI: -0.40 to -0.02, P = 0.03) and at 48 h (R = -0.21, 95% CI: -0.40 to -0.03, P = 0.02); gestational age at 24 h (R = 0.22, 95% CI: 0.03-0.40, P = 0.02); change in hemoglobin at 24 h (R = -0.30, 95% CI: 0.51 to -0.10, P < 0.01); and total opioids at 48 h (R = -0.45, 95% CI: -0.62 to -0.27, P < 0.001). There was a significant difference between 24 h and 48 h postoperative ObsQoR-10A scores (median difference: -18; P < 0.001 which shows responsiveness). Other key measures included a Cronbach's alpha of 0.87, split-half 0.75, and intra-class correlation >0.62 with no floor or ceiling effects. Median (IQR) completion time was 3 (3-5) and 3 (2.5-3.5) minutes at 24 h and 48 h. ObsQoR-10A is a valid, reliable, responsive, and a clinically feasible tool in an Arabic-speaking obstetric population.

Child-Mother Index: a new risk factor for selected adverse maternal birth outcomes

Over decades, obstetricians have evaluated a range of risk factors to improve the prediction of adverse birth outcomes. This study aimed to assess the effectiveness of the Child-Mother Index as a risk factor indicator for selected adverse maternal birth outcomes. We assessed the Child-Mother Index by multinomial regression models using register-based data containing all singleton births in Denmark in 2009 with a gestational age between 37+0 and 41+6 weeks. The Child-Mother Index is defined as the weight of the newborn divided by the squared maternal height. Data from 47,007 births were included. Both the Child-Mother Index mean and Child-Mother Index median were 12.6 hg/m2 (range, 4.8-22.4). In the multivariable model, the relative risk ratios for Child-Mother Index above 14.1 hg/m2 were 2.2 (95% confidence interval, 1.6-3.1) for third- and fourth-degree perineal tears, 2.0 (1.6-2.5) for nonelective cesarean delivery, and 1.0 (0.8-1.3) for instrumental procedures. Equivalent figures for a Child-Mother Index below 11.2 hg/m2 were 0.6 (0.4-1.0), 1.0 (0.8-1.2), and 0.7 (0.6-0.9), respectively.By comparing a multivariable model with the Child-Mother Index included with a model without the Child-Mother Index included using a likelihood ratio test, a statistically significant difference was found in favor of the Child-Mother Index inclusion (P<.001). The Child-Mother Index constitutes a potential useful risk factor indicator for statistical analyses on data after birth. The value of the Child-Mother Index based on the estimated fetal weight before birth deserves evaluation.

Obstetric and perinatal outcomes in parturients with active SARS-CoV-2 infection during labor and delivery: a retrospective cohort study

BackgroundThe COVID-19 pandemic is an ongoing global healthcare crisis that negatively affects pregnant women. Although patients with an acute infection during pregnancy have been widely studied, information regarding labor and delivery while infected is sparse. The aim of the study was to ascertain maternal, obstetrical, and perinatal outcomes of women who gave birth while infected with SARS-CoV-2.MethodsPatients diagnosed with COVID-19 during pregnancy at a tertiary medical center in 4/20–2/21 were identified by a retrospective database search. Those with an active intrapartum SARS-CoV-2 infection were compared with those who recovered at least 10 days before labor and delivery.ResultsOf the 176 women included in the study, 84 had a SARS-CoV-2 infection at the time of delivery and 92 had recovered from the infection. There was no statistically significant between-group difference in mean gestational age at delivery (39 weeks for both, p = 0.71) and overall rate of cesarean delivery (26.2% vs 17.4%, respectively, p = 0.35) or non-elective cesarean delivery (10.71% vs 4.34%, respectively, p = 0.48). In the active-infection group, the rate of severe disease was 2.4%, and of critical disease (with intensive care unit admission, mechanical ventilation, and ECMO), 3.6%, compared to zero for both in the recovered group. No differences were found between the groups in adverse perinatal outcomes.ConclusionDelivery is safe and feasible in women with active SARS-CoV-2 infection. Nevertheless, we found a non-significant trend for more severe disease and for cesarean delivery and urgent cesarean delivery (for COVID-19-related indications) in women with an intrapartum SARS-CoV-2 infection.

Adjunctive azithromycin prophylaxis protects women from uterine cesarean scar defect: A randomized controlled trial.

Cesarean scar defect (CSD) is a long-term outcome of cesarean section (CS) and associated with numerous gynecological and obstetric problems. Previous studies indicate that infection may be a risk factor for CSD. Adjunctive azithromycin was shown to reduce the risk of postoperative infection in patients undergoing non-elective primary cesarean delivery in labor or after the rupture of membranes compared with standard antibiotic prophylaxis. This study investigated the protective effect of adjunctive azithromycin in combination with single-dose cephalosporin against CSD in women undergoing non-elective cesarean delivery. A randomized, double-blind, controlled clinical trial was conducted in a University hospital in Shanghai, China. A total of 242 women who underwent their first non-elective CS were randomly assigned to receive 1500 mg cefuroxime sodium plus 500 mg intravenous azithromycin (n=121; experimental group) or 1500 mg cefuroxime sodium plus a placebo (n=121; placebo group). The primary outcome was CSD prevalence, as determined by transvaginal ultrasound and saline infusion sonohysterography within 6months of delivery. Secondary outcomes were changes in infectious indicators (eg hypersensitive C-reactive protein and procalcitonin), postoperative morbidity, and use of postoperative antibiotics. We also examined the operative procedure, pathogenic microorganism cultures, and fetal outcomes. Outcomes were compared between groups with the chi-squared test, Fisher's exact test, or Student's t test. Between May 2018 and May 2021, 121 women were randomized to each arm. Because the sonographic follow up was disrupted by the coronavirus disease 2019 pandemic and strict management policies, we merged the follow-up time points (6 weeks and 6months) into a single time period (6 weeks to 6months); 104 and 108 women in the experimental and placebo groups, respectively, completed the first sonographic follow up. CSD was diagnosed by sonography in 34/104 (32.7%) and 50/108 (46.3%) patients in the experimental and placebo groups, respectively (relative risk 0.71, 95% confidence interval 0.50-0.99; p=0.043). Characteristics of CSD and short-term infection outcomes did not differ between groups. A single dose of intravenous 500 mg azithromycin adjunctive to single-dose cefuroxime prophylaxis significantly reduced the incidence of CSD in women undergoing non-elective CS.

Prediction model for prolonged hospitalization following cesarean delivery

IntroductionA rise in the rate of cesarean delivery (CD) has been found to be associated with a higher length of hospital stay, making it a public health concern. We aimed to evaluate risk factors for prolonged hospitalization following CD. MethodsA retrospective cohort study, in a single tertiary medical center, was conducted (2011–2019). Cesarean deliveries were categorized into three groups according to the postpartum length of stay (a) up to 3 days (the routine post cesarean hospital stay in our center, reference group) (b) 4–9 days, and (c) 10 days or above (prolonged hospitalization). Risk factors were examined using univariate analysis as well as multivariate logistic regression. A specific risk prediction score was developed to predict the need for prolonged hospitalization and ROC curve was assessed utilizing the performance of our model. ResultsOverall, 87,424 deliveries occurred during the study period. Of them, 19,732 (22.5%) were cesarean deliveries. Hospitalization period was distributed as follows: 10,971 (55.6%) women were hospitalized for up to 3 days, 7,576 (38.4%) stayed for 4–9 days and 1,185 (6%) had a prolonged hospitalization period (≥10 days). Using multivariate analysis, multiple pregnancy (OR = 1.29, 95%CI 1.05–1.58), preterm delivery < 37 weeks (OR = 8.32, 95%CI 6.7–10.2), Apgar score < 7 (OR = 1.41, 95%CI 1.11–1.78) and non-elective CD (OR = 1.44, 95%CI 1.15–1.8) were identified as independent risk factors for prolonged hospitalization. Antenatal thrombocytopenia (PLT < 100 K) was found to be a protective factor (OR = 0.51, 95%CI 0.28–0.92). Our score model included antenatal risk factors and was found to be predicting the outcome, with an AUC of 0.845 (95%CI 0.83–0.86, p-value < 0.001). ConclusionA prediction score model for prolonged hospitalization after CD may be beneficial for risk assessment and post-partum management.

Overall Vertical Transmission of Hepatitis C Virus, Transmission Net of Clearance, and Timing of Transmission.

It is widely accepted that the risk of hepatitis C virus (HCV) vertical transmission (VT) is 5%-6% in monoinfected women, and that 25%-40% of HCV infection clears spontaneously within 5 years. However, there is no consensus on how VT rates should be estimated, and there is a lack of information on VT rates "net" of clearance. We reanalyzed data on 1749 children in 3 prospective cohorts to obtain coherent estimates of overall VT rate and VT rates net of clearance at different ages. Clearance rates were used to impute the proportion of uninfected children who had been infected and then cleared before testing negative. The proportion of transmission early in utero, late in utero, and at delivery was estimated from data on the proportion of HCV RNA positive within 3 days of birth, and differences between elective cesarean and nonelective cesarean deliveries. Overall VT rates were 7.2% (95% credible interval [CrI], 5.6%-8.9%) in mothers who were human immunodeficiency virus (HIV) negative and 12.1% (95% CrI, 8.6%-16.8%) in HIV-coinfected women. The corresponding rates net of clearance at 5 years were 2.4% (95% CrI, 1.1%-4.1%), and 4.1% (95% CrI, 1.7%-7.3%). We estimated that 24.8% (95% CrI, 12.1%-40.8%) of infections occur early in utero, 66.0% (95% CrI, 42.5%-83.3%) later in utero, and 9.3% (95% CrI, 0.5%-30.6%) during delivery. Overall VT rates are about 24% higher than previously assumed, but the risk of infection persisting beyond age 5 years is about 38% lower. The results can inform design of trials of interventions to prevent or treat pediatric HCV infection, and strategies to manage children exposed in utero.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Strategies to Lower NTSV Cesarean Birth Rates - An Evidence Based Practice Project

Of the annual 4.1 million births in the United States, more than 1.3 million are via cesarean. Research shows that “Failure to progress in labor” (i.e., labor dystocia) is the leading cause of post labor non-elective primary cesarean delivery. It directly or indirectly accounts for approximately 60% of all cesarean deliveries (Spong, C.Y. et al., 2012). In comparing statistics, it was evident that NRHS 2018 & 2019 average NTSV cesarean birth rate of 27.4% was notably higher than the National & State averages, (25.8% & 24.6% respectively), and above the proposed Healthy People 2020 Benchmark of 23.9%. It also became very evident that the top driver of NHRS’ NTSV cesarean births (September 2019 – August 2020) was Labor Induction, and specifically, Cytotec / Cervidil to Pitocin Inductions. Monthly case reviews further revealed a consistency between these labor inductions and the diagnosis of labor dystocia (arrested progress). This diagnosis is currently the documented leading indication for NRHS’ NTSV cesarean births.

Carbetocin Compared With Oxytocin in Nonelective Cesarean Delivery: A Systematic Review, Meta-analysis, and Trial Sequential Analysis of Randomized-controlled Trials

(Can J Anesth. 2020;67:1524–1534) Uterotonic agents, such as oxytocin and carbetocin, are used in the management of uterine atony, a major cause of postpartum hemorrhage (PPH). While oxytocin and carbetocin both have fast onset of action, oxytocin has a short duration of action, requiring immediate intravenous (IV) infusion during the perioperative period. In contrast, carbetocin has a longer duration with effects lasting for 60 minutes after onset. Previous literature suggests that carbetocin may be as effective as oxytocin, and a recent study showed that the need for additional uterotonics was reduced by 53% with carbetocin versus oxytocin for elective cesarean delivery (CD). However, it remains unclear how these 2 uterotonics compare in pregnant women undergoing nonelective CD. The aim of this study was to compare the efficacy of carbetocin with oxytocin in women undergoing nonelective CD.

Incidence of Infertility and Pregnancy Complications in US Female Surgeons

While surgeons often delay pregnancy and childbearing because of training and establishing early careers, little is known about risks of infertility and pregnancy complications among female surgeons. To describe the incidence of infertility and pregnancy complications among female surgeons in the US and to identify workplace factors associated with increased risk compared with a sociodemographically similar nonsurgeon population. This self-administered survey questionnaire was electronically distributed and collected from November 2020 to January 2021 through multiple surgical societies in the US and social media among male and female attending and resident surgeons with children. Nonchildbearing surgeons were asked to answer questions regarding the pregnancies of their nonsurgeon partners as applicable. Surgical profession; work, operative, and overnight call schedules. Descriptive data on pregnancy loss were collected for female surgeons. Use of assisted reproductive technology was compared between male and female surgeons. Pregnancy and neonatal complications were compared between female surgeons and female nonsurgeon partners of surgeons. A total of 850 surgeons (692 women and 158 men) were included in this survey study. Female surgeons with female partners were excluded because of lack of clarity about who carried the pregnancy. Because the included nonchildbearing population was therefore made up of male individuals with female partners, this group is referred to throughout the study as male surgeons. The median (IQR) age was 40 (36-45) years. Of 692 female surgeons surveyed, 290 (42.0%) had a pregnancy loss, more than twice the rate of the general population. Compared with male surgeons, female surgeons had fewer children (mean [SD], 1.8 [0.8] vs 2.3 [1.1]; P < .001), were more likely to delay having children because of surgical training (450 of 692 [65.0%] vs 69 of 158 [43.7%]; P < .001), and were more likely to use assisted reproductive technology (172 of 692 [24.9%] vs 27 of 158 [17.1%]; P = .04). Compared with female nonsurgeon partners, female surgeons were more likely to have major pregnancy complications (311 of 692 [48.3%] vs 43 of 158 [27.2%]; P < .001), which was significant after controlling for age, work hours, in vitro fertilization use, and multiple gestation (odds ratio [OR], 1.72; 95% CI, 1.11-2.66). Female surgeons operating 12 or more hours per week during the last trimester of pregnancy were at higher risk of major pregnancy complications compared with those operating less than 12 hours per week (OR, 1.57; 95% CI, 1.08-2.26). Compared with female nonsurgeon partners, female surgeons were more likely to have musculoskeletal disorders (255 of 692 [36.9%] vs 29 of 158 [18.4%]; P < .001), nonelective cesarean delivery (170 of 692 [25.5%] vs 24 of 158 [15.3%]; P = .01), and postpartum depression (77 of 692 [11.1%] vs 9 of 158 [5.7%]; P = .04). This national survey study highlighted increased medical risks of infertility and pregnancy complications among female surgeons. With an increasing percentage of women representing the surgical workforce, changing surgical culture to support pregnancy is paramount to reducing the risk of major pregnancy complications, use of fertility interventions, or involuntary childlessness because of delayed attempts at childbearing.

Analgesic effects of intravenous ketamine after spinal anaesthesia for non-elective caesarean delivery: a randomised controlled trial

ObjectivesThis study aimed to determine if low dose intravenous ketamine is effective in reducing opioid use and pain after non-elective caesarean delivery.DesignProspective, randomised, double-blind.SettingTertiary hospital, Bisheshwar Prasad Koirala Institute of...

Incidence and Risk Factors for Maternal Hypoxaemia During Induction of General Anesthesia for Non-elective Caesarean Section: A Prospective Multicentre Study

(British J Anaesthesia. 2020;125:e81–e87) General anesthesia, which can increase the risk of respiratory complications, is used in about 5% of deliveries and is mainly used in emergency cesarean sections. One study found that hypoxemia affected 2% of cesarean patients undergoing general anesthesia, but no risk factors were identified. This study aimed to determine the incidence and risk factors of hypoxemia in patients undergoing general anesthesia for non-elective cesarean delivery.

Choice of Hypnotic Drug for Obstetric and Non-obstetric General Anaesthesia. Comment on Br J Anaesth 2020; 125: e81-7

(Br J Anaesth. 2020;125:e452–e453) Airway management conditions are affected by many factors, including the anesthetic induction drugs used. A recent study by Bonnett and colleagues in patients undergoing non-elective Cesarean delivery found co-administering propofol with succinylcholine resulted in superior intubating conditions compared with the co-administration of thiopental with succinylcholine. These results support the use of propofol rather than thiopental in obstetric general anesthesia.

Fetal lactate levels align with the stage of labour

AimTo evaluate the association between lactate concentrations in fetal blood samples and the different advanced labour stages. MethodsEighteen-month prospective population-based clinical study of 187 singleton pregnant women in labour who were monitored by fetal blood sampling (FBS) because of non-reassuring intrapartum CTG results at Kuopio University Hospital, Finland. Peripheral lactate concentration and pH were analysed at different stages of labour and in umbilical arterial samples immediately after delivery. ResultsFBS samples (N = 350) were obtained from 5.4 % of all women in labour during the study period, and 48 % had spontaneous delivery, 27 % had vacuum-assisted vaginal delivery, and 25 % had nonelective Caesarean delivery. FBS lactate levels increased 4–11% with every 1–2 cm of cervical dilation and 18 % from early labour to fully dilated cervix. In 42 women with at least two FBSs, lactate levels increased significantly from the early I stage of labour and up to a fully dilated cervix. Lactate values were significantly higher in umbilical arterial samples compared to FBSs. Sensitivity of the highest FBS lactate values for the detection of birth asphyxia were considerably low varying between 42.9–57.1%. ConclusionFBS lactate levels were related to the stage of labour during vaginal delivery attempt. Wide range of lactate levels during labour complicates its use as a predictor of birth asphyxia.

1103 Timing of adjunctive azithromycin administration for cesarean prophylaxis and the risk of post-operative infectious morbidity

To assess whether timing of adjunctive azithromycin administration together with standard antibiotic prophylaxis is associated with risk of infectious morbidity after non-elective cesarean delivery (CD). Secondary analysis of women from the C/SOAP multicenter RCT of adjunctive azithromycin versus placebo (+ standard antibiotic prophylaxis) in women with singletons undergoing unscheduled CD. The primary exposure was timing of antibiotic administration (in 30 minute increments) relative to skin incision. The primary outcome was a post-operative infection composite of endometritis, wound infection and other maternal infections occurring within 6 weeks of CD. Outcomes were compared across antibiotic timing groups using multivariable logistic regression with >60 mins as the referent group. We also assessed potential interaction between antibiotic administration timing and randomization status. Of 2013 women from the parent RCT, 1973 patients with complete data were included: 1355 (68.7%) received any perioperative antibiotics in the 30 minutes preceding the skin incision, while 92 (<5%) received antibiotics >60 min prior to skin incision. The antibiotic timing groups differed in parity (p=0.012) and alcohol use (p<0.001). There was no significant difference in the odds of the primary post-operative composite infection outcome (or any of its individual components) among the timing groups (Table 1). Tests of interaction showed no significant differences in post-infectious morbidity among the randomized groups of antibiotic timing (p>0.05; Table 2). Adjunctive azithromycin administration decreases post-operative infectious morbidity at non-elective cesarean deliveries even when administered more than 60 minutes prior to skin incision or in the postpartum period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)