Patients Undergoing Cesarean Delivery Research Articles

Effect of an Oxytocin Protocol on Secondary Uterotonic Use in Patients Undergoing Cesarean Delivery

(Can J Anaesth. 2023;70(7):1194–1201) Following childbirth, it is customary to administer oxytocin to prevent postpartum hemorrhage (PPH). Oxytocin, the first line uterotonic, is typically given intravenously immediately after vaginal and cesarean delivery. Different oxytocin protocols exist and the optimal dosing regimen is yet to be determined. A rule of three’s oxytocin protocol was previously described and found to reduce the overall amount of oxytocin administered during scheduled cesarean deliveries (CD) while maintaining adequate uterine tone. The aim of the study was to compare a modified rule of three’s oxytocin protocol to a free-flow oxytocin infusion after CD.

Interactions Between Endocannabinoid and Endogenous Opioid Systems Prospectively Influence Postoperative Opioid Use in Pregnant Patients Undergoing Cesarean Delivery

Both endocannabinoid (EC) and endogenous opioid systems are involved in nociceptive processing and may work together synergistically based on preclinical models. This study evaluated the interactive effects of preoperative beta-endorphin (BE) concentrations (a key analgesic endogenous opioid) in cerebrospinal fluid (CSF) and ECs (CSF and plasma 2-arachidonoylglycerol and plasma anandamide) on postoperative opioid use and pain intensity in a prospective cohort of n = 112 pregnant patients undergoing scheduled cesarean delivery. Maternal blood and CSF samples were collected preoperatively for BE and EC assays. Patients completed measures of outpatient opioid use (number of tablets used and days of use) and average pain intensity at 2 weeks postoperatively. Results of general linear model analyses controlling for maternal age, body mass index at time of delivery, and race revealed significant multiplicative interactions between EC and BE concentrations on number of opioid tablets used (based on pill count), days of opioid use, and total milligram morphine equivalents used in the 2-week follow-up period. Elevated preoperative plasma and CSF 2-arachidonoylglycerol predicted reduced outpatient opioid analgesic use, particularly for patients low in CSF BE. Similar analyses for pain intensity at 2-week follow-up indicated a significant interaction (P < .02) characterized by higher preoperative BE concentrations being associated with lower subsequent pain only for individuals with low preoperative plasma anandamide concentrations. Further exploration of interactions between EC and endogenous opioid inhibitory systems as they influence responses to opioid analgesics in other clinical pain populations may help guide the development of precision pain management approaches. PerspectiveIn the postoperative setting of patients undergoing cesarean delivery, elevated ECs were linked to reduced outpatient opioid analgesic use in individuals who had low endogenous opioid concentrations in CSF. Further exploration of interactions between these 2 inhibitory systems as they impact responses to pain management interventions appears warranted.

73 Endocannabinoids and Related Lipids are Associated with Postoperative Opioid Use in Patients Undergoing Cesarean Delivery

73 Endocannabinoids and Related Lipids are Associated with Postoperative Opioid Use in Patients Undergoing Cesarean Delivery

559 Associations between Endocannabinoids and Preoperative Pain in Patients Undergoing Cesarean Delivery: an Exploratory Study

559 Associations between Endocannabinoids and Preoperative Pain in Patients Undergoing Cesarean Delivery: an Exploratory Study

Perioperative Pain Control for Patients Undergoing Cesarean Delivery

Perioperative Pain Control for Patients Undergoing Cesarean Delivery

Perioperative Pain Control for Patients Undergoing Cesarean Delivery

Perioperative Pain Control for Patients Undergoing Cesarean Delivery

Effect of Intravenous Ketamine Infusion on Hemodynamics of Patients Undergoing Cesarean Delivery after Spinal Anaesthesia: A Randomized, Double-Blind, Controlled Trial.

Hypotension is the most frequent side effect of intrathecal anaesthesia, with an incidence of more than 80%. Following neuraxial anaesthesia, perioperative shivering is a serious complication affecting 40-60% of patients undergoing surgery. This study aimed to determine the effectiveness of low-dose ketamine on blood pressure in patients undergoing cesarean delivery after spinal anaesthesia. We included 126 female patients undergoing cesarean deliveries, American Society of Anesthesiologists (ASA)-(II and III), and aged 21-40 selected from the outpatient clinics of the anaesthesia department. Patients were randomized to two groups; Group K (63 patients), who received 0.3 mg kg-1 of ketamine IV diluted to 10 mL, followed by an infusion of 0.1 mg kg-1 h-1. Group C (Controlled) (63 patients) received 10 mL of normal saline, followed by an infusion of 0.1 mL kg-1 h-1, which started before spinal anaesthesia. Compared with the saline group, the average heart rate, blood pressure, and level of sedation were significantly higher in the ketamine group (P < 0.05). The ketamine group reported a significantly lower incidence of shivering (P < 0.01). The ketamine groups exhibited significantly less mild or severe hypotension (P < 0.05). There was no significant difference between the two groups in terms of nystagmus, diplopia, hallucinations, or neonatal outcomes (P > 0.05). Ketamine decreases the incidence of hypotension and shivering in patients undergoing spinal anaesthesia during cesarean delivery. In addition, it resulted in improved sedation for the mother and prolonged postoperative analgesia without neonatal illness.

Detection of Postpartum Hemorrhage Using Compensatory Reserve Index in Patients Undergoing Cesarean Delivery.

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Early recognition and management are imperative for improved outcomes. The compensatory reserve index (CRI) is a novel physiological parameter that trends changes in intravascular volume, by continuously comparing extracted photoplethysmogram waveforms to a reference model that was derived from a human model of acute blood loss. This study sought to determine whether the CRI pattern was differential between those who do and do not experience PPH during cesarean delivery and compare these results to the American Society of Anesthesiologists (ASA) standards for noninvasive monitoring. Parturients undergoing cesarean delivery were enrolled between February 2020 and May 2021. A noninvasive CRI monitor was applied to collect continuous CRI values throughout the intraoperative and immediate postpartum periods. Patients were stratified based on blood loss into PPH versus non-PPH groups. PPH was defined as a quantitative blood loss >1000 mL. Function-on-scalar (FoS) regression was used to compare trends in CRI between groups (PPH versus non-PPH) during the 10 to 60-minute window after delivery. Two subanalyses excluding patients who received general anesthesia and preeclamptics were performed. Fifty-one patients were enrolled in the study. Thirteen (25.5%) patients experienced PPH. Pregnant patients who experienced PPH had, on average, lower postdelivery CRI values (-0.13; 95% CI, -0.13 to -0.12; P < .001) than those who did not experience PPH. This persisted even when adjusting for preeclampsia and administration of uterotonics. The average mean arterial pressure (MAP) measurements were not statistically significant (-1.67; 95% CI, -3.57 to 0.22; P = .09). Similar trends were seen when excluding patients who underwent general anesthesia. When excluding preeclamptics, CRI values remained lower in those who hemorrhaged (-0.18; 95% CI, -0.19 to -0.17; P < .001). CRI detects changes in central volume status not distinguished by MAP. It has the potential to serve as a continuous, informative metric, notifying providers of acute changes in central volume status due to PPH during cesarean delivery.

Race Differences in Transfusion Thresholds in Patients Undergoing Cesarean Delivery [ID: 1377655

INTRODUCTION: Transfusion is a major contributor to severe maternal morbidity (SMM) and is influenced by the presence of anemia on admission for delivery. As rates of SMM vary by race, we sought to describe transfusion thresholds by race and hemoglobin on admission for delivery. METHODS: This was an IRB-approved retrospective cohort analysis of deliveries in a single health care network from 2015 to 2020. Multivariable binomial regression models assessed the relationship between transfusion, hemoglobin on admission for delivery, and race. Patients with hemorrhage, abruption, or placenta abnormalities were excluded to control for events associated with transfusion. Models were adjusted for age, parity, insurance, marital status, and tobacco use and evaluated by mode of delivery. Anemia was defined as hemoglobin less than 11.0 mg/dL. RESULTS: Eighty-one thousand six hundred thirteen delivery admissions were included. People of Black race diagnosed with anemia had 1.4 times the odds of transfusion compared to White race (95% CI 1.1–1.8). In anemic patients undergoing cesarean, people of Black race had two times the odds of transfusion than people of White race (95% CI 1.4–2.7). For example, people of Black race undergoing cesarean with starting hemoglobin of 6.0 mg/dL had a 76% (95% CI 64–88%) predicted probability of transfusion compared to 27% (95% CI 17–37%) for people of White race at the same starting hemoglobin undergoing cesarean. CONCLUSION: Transfusion was more likely in people of Black race compared to White race regardless of starting hemoglobin value or underlying risk factors. This was most pronounced in patients undergoing cesarean. Exploration of specific factors contributing to this finding in the context of structural racism and inequitable care are warranted.

Comparison of Neonatal Outcomes among Patients Undergoing Cesarean Delivery under General or Spinal Anesthesia

Comparison of Neonatal Outcomes among Patients Undergoing Cesarean Delivery under General or Spinal Anesthesia

Efficacy of Surgical Transversus Abdominis Plane Block in Patients Undergoing Cesarean Delivery

ABSTRACTBackgroundThe surgical transversus abdominis plane (TAP) block is an established technique for postoperative analgesia following abdominal surgery. However, it has not been practiced frequently by obstetricians. This work was done to study the efficacy of the surgical TAP block after cesarean delivery (CD).Materials and methodsThe study included 100 women undergoing CD in MVJ Medical College and Research Hospital, Hoskote, Bengaluru, Karnataka. The operating obstetrician performed a surgical TAP block for 50 participants in the “Study” group. Twenty milliliters of 0.25% bupivacaine was injected in the transversus abdominis neurofascial plane, on either side. Another 50 participants were included in the “Control” group. Postoperatively, visual analog scores (VAS) for pain were monitored for 24 hours. Whenever the patient demanded rescue analgesia or VAS was recorded as 4 or more, rescue analgesia was administered with intravenous injection tramadol 50 mg. The time of the first rescue analgesia and the total dose of rescue analgesics required in the first 24 hours were recorded. The patients in the “Control” group routinely received intravenous injection tramadol 50 mg, 8th hourly for pain relief.ResultsThe difference in the mean VAS score at all time intervals between the two groups was statistically significant (p&lt; 0.05). The mean time to first rescue analgesia in the “Study” group and “Control” group was 11.7 ± 7.344 and 2.1 ± 1.125 hours, respectively, and the total tramadol consumption was 50 ± 28.571 and 180 ± 26.726 mg, respectively. This difference was statistically highly significant (p&lt; 0.001).ConclusionSurgical TAP block is an important adjunct in the multimodal pain management strategy and should be practiced more often in obstetric practice.How to cite this articleSravani P, Indrani C, Rajanna SP,et al. Efficacy of Surgical Transversus Abdominis Plane Block in Patients Undergoing Cesarean Delivery. J South Asian Feder Obst Gynae 2020;12(5):302–306.

Dexamethasone Administered Via the Epidural Catheter as an Adjunct in Patients Undergoing Cesarean Delivery

Dexamethasone Administered Via the Epidural Catheter as an Adjunct in Patients Undergoing Cesarean Delivery

Comparison of Hemodynamic Changes Due to Endotracheal Intubation With Labetalol and Remifentanil in Severe Preeclamptic Patients Undergoing Cesarean Delivery With General Anesthesia

Objectives: Stress replication to laryngoscopy and intubation are exaggerated in the patient with severe preeclampsia and this stress can lead to an increased risk of maternal mortality and morbidity. The aim of this study was to compare the efficacies of remifentanil and labetalol in attenuating these responses in women with violent preeclampsia undergoing cesarean section (C-section) with general anesthesia. Methods: In this double-blind study, 70 women with violent preeclampsia undergoing cesarean delivery were randomly assigned to two groups to receive either remifentanil 1 µg/kg or labetalol 0.25 mg/kg before the induction of anesthesia. Then, blood pressure (BP) and heart rate (HR) were measured before and 1, 3, and 5 minutes after the intubation. The first and 5th-minute Apgar scores were evaluated as well. Results: All hemodynamic variables decreased in both groups after the administration of remifentanil or labetalol. Labetalol significantly attenuated the rise in BP and HR during laryngoscopy and intubation compared to remifentanil (P&lt;0.001). Eventually, no significant difference was found between the Apgar scores of the two groups (P=0.97 and P=0.19, respectively). Conclusion: Overall, the administration of labetalol before the inspiration of anesthesia can control stress replication to laryngoscopy and shows better intubation and more stability than remifentanil in patients with severe preeclampsia undergoing C-section.

Creating a Surgical Site Infection Prevention Bundle for Patients Undergoing Cesarean Delivery: 1.6 www.aornjournal.org/content/cme.

We formed an interdisciplinary team to create a standardized, evidence-based protocol that would reduce cesarean delivery surgical site infection rates at our tertiary teaching facility. The Joint Commission's current implementation guide for surgical site infections, although comprehensive, does not specifically address strategies associated with the obstetric patient population. The team's approach included developing and providing patient education and preparation, standardizing prophylactic antibiotic administration, developing consistent evidence-based abdominal and vaginal preparation processes, standardizing postoperative incision care, and engaging clinical team members in process improvement. This collaboration resulted in a decrease in surgical site infection rates from 4.1% in 2014 and 5.9% in 2015 to 0.8% by the end of 2016 and 0.6% in the first two quarters of 2017. Systemizing processes initiated by the interdisciplinary team improved patient outcomes, limited readmissions, and reduced costs to the institution.

Patients Undergoing Cesarean Delivery After Exposure to Oxytocin During Labor Require Higher Postpartum Oxytocin Doses

(Anesth Analg. 2018;126:920–924) The effective dose in 90% of patients (ED90) of oxytocin infusion after cesarean delivery (CD) without labor has been reported to be 17.4 IU/h. A recent study has demonstrated an increased ED90 of 44.2 IU/h for patients who were exposed to oxytocin during labor and then progressed to CD. The University of Chicago Family Birth Center protocol for oxytocin administration in the third stage of labor calls for administration of 18 IU/h of oxytocin, with the option for doubling the infusion rate to 36 IU/h in cases of inadequate response. In this retrospective study, the authors determined the clinical relevance of increased dosing requirements for third-stage oxytocin among those patients who were exposed to oxytocin before CD versus those who were not, with the hypothesis that patients exposed to oxytocin before CD would require a higher infusion rate than called for in the protocol.

Patients Undergoing Cesarean Delivery After Exposure to Oxytocin During Labor Require Higher Postpartum Oxytocin Doses

Experts recommend postpartum oxytocin to prevent uterine atony and hemorrhage, but oxytocin may be associated with dose-dependent adverse effects, and the correct dose of postpartum oxytocin has yet to be determined. The effective dose in 90% of patients (ED90) of oxytocin after cesarean delivery may be higher in patients exposed to oxytocin during labor compared to patients unexposed. We therefore undertook this study to compare postpartum oxytocin requirements in patients exposed to oxytocin prior to cesarean delivery versus those not exposed, when all were treated according to a specific institutional protocol. In this retrospective chart review, we reviewed medical records of patients who underwent cesarean delivery under neuraxial anesthesia and noted demographic data, relevant comorbidities, and oxytocin exposure, infusion rate, and duration prior to delivery. Patients exposed to oxytocin before cesarean (OXY+ group) were compared to those not exposed (OXY- group). The primary outcome variable was highest infusion rate of postpartum oxytocin required per institutional protocol. Secondary outcomes included estimated blood loss, proportion of patients with postpartum hemorrhage, and proportions who received other uterotonic medications or red blood cell transfusion. OXY+ patients were more likely to be nulliparous and had higher estimated gestational age and neonatal weight than OXY- patients. They also had higher incidence of chorioamnionitis and lower incidence of multiple gestation. OXY+ patients required a high postpartum oxytocin infusion rate more often than OXY- patients (adjusted odds ratio 1.94 [95% confidence interval, 1.19-3.15; P = .008]). They also received other uterotonic agents more commonly. Estimated blood loss, hemorrhage rates, and transfusion rates did not differ between groups. Reported increases in the ED90 of postpartum oxytocin after oxytocin exposure during labor appear to be clinically significant. We have therefore altered our institutional protocol so that women preexposed to oxytocin routinely receive higher initial postpartum oxytocin infusion rates.

Mode of Anesthesia and Clinical Outcomes of Patients Undergoing Cesarean Delivery for Invasive Placentation: A Retrospective Cohort Study of 50 Consecutive Cases

(Can J Anaesth. 2016;63(11):1233–1244) The main aim of this retrospective cohort study of 50 consecutive cases at the authors’ institution between 2000 and 2012 was to analyze the impact of mode of anesthesia on maternal and neonatal outcomes in patients with invasive placentation undergoing cesarean delivery (CD). In the cohort, 25 women (50%) underwent elective CD, while the remaining had unplanned CD (50%); 34 of these women (68%) underwent surgery under regional anesthesia (RA) while the other 16 received general anesthesia (GA) (32%). Of these 50 patients with invasive placentation, 36 (72%) required cesarean hysterectomies (CHyst).

A Randomized Controlled Trial Comparing the Efficacy of the Transversus Abdominus Plane Block with Two Concentrations of Bupivacaine in Patients Undergoing Cesarean Delivery

Background: To investigate whether Transversus Abdominis Plane (TAP) block using either 0.5% or 0.25% bupivacaine confers additional analgesia for Cesarean section patients when compared to placebo. Methods: 60 parturients undergoing elective Cesarean delivery under combined spinal epidural anesthesia were enrolled and randomized into 3 groups. Bilateral TAP block was performed postoperatively using 15 ml solution on each side. Arm 1 received 0.5% bupivacaine, arm 2 received 0.25% bupivacaine and arm 3 received normal saline. All patients received epidural morphine after the umbilical cord was clamped. Pain and other parameters were assessed at 0 h, 3 h, 6 h, 24 h, and 48 h postoperatively. The primary outcome is the number of PCA boluses used by the patients postoperatively within 24 h. Appropriate statistical tests were used. Results: The pain scores at 3 h, 6 h, 24 h, and 48 h were significantly lower in both bupivacaine groups compared to the placebo group (p-value between 0.0281-0.0066). Fewer PCA boluses (p-value between 0.0245-0.0011) and higher satisfaction (p-values between 0.0092-0.0009) were found in both bupivacaine groups compared to the placebo group. No significant difference was noted between bupivacaine groups. No significant differences were noted in secondary objectives among the three groups. Conclusion: 0.5% and 0.25% bupivacaine TAP blocks were associated with reduced pain scores, decreased PCA requirements, and greater satisfaction than placebo. We conclude that 0.25% bupivacaine is ideal for use in TAP block as a part of multimodal analgesic regimen that includes neuraxial morphine in cesarean section patients.

The Use of Abdominal Binders in Patients Undergoing Cesarean Delivery

The Use of Abdominal Binders in Patients Undergoing Cesarean Delivery

Preoperative Music Intervention for Patients Undergoing Cesarean Delivery

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