Postpartum Hospital Research Articles

The Relationship between Preeclampsia with the Occurrence of Postpartum Depression in Masyita Delivery Hospital Makassar, Indonesia

Preeclampsia in Indonesia remains a huge problem during pregnancy with high morbidity and mortality.Many risk factors influence the occurrence of preeclampsia, such as the family history of preeclampsia,kidney disease, diabetes mellitus, chronic hypertension that has been suffered previously by pregnant mothersbefore pregnancy (preeclampsia superimposed), obesity, and postpartum depression. The research objectivewas to determine the relationship between preeclampsia and the occurrence of postpartum depression inMasyita Delivery Hospital Makassar. This study used quantitative research method with a cross-sectionaldesign. Sampling using purposive sampling with a sample size of 61 postpartum mothers. Collecting datausing a questionnaire and analyzed using the Chi-Square test. This study found that pregnant mothers whoexperienced mild preeclampsia were 34 subjects with 8.8% of them had postpartum depression, severepreeclampsia experienced by 7 subjects with 71,4% of them had postpartum depression. The results ofstatistical tests using Chi-square obtained the p-value=0.001. This study concluded that there is a significantrelationship between preeclampsia and the incidence of postpartum depression in Masyita Delivery HospitalMakassar, Indonesia.

Risk factors for postpartum readmission among women after having a stillbirth

Compared to women with a live birth, women with a stillbirth are more likely to have maternal complications during pregnancy and at birth, but risk factors related to their postpartum health are uncertain. This study aimed to identify patient-level risk factors for postpartum hospital readmission among women after having a stillbirth. This was a population-based cohort study of 29,654 women with a stillbirth in California from 1997 to 2011. Using logistic regression models, we examined the association of maternal patient-level factors with postpartum readmission among women after a stillbirth within 6 weeks of hospital discharge and between 6 weeks and 9 months after delivery. Within 6 weeks after a stillbirth, 642 women (2.2%) had a postpartum readmission. Risk factors for postpartum readmission after a stillbirth were severe maternal morbidity excluding transfusion (adjusted odds ratio, 3.02; 95% confidence interval, 2.28-4.00), transfusion at delivery but no other indication of severe maternal morbidity (adjusted odds ratio, 1.95; 95% confidence interval, 1.35-2.81), gestational hypertension or preeclampsia (adjusted odds ratio, 1.93; 95% confidence interval, 1.54-2.42), prepregnancy hypertension (adjusted odds ratio, 1.80; 95% confidence interval, 1.36-2.37), diabetes mellitus (adjusted odds ratio, 1.78; 95% confidence interval, 1.33-2.37), antenatal hospitalization (adjusted odds ratio, 1.78; 95% confidence interval, 1.43-2.21), cesarean delivery (adjusted odds ratio, 1.73; 95% confidence interval, 1.43-2.21), long length of stay in the hospital after delivery (>2 days for vaginal delivery and >4 days for cesarean delivery) (adjusted odds ratio, 1.59; 95% confidence interval, 1.33-1.89), non-Hispanic black race and ethnicity (adjusted odds ratio, 1.38; 95% confidence interval, 1.08-1.76), and having less than a high school education (adjusted odds ratio, 1.35; 95% confidence interval, 1.02-1.80). From 6 weeks to 9 months, 1169 women (3.90%) had a postpartum readmission; significantly associated risk factors were largely similar to those for earlier readmission. Women with comorbidities, with birth-related complications, of non-Hispanic black race and ethnicity, or with less education had increased odds of postpartum readmission after having a stillbirth, highlighting the importance of continued care for these women after discharge from the hospital.

The effect of active and passive maternal smoking before and during pregnancy on neonatal weight at birth.

IntroductionSmoking during pregnancy is a risk factor for adverse pregnancy outcomes. Data on the correlation between passive maternal smoking and pregnancy outcomes remain limited. We investigated the effect of active smoking and environmental tobacco smoke (ETS) during pregnancy on neonatal birthweight, including the risk for low birthweight (LBW).Material and methodsThe study was conducted between 2010 and 2012. A group of 8625 women were surveyed during postpartum hospitalization. Outcome measures included mean birthweight of newborns. Additionally, odds ratios with confidence intervals were calculated to investigate the risk for LBW in active and passive smoking groups of mothers.ResultsLower birthweight (46 g – 307 g; p < 0.05) and a higher risk for LBW (OR = 1.35, 95% CI: 1.05–1.75; p < 0.05) were observed in all infants born to smoking mothers. A negative effect of ETS in pregnancy on the reduction of mean birthweight was also found. Additionally, we analyzed the cumulative effect of active and passive smoking on neonatal birthweight. A statistically significant reduction in neonatal weight at birth was found in a group of women who smoked actively and passively during pregnancy (130 g; p < 0.05).ConclusionsSmoking is associated with decreased birthweight and in a group of active smoking mothers increased risk for LBW. This effect is dose-dependent and is also present in a group of women who smoked before pregnancy. There is also a cumulative effect of active smoking and ETS causing decreased neonatal birthweight and increased risk for low birthweight.

123 Is housing instability a social determinant of prenatal care utilization and perinatal outcomes?

To evaluate whether housing instability is associated with differences in prenatal care utilization and perinatal outcomes. In this observational cohort study, women were surveyed during their postpartum hospitalization regarding housing instability during pregnancy and their medical records were reviewed. Women were considered housing unstable if they answered affirmatively to at least one of six screening items (Figure). The primary outcome was adequacy of prenatal care measured by the Adequacy of Prenatal Care Utilization index, comparing adequate or intermediate care versus inadequate care. Secondary maternal outcomes were gestational weight gain, cesarean delivery, and hypertensive disorders of pregnancy; neonatal outcomes were preterm birth, large for gestational age status, and NICU transfer. Propensity scoring was performed using sociodemographic and clinical covariates. Multivariable logistic regression models were adjusted for propensity score weighting. In this cohort (N=489), 11.0% (N=54) experienced housing instability during pregnancy. Unstably housed women were more likely to be minority race, have less than a college education, be single, be unemployed and have had a prior preterm birth. Unstably housed women were more likely to have had inadequate prenatal care (16.7% vs 3.9%, p<0.001), but findings were not significant after propensity score adjustment (Table). There was no statistically significant association with maternal or neonatal secondary outcomes. One in 10 women in this urban population experienced housing instability during pregnancy. Housing instability appears to be a risk marker that is related to other social determinants of health; however, in this population, it does not appear to be an independent risk factor for inadequate prenatal care or other perinatal outcomes. Given the range of housing instability experiences, future research must investigate specific types of housing instability and the potential perinatal consequences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1039 Maternal transfer of care and mortality risk in obstetric patients with sepsis

Maternal sepsis is a leading cause of maternal mortality in the United States. Management typically involves prompt treatment and possible transfer to centers with higher levels of care. There is little data on obstetric transfers with sepsis. The objective of this study was to assess sepsis transfers and associated maternal mortality. A cross sectional analysis of obstetric hospitalizations with a diagnosis of shock/sepsis was conducted using the 2008-2015 National Inpatient Sample. Patients were stratified based on whether they were directly admitted or transferred in from another acute care facility. The primary outcome was inpatient mortality. Hospitals were analyzed by location and teaching status. Log linear models were fit to determine associations between transfer status and hospital factors and inpatient mortality, adjusting for patient, clinical, year, and whether patients were hospitalized antepartum, for delivery, or postpartum. Of the 58,554 cases of maternal sepsis, there were 1,806 (3.1%) inpatient mortalities and 4,942 (8.5%) maternal transfers. Most patients were admitted during an antepartum hospitalization (49.7%) followed by during a delivery (32.9%) and postpartum (17.4%) hospitalizations. Mortality rates were higher among transfer patients (9.0% vs. 2.5%), and overall higher when stratified by hospital bed size and teaching status (Figure). Adjusted analysis noted that maternal transfers were at nearly three times higher risk of mortality (aRR 2.70, 95% CI: 2.40, 3.04) compared to non-transfers. Urban teaching, urban non-teaching, and larger sized facilities were associated with significantly higher risks of maternal mortality (Table). Maternal transfers are associated with a disproportionately higher risk of inpatient mortality in the context of other hospital factors. Earlier identification of patients with sepsis and appropriate transfers to referral centers may be important in reducing maternal death from this cause.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

911 Readmission for hypertension among women in a postpartum remote blood pressure monitoring program

The effect of remote postpartum blood pressure (BP) monitoring on readmission has been variable, with studies reporting 0-15% of women being readmitted. Our objective was to describe patterns in postpartum hospital visits and readmission among women enrolled in a remote postpartum BP monitoring program. Retrospective longitudinal evaluation of a text-based blood pressure program (9/2018-8/2019). The program used twice daily reminders and two-way communication on BP for 10 days after hospital discharge. BP was triaged by a Maternal-Fetal Medicine physician. Women diagnosed with chronic hypertension (HTN) or a hypertensive disorder of pregnancy at the time of delivery discharge were included. Clinical data were abstracted from the electronic medical record. The primary outcome was readmission for HTN within 6 weeks of discharge. Bivariate analyses were performed to analyze factors associated with readmission. Monthly readmissions were assessed with a p chart. Of 877 women discharged with remote monitoring, 60 (6.8%) were seen in the obstetric (OB) triage for BP or symptoms of preeclampsia. Twelve (20%) were sent through the program and 48 (80%) presented independently or at the direction of an OB nurse or physician. Eighteen (30.0%) were readmitted, resulting in a readmission rate of 2.1% per year. Median time from delivery to readmission was 6 days (range 3-18). Demographic and clinical factors were not associated with readmission (Table). Triage evaluations initiated through the program were more likely to result in readmission (58.3% vs. 22.9%, RR 2.54 [95%CI 1.26-5.15]). Readmission rates ranged from 0-4.9% per month without significant change over time (Figure). Readmission was infrequent among postpartum women with remote blood pressure monitoring. The majority of triage visits initiated outside the program did not result in readmission, possibly representing unnecessary hospital encounters. Education for providers and patients on triaging BP through the program may result in fewer triage visits, which in turn may lead to fewer readmissions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

445 Should we restrict food intake during labor?

There is insufficient data regarding the safety of food intake during labor and its influence on labor’s course and outcome. The advantages of energy maintenance versus the risks of emesis, reflux or pulmonary aspiration during labor are not well established in the literature. Our objective was to evaluate whether eating during labor influences progression and the use of analgesics. We randomised laboring patients at 37 to 41 weeks into groups of eating versus drinking clear fluid only, during their labor and delivery. Patients with diabetes were excluded. The primary outcome was labor progression for which the sample size needed to detect a 50% difference was 126 patients. Secondary outcomes were need of analgesia, mode of delivery and early maternal and neonatal outcomes. 133 patients were randomized. The groups had similar basic characteristics. Labor progression and oxytocin requirements were similar in both groups. The rate of meconium stained amniotic fluid was higher among in the eating group without a correlation to the fetal heart rate tracing, mode of delivery or neonatal outcomes. There was no difference in the length of post-partum hospitalization or the need of pain relievers. Eating during labor and delivery does not have an adverse effect on its progression and outcome. Our data support patient’s autonomy to choose whether to eat or not during their labors.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Relationship between maternal mental status and social supports during pregnancy and until one month after childbirth in a local city.

The aim of this study was to clarify the relationship between maternal mental status and social supports during pregnancy and until one month after childbirth in order to evaluate the actual situation in a local city. A survey was conducted on 78 pregnant women who completed the CES-D (depression score), STAI (anxiety score) and Social Support Scale. Data were collected four times : during the second trimester, the third trimester, postpartum hospitalization, and 1 month after childbirth. The CES-D and STAI scores were initially high during pregnancy and decreased during the postpartum period. The Social Support Scale score, however, was initially low during pregnancy and increased during the postpartum period. The CES-D and STAI scores was significantly and negatively correlated with The Social Support Scale score during all four time periods. Participants ≧ 35 years of age scored lower on The Social Support Scale than did participants < 35 years of age in the second trimester, third trimester, and 1 month after childbirth. These findings should assist with the implementation of a comprehensive support center and may be useful for a local city in Japan. J. Med. Invest. 68 : 265-270, August, 2021.

Elaboration and Validation of Two Predictive Models of Postpartum Traumatic Stress Disorder Risk Formed by Variables Related to the Birth Process: A Retrospective Cohort Study.

This study aimed to develop and validate two predictive models of postpartum post-traumatic stress disorder (PTSD) risk using a retrospective cohort study of women who gave birth between 2018 and 2019 in Spain. The predictive models were developed using a referral cohort of 1752 women (2/3) and were validated on a cohort of 875 women (1/3). The predictive factors in model A were delivery type, skin-to-skin contact, admission of newborn to care unit, presence of a severe tear, type of infant feeding at discharge, postpartum hospital readmission. The area under curve (AUC) of the receiver operating characteristic (ROC) in the referral cohort was 0.70 (95% CI: 0.67–0.74), while in the validation cohort, it was 0.69 (95% CI: 0.63–0.75). The predictive factors in model B were delivery type, admission of newborn to care unit, type of infant feeding at discharge, postpartum hospital readmission, partner support, and the perception of adequate respect from health professionals. The predictive capacity of model B in both the referral cohort and the validation cohort was superior to model A with an AUC-ROC of 0.82 (95% CI: 0.79–0.85) and 0.83 (95% CI: 0.78–0.87), respectively. A predictive model (model B) formed by clinical variables and the perception of partner support and appropriate treatment by health professionals had a good predictive capacity in both the referral and validation cohorts. This model is preferred over the model (model A) that was formed exclusively by clinical variables.

Is Myomectomy during Caesarean Section a Safe Procedure? Prospective Cohort Study

Background: Benign uterine myoma is the commonest female tumor in the reproductive tract, and its incidence in pregnancy was estimated to be 2% to 5%. Traditionally, cesarean myomectomy was rejected as there is a liability of intrapartum and postpartum hemorrhage. The aim of this work is to investigate the significance of cesarean myomectomy together with early impact on the mother. Patients and methods: This study was conducted on 73 patients having different types and sizes of myoma during caesarean section delivery, the myomectomy was done by traditional technique but timing of myomectomy either pre or post delivery of the baby varied between different cases .Infusion of oxytocin during the operation and for 24 h later. Results: All women with uterine myoma were aging from 20- 38 years and had different parity. The participating women had myoma with different characteristics mostly from 5-10 cm. Also, the commonest types were intramural alone and sub-serous alone (76.8%). The commonest sites of fibroid were the uterine fundus and upper segment (80%).Intrapartum hemorrhage occurred in 10 cases that were overcome by ecbolics and bilateral uterine artery ligations with or without B-lynch technique. Five cases suffered from post operative fever that was overcome by antibiotics and antipyretics. The post partum hospital stay was 3 days in 63% of cases .Conclusion: caesarean myomectomy is a safe procedure but can be only done by experienced surgeon with some precautions.

A prospective pilot study to assess the impact of the etonogestrel implant on postpartum depression

Objectives To assess the feasibility of comparing the rates of positive depression screens at 6 weeks and 3 months postpartum in women using immediate postpartum etonogestrel implant (ENG-implant) and women using non-hormonal contraception or sterilisation. Methods This was a pilot prospective cohort study performed to test the design adequacy of comparing the rates of positive postpartum PHQ-9 screens (≥10) in women using immediate postpartum ENG-implant and women using non-hormonal contraception or sterilisation. Participants were recruited during the third trimester of pregnancy or during delivery hospitalisation. They self-allocated to one of the two comparison groups. PHQ-9 surveys were administered during the third trimester of pregnancy, immediately postpartum, and at 6 weeks and 3 months postpartum. Results Between June 2017 and March 2018, 91 patients were recruited. Of these patients, 11 were excluded and the remaining 80 were split evenly into each cohort. The women in the ENG-implant group were younger, less educated, and more often publicly insured. The percentage of participants with positive PHQ-9 screens were: 3% during the postpartum hospitalisation, 6.2% at 6 weeks postpartum, and 10.2% at 3 months postpartum. PHQ-9 scores were similar between groups at both postpartum time points. Conclusion The rates of positive PHQ-9 screens at 6 weeks postpartum were similar between groups. These preliminary data suggest that immediate postpartum placement of the ENG-implant does not negatively impact the risk for a positive depression screen. Larger-scale, adequately powered studies are warranted to further investigate this finding.

Women's Selection of Mode of Birth for their Breech Presentation.

Many studies since the Term Breech Trial have demonstrated the safety of vaginal breech birth (VBB), and today it is an option for breech presentation at term. However, women with breech presentation often face a difficult decision regarding mode of birth, especially when planned cesarean was the standard of care in the not-so-distant past. We aim to clarify the decision-making process and barriers women face when making this decision. Between January and April 2016, women who delivered with breech presentation were approached during their postpartum hospital stay to obtain consent for the study. The follow-up, semi-structured interview probed the woman's acquisition of knowledge and supports and barriers to her choices leading up to delivery. The responses were recorded and transcribed for analysis, and themes were identified for reporting. Of the 95 women who completed the interview, 21 preferred VBB but only 1 had a VBB. Most unplanned cesarean deliveries were performed for obstetrical indications, but 5 women expressed a lack of support for VBB or did not recall being provided options. Themes were identified with respect to the influences the women experienced, including passive external, provider-based, evidence-based, and internal. Despite the availability of options for breech pregnancy, the majority of women continue to have planned cesarean deliveries. The retrospective process reveals that women did not fully understand the eligibility criteria for VBB and all available options (including external cephalic version). Shared decision-making and continuity of care should remain a priority during the counselling process and delivery of care.

Fetal and Placental Weight in Pre-Gestational Maternal Obesity (PGMO) vs. Excessive Gestational Weight Gain (EGWG)-A Preliminary Approach to the Perinatal Outcomes in Diet-Controlled Gestational Diabetes Mellitus.

Both pre-gestational maternal obesity (PGMO) and excessive gestational weight gain (EGWG) increase the risk of gestational diabetes mellitus (GDM). Here, we conducted a retrospective study to comparatively examine the relation between fetal birth weight (FW) and placental weight (PW) in PGMO (n = 100) compared to EGWG (n = 100) with respect to perinatal outcomes in diet-controlled GDM. The control group was made up of 100 healthy pregnancies. The mean FW and the mean PW in EGWG were correlated with lowered fetal weight/placental weight ratio (FW/PW ratio). The percentage of births completed by cesarean section accounted for 47%, 32%, and 18% of all deliveries (EGWG, PGMO, and controls, respectively), with the predominance of FW-related indications for cesarean section. Extended postpartum hospital stays due to neonate were more frequent in EGWG, especially due to neonatal jaundice (p < 0.05). The results indicate the higher perinatal risk in mothers with EGWG compared to PGMO during GDM-complicated pregnancy. Further in-depth comparative studies involving larger patient pools are needed to validate these findings, the intent of which is to formulate guidelines for GDM patients in respect to management of PGMO and EGWG.

Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester.

The concept of the "fourth trimester" emphasizes the importance of individualized postpartum follow-up. Women seek care for urgent issues during this critical time period. Our objective was to evaluate trends in presenting complaints and admissions in an emergency setting over the first 42 days following delivery. Postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were studied. Demographic information, delivery route, and emergent hospital encounter details were obtained from the electronic medical record. The postpartum encounters were analyzed by week of presentation. Statistical analysis included Student's t-test and Mantel-Haenszel test with p <0.05 considered significant. Of the 8,589 deliveries, 491 (5.7%) were complicated by an emergent hospital presentation within 42 days of delivery resulting in 576 hospital encounters. 35.9% of these visits occurred in the first week and 75.5% occurred within the first 3 weeks. Women presenting to the hospital were more commonly African American, higher body mass index, and delivered via cesarean. The most common chief complaints were fever, headache, abdominal pain, vaginal bleeding, hypertension, and wound concerns with temporal trends noted. 72% of admissions occur within 14 days of delivery and drop dramatically thereafter (p = 0.001). The most common diagnoses were hypertension/preeclampsia with severe features, vaginal bleeding/delayed postpartum hemorrhage, and wound infection. We observed important trends in presenting complaints and admission diagnoses of emergency postpartum visits in the first 42 days. The majority of hospital visits and admissions occur within the first 2 weeks postpartum. Understanding maternal conditions and reasons for accessing care through an emergency setting allows for tailoring of routine postpartum follow-up. · Women presenting in the postpartum period most commonly seek care within 3 weeks of delivery.. · Postpartum presentations requiring admission most frequently occur within 2 weeks of delivery.. · The most common diagnoses on presentation were hypentension, vaginal bleeding, and wound infections..

The importance of socioeconomic position in smoking, cessation and environmental tobacco smoke exposure during pregnancy

Tobacco is still a leading cause of premature death and morbidity. Particular attention has been given to pregnant women due to the scientific evidence on the importance of early life exposures for disease onset later in life. The purpose of this study was to assess smoking prevalence, smoking cessation rate and environmental tobacco smoke (ETS) exposure, and the role of socioeconomic position (SEP) on these behaviors among pregnant women. Cross-sectional data of 619 pregnant women, aged between 18 and 46 years, from Porto Metropolitan Area, Portugal, on current smoking, ETS exposure and SEP indicators was collected, face-to-face, using a questionnaire filled in during a personal interview at the postpartum hospital stay. The smoking prevalence, and ETS exposure among non-smokers before pregnancy was 27.6% and 57.4%, respectively. 4.1% of the participants reported to have stopped smoking before pregnancy, whereas about 41% quitted along pregnancy, resulting in a smoking prevalence at birth of 14.6%. Exposure to ETS also decreased throughout pregnancy to 49.8% at birth. Lower educational level was significantly associated with both higher smoking prevalence and exposure to ETS and lower smoking cessation. This study demonstrates that smoking and ETS exposure during pregnancy remains high, and that there are still significant socioeconomic inequalities in smoking; thus tobacco-focused preventive interventions need to be reinforced.

A Project to Reduce Opioid Administration for Women in the Postpartum Period

ObjectiveTo decrease the need for opioids for women in the postpartum period by using the PainPack Protocol to administer alternating acetaminophen and ibuprofen. DesignQuality improvement project. SettingSouthwestern Ohio Level II community hospital with approximately 4,000 births per year. ParticipantsA pilot group of women who gave birth from July 2017 through December 2017 (n = 210). Full implementation included women who gave birth from January 2018 through June 2019 (n = 5,560). Intervention/MeasurementsThe PainPack Protocol used in the outpatient setting was modified and implemented for use in the inpatient setting. Outcomes were measured via chart review and were based on morphine milligram equivalents (MMEs) given in the hospital and prescribed after discharge. Feedback from women during nurse leader rounds was also considered. ResultsThe average amount of MMEs administered in the hospital was reduced from 143.2 to 105.8 for women birthing via cesarean and from 32.8 to 26.1 for women birthing vaginally. The average amount of MMEs prescribed at discharge was reduced from 281.0 to 166.9 for women birthing via cesarean and from 99.0 to 45.0 for women birthing vaginally. ConclusionThis protocol was associated with reduced amounts of opioids administered to women during postpartum hospitalization and prescribed upon discharge. At the same time, women reported effective pain control during nurse leader rounds.

Early postpartum discharge during the COVID-19 pandemic.

Objectives To report our experience with early postpartum discharge to decrease hospital length of stay among low-risk puerperium patients in a large obstetrical service during the COVID-19 pandemic in New York. Methods Retrospective analysis of all uncomplicated postpartum women in seven obstetrical units within a large health system between December 8th, 2019 and June 20th, 2020. Women were stratified into two groups based on date of delivery in relation to the start of the COVID-19 pandemic in New York (Mid-March 2020); those delivering before or during the COVID-19 pandemic. We compared hospital length of stay, defined as time interval from delivery to discharge in hours, between the two groups and correlated it with the number of COVID-19 admissions to our hospitals. Statistical analysis included use of Wilcoxon rank sum test and Chi-squared test with significance defined as p-value<0.05. Results Of the 11,770 patients included, 5,893 (50.1%) delivered prior to and 5,877 (49.9%) delivered during the COVID-19 pandemic. We detected substantial shortening in postpartum hospital length of stay after vaginal delivery (34 vs. 48h, p≤0.0001) and cesarean delivery (51 vs. 74h, p≤0.0001) during the COVID-19 pandemic. Conclusions We report successful implementation of early postpartum discharge for low-risk patients resulting in a significantly shorter hospital stay during the COVID-19 pandemic in New York. The impact of this strategy on resource utilization, patient satisfaction and adverse outcomes requires further study.

Postpartum Opioid Use Following Vaginal Deliveries with No or Minor Obstetric Perineal Lacerations

Background: Recommendations for management of pain following vaginal delivery are not specific and do not differentiate patients based on the degree of perineal trauma. Our objective is to describe patterns of postpartum opioid use in women with no or minor perineal trauma. Methods: This is a retrospective cohort study describing the characteristics of opioid analgesia usage among women with no or minor perineal lacerations at the time of vaginal delivery in a university affiliated regional hospital. Results: For the 6-month study period, 433 patients were eligible for inclusion. Of these, 423 (97.69%) were ordered as needed narcotics during their post-partum hospitalization. Of women with an as needed narcotic prescribed, 285 (65.82%) used at least one dose of narcotics while hospitalized. Significant patient characteristics of women using opioids during their inpatient post-partum course included those who used epidural analgesia during labor (p=0.009) and primiparous patients (p=0.05). Thirty-five of the women included in the study received a prescription for opioid analgesics at the time of discharge (8.08%). Significant findings among these women include increasing maternal age (p=0.007). Non-academic physicians with resident coverage were 3.1 times more likely to prescribe opioids at discharge compared to academic physicians with residents and non-academic physicians without resident coverage. Conclusions: Focusing specifically on women with no or minor perineal lacerations at the time of delivery, our findings indicate that if given the option of opioids analgesia during their hospitalization, many women will request at least one dose of opioid analgesia, but rarely require opioids after discharge.

The Effects of Antepartum Depressive Symptoms on Postcesarean Opioid Consumption.

The study aimed to test the hypothesis that higher Edinburgh Postnatal Depression Scale (EPDS) scores are associated with increased pain scores and opioid use during postpartum hospitalization following cesarean section. We conducted a retrospective cohort of English or Spanish-speaking women ≥18 years who had prenatal care for a singleton gestation and delivered by cesarean at ≥36 weeks within a tertiary center during 2017. Exclusions included women with fetal anomalies, intrauterine fetal demise, sickle cell disease, previously diagnosed pain disorders (e.g., chronic pain or fibromyalgia), substance use disorder (based on documented prescription or use of methadone or buprenorphine), or reoperation during hospital stay. Women without an EPDS recorded antenatally were also excluded. Major depressive symptoms (MDS) were defined as a documented antenatal EPDS ≥12. Women with and without MDS were compared, and multivariable linear regression models were generated to evaluate associations between MDS status and both pain scores and opioid use. Of the 891 women meeting other inclusion criteria, 676 (76%) had documented antenatal EPDS scores, and 104 (15.4%) of those had MDS. Women with MDS were more likely to be use tobacco and have general anesthesia for cesarean delivery, but groups were otherwise similar. Women with MDS reported higher daily and average pain scores postpartum (2.4 vs. 1.7 average; p < 0.001). Women with MDS used more morphine milligram equivalents (MME) each day during their postpartum hospitalization, leading to a higher total MME use (121 mg [60.5-214.5] vs. 75 mg [28.5-133.5], p < 0.001). We found an association between antepartum depressive symptoms and acute pain after cesarean delivery leading to increased opioid use. Given the current focus on opioid stewardship, further research into this association, exploration of tailored pain control, and determining whether treatment of antepartum MDS reduces postpartum pain, and therefore opioid use, will be of the utmost priority. · Women with MDS report higher pain scores postcesarean.. · Women with MDS use more opioids postcesarean.. · Future studies are needed for the treatment of MDS..

Trial of labor after cesarean delivery in grand multiparous women: maternal and neonatal outcomes

Objective To evaluate success rates of vaginal birth after cesarean (VBAC) and maternal and neonatal outcomes associated with trial of labor after cesarean in grand multiparous women. Study design A retrospective computerized data base study was conducted at a single tertiary center, between 2005 and 2019. The study compared the maternal and neonatal outcomes of trial of labor after cesarean delivery in grand multiparous women (parity ≥ 6) as compared to multiparous women (parity: 3–5). Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. Results During the study period we identified 2749 and 4294 cases of trial of labor after cesarean in grand multiparous and multiparas, respectively. VBAC was observed in 94.6% of the grand multiparous as compared to 96.5% in the multiparous group, p < .01. The grand multiparous group had a higher rate of postpartum hemorrhage (3 vs. 2.2%, p = .03) and prolonged postpartum hospitalization (1.4 vs. 0.7%, p < .01). The rates of uterine rupture (0.3 vs. 0.2%, p=.50), peripartum hysterectomy (0.1 vs. 0%, p = .33) and adverse neonatal outcomes were comparable between the groups. Conclusion Trial of labor after cesarean in grand multiparous women is associated with favorable maternal and neonatal outcomes. Consideration and awareness should be given for the increased risk for postpartum hemorrhage, not associated with uterine rupture.