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A case of postcesarean vesico-uterine fistula in conjunction with a fibrous cord joining the anterior and posterior wall of the bladder is reported. The symptoms of menouria and amenorrhoea in the absence of urinary incontinence are explained by reference to the pressure gradients which normally exist in the bladder and the uterine cavity. The etiology, diagnosis and therapy of this and other reported cases are reviewed.
Wound infections are a common surgical complication, often requiring a prolonged hospital stay and leading to increased costs. Over a one-year period, 2,431 patients were followed after cesarean delivery with prompt evaluation and culture of all suspicious wounds. Seventy subjects (2.8%) developed confirmed wound infection, and 42 (1.7%) developed noninfected open surgical wounds. Seven (0.3%) fascial dehiscences were diagnosed, requiring surgical repair. Forty of 63 (64%) infected wounds had positive bacterial cultures, with Staphylococcus epidermidis (29%), Enterococcus faecalis (17%), Staphylococcus aureus (17%), Escherichia coli (11%) and Proteus mirabilis (10%) the most frequent isolates. Only 7 of 42 (17%) noninfected wounds had positive cultures, with only S aureus, S epidermidis and Corynebacterium species isolated. Ninety-five percent of the noninfected wounds had blood or serous collections present. Rupture of membranes lasting longer than six hours, emergency cesarean delivery and morbid obesity were associated with a statistically increased likelihood of the development of infected wounds. Emergency cesarean delivery and morbid obesity, but not prolonged rupture of membranes, were associated with an increased likelihood of the development of noninfected wounds. Therefore, it appears that at least two mechanisms are responsible for the development of postcesarean open wounds: (1) increased amniotic fluid and wound colonization due to prolonged rupture of membranes, resulting in a wound infection containing one or more bacterial species derived from the cervicovaginal flora, and (2) increased exogenous bacterial contamination and flora consistent with skin species or breaks in sterile technique, often accompanying difficult or emergency surgery.
UNLABELLED: In this randomized, double-blind trial in 240 women, we investigated the analgesic efficacy and duration of subarachnoid fentanyl 15 microg with morphine, clonidine, or both morphine and clonidine for cesarean delivery. A dose-finding analysis showed similar postoperative efficacy and side effects for groups receiving morphine 100 microg with clonidine 60, 90, or 150 microg. Data from these groups were combined (MC60-150, n = 113) and compared with groups receiving morphine 100 microg (n = 39), clonidine 150 microg (n = 39), or morphine 100 microg plus clonidine 30 microg (n = 41). The four groups differed in the time to patient-controlled morphine use and cumulative morphine consumption (P < 0.0001 and P < 0.001, respectively), with the longest duration and smallest dose in MC60-150. Pain scores were significantly different among groups. Onset of sensory block, ephedrine requirement and incidence of hypotension, patient satisfaction, and recovery were similar. Groups receiving clonidine had greater sedation, those receiving morphine had more severe pruritus, and group MC60-150 showed a trend to more vomiting intraoperatively. Compared with morphine 100 microg or clonidine 150 microg alone, the combination of subarachnoid morphine 100 microg and at least 60 microg of clonidine was found to increase the duration of postcesarean analgesia, reduce opioid requirement, and increase intraoperative sedation. IMPLICATIONS: A multimodal approach to postcesarean analgesia, using subarachnoid bupivacaine, fentanyl, morphine 100 microg, and clonidine 60 microg, improves pain relief compared with morphine 100 microg or clonidine 150 microg alone, but increases intraoperative sedation and may increase perioperative vomiting.
The purpose of this prospective investigation was to compare a single intravenous dose of cefazolin to a single dose of cefonicid as prophylaxis for women having unscheduled cesarean delivery. In a double-blind, randomized design, 96 patients were assigned to receive a 1-g dose of cefazolin and 103 patients were designated to receive a 1-g dose of cefonicid. The antibiotics were administered after delivery of the infant. The two groups were comparable with respect to recognized risk factors for postcesarean infection. There were no statistically significant differences between the groups in the incidence of standard febrile morbidity, endomyometritis, urinary tract infection, wound infection, and bacteremia. There were also no significant differences between the groups in the fever index or the duration of hospitalization. We conclude that cefazolin and cefonicid provide a similar degree of prophylaxis against infection in patients having unscheduled cesarean delivery.
OBJECTIVE: To evaluate the cost-effectiveness of thromboprophylaxis at cesarean delivery with intermittent pneumatic compression. METHODS: A decision tree model using Markov analysis was developed to compare two approaches to perioperative care at the time of cesarean delivery: 1) no use of perioperative thromboprophylaxis and 2) the use of intermittent pneumatic compression for thromboprophylaxis at the time of cesarean delivery. Postcesarean deep venous thrombosis was estimated to occur in 0.7% of patients (75% of whom were asymptomatic), and result in a 9% chance of postthrombotic syndrome. Mechanical prophylaxis was assumed to decrease the risk of deep venous thrombosis by 70% and to cost 120 dollars. Probability of morbidity and mortality of venous thromboembolism as well as anticoagulation and the costs and utilities for different health state were derived from published studies. Sensitivity analysis was performed over a wide range of variable estimates. RESULTS: Using the assumptions in our base case, routine thromboprophylaxis for cesarean delivery cost 39,545 dollars per quality-adjusted life year. One-way sensitivity analysis revealed that as long as the incidence of postcesarean deep venous thrombosis was at least 0.68%, intermittent pneumatic compression reduced the incidence of deep venous thrombosis by at least 50%, or the cost of intermittent pneumatic compression was less than 180 dollars, the cost-effectiveness of mechanical prophylaxis did not exceed 50,000 dollars per quality-adjusted life year. CONCLUSION: Mechanical thromboprophylaxis is estimated to be a cost-effective strategy under a wide range of circumstances.
Epidural narcotics are finding increasing favor in management of postcesarean birth pain. Effective pain relief coupled with minimal side effects often make this technique the method of choice. To provide comprehensive and safe nursing care for the mother using epidural narcotics, nurses must be knowledgeable about the technique, drugs, and associated patient responses. Nursing management using a care plan with nursing diagnosis and expected patient outcomes will help nurses plan their care of these patients.
We encountered in a woman at the 28th day after cesarean delivery the transient appearance of a uterine cervical mass with a prominent blood flow, that was revealed to be an acquired arteriovenous fistula. The size and blood flow of the mass were monitored using transvaginal color Doppler scanning and magnetic resonance imaging (MRI). Based on these findings, the arteriovenous fistula was managed conservatively without any adverse complications.
Volvulus is an uncommon cause of bowel obstruction during pregnancy. We present an unusual case in which cesarean delivery at 26 weeks of gestation was complicated by volvulus of the small bowel 1 week following delivery. At laparotomy, detorsion of the loop of the terminal ileum sufficed, and bowel resection was not required. We review the literature pertaining to volvulus of the bowel during pregnancy and discuss recent new diagnostic imaging modalities for midgut volvulus, which may assist early noninvasive diagnosis of this condition.
Hemorrhage remains a serious obstetric complication with uterine atony as its most common cause. Postpartum atony is controlled with oxytocics and prostaglandins. Uterine arterial ligation is used to decrease the degree of postpartum hemorrhage. Hypogastric arterial ligation and hysterectomy are used when conservative measures fail. With placenta previa accreta, the aforementioned techniques are often not successful in the control of bleeding in the lower segment. The technique of packing of the lower uterine segment is described for use when local control of bleeding points is unsuccessful and hysterectomy is contemplated. Preservation of reproductive potential may be accomplished with this technique with minimal maternal morbidity.
OBJECTIVE: This study was done to determine the impact of the method of placental removal and the site of uterine repair on postcesarean infectious morbidity rates in women receiving prophylactic antibiotics at cesarean delivery. STUDY DESIGN: This prospective study included 284 women who underwent cesarean delivery and who were randomly assigned to four groups based on the method of placental removal and the site of uterine repair: group 1, spontaneous placental removal and in situ uterine repair; group 2, spontaneous placental removal and exteriorized uterine repair; group 3, manual placental removal and in situ uterine repair; and group 4, manual placental removal with exteriorized uterine repair. Exclusion criteria were repeat cesarean deliveries without labor, active infection at the time of cesarean delivery, and patient refusal to participate. RESULTS: There was no significant difference among the groups in maternal age, race, parity, weight, the length of time from rupture of membranes (ROM) or the number of vaginal examinations from ROM to cesarean delivery, or preoperative hematocrit. Intraoperatively, the type of uterine incision, anesthesia administered, incidence of meconium-stained amniotic fluid, Apgar scores, and cord gases were similar between groups. The incidence of postcesarean endometritis was greater in group 4 (32 [45 percent] of 71, p = 0.003) compared with group 1 (17 [24 percent] of 71), group 2 (12 [30 percent] of 71); and group 3 (13 [18 percent] of 71). CONCLUSIONS: Manual placental removal and exteriorization of the uterus for repair of the surgical incision increases the infectious morbidity rate in women receiving prophylactic antibiotics at the time of cesarean delivery and increases the length of hospitalization.
UNLABELLED: Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia (PCA) with meperidine is associated with significantly more neonatal neurobehavioral depression than PCA with morphine. A single dose of epidural morphine (4 mg) decreases postcesarean opioid analgesic requirements and may reduce or prevent neonatal neurobehavioral depression associated with PCA meperidine. Prospectively, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. After umbilical cord clamping, each patient received epidural morphine 4 mg and was randomly allocated to receive either PCA meperidine or PCA morphine. Initial neonatal characteristics, included gestational age, Apgar scores, weight, and umbilical cord gas partial pressures. Brazelton Neonatal Behavioral Assessment Scale (NBAS) examinations were performed on each of the first 4 days of life. Nursing infants (n = 47) were grouped according to maternal PCA opioid in breast milk (meperidine [n = 24] or morphine [n = 23]); bottle-fed infants (n = 56) served as the control group. The three infant groups were equivalent with respect to initial characteristics and NBAS scores on the first 2 days of life. On the third day of life, infants in the morphine group were significantly more alert and oriented to animate human cues compared with infants in the meperidine or control group. On the fourth day of life, infants in the morphine group remained significantly more alert and oriented to animate human auditory cues than infants in the meperidine group. Average PCA opioid consumption through 48 h postpartum was equivalent (0.54 mg/kg morphine and 4.7 mg/kg meperidine); however, even with these small doses, meperidine was associated with significantly poorer neonatal alertness and orientation than morphine. Morphine is the PCA opioid of choice for postcesarean analgesia among nursing parturients. IMPLICATIONS: Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia with meperidine is associated with more neonatal neurobehavioral depression than patient-controlled analgesia with morphine. In this study, we found that nursing infants exposed to morphine were more alert and oriented to animate human cues than those exposed to meperidine.
Traditionally obstetric infections have been treated with combination antimicrobial agents that provide coverage against aerobic and anaerobic bacteria commonly found in these infections. New antibiotics may be a monotherapy alternative for this type of infections. The objective of the study was to compare the efficacy of the agent piperacillin/tazobactam against ampicillin plus gentamicin in the treatment of postcesarean endometritis. By randomized way 14 patients were enrolled in the piperacillin/tazobactam group and 42 in the ampicillin-gentamicin group. A favorable clinical response occurred in 78.6% of piperacillin/tazobactam patients and 88.1% of ampicillin and gentamicin patients (p = NS). There was no statistically significant difference in the times to recovery and days of hospitalization between the two groups. The combination piperacillin/tazobactam did not show advantage towards the standard treatment, so combination antimicrobial agent continue been the optimal approach to the management of obstetric infection.
Nurses need to be actively involved in current research on TENS therapy. A thorough in-service training program for all nurses involved in the TENS program must be developed in order for nurses to knowledgeably assist their patients in maximal adaptation to TENS therapy. Transcutaneous electrical nerve stimulation therapy is not a panacea in postpartal pain management. It can be argued that TENS is another extension of technology interfering with the original natural simplicity of the birthing process; however, further research in the technique needs to be conducted before TENS can be rejected as such. Ultimately, the goal of postpartal care for the cesarean-birth family is to allow the parents to enjoy the birth experience without the dangers of the past and the, at times, unnecessary interference of the present. TENS therapy may be a means toward that end.
Serum levels of tobramycin were determined with an enzyme immunoassay technique in 20 puerperal women with postcesarean endometritis who were being treated with metronidazole-tobramycin. Ideal dosing was then calculated to attempt to provide peak serum levels between 5 and 8 micrograms/mL and trough serum levels less than 2 micrograms/mL. In eight patients, therapeutic serum levels could not be attained even at doses greater than the package-insert recommendation of 3 mg/kg/d. Therapeutic levels were achieved in five patients with doses between 3 and 5 mg/kg/d and in seven patients only at doses above the maximum recommended daily dose of 5 mg/kg. The puerperal patient appears to usually require much higher dosages of tobramycin than usual, and serum levels must be monitored for therapeutic reasons rather than for toxicity.
The objective of the study was to increase breastfeeding initiation and duration rates among postcesarean women by implementing a culturally appropriate breastfeeding intervention. This study was a prospective population-based, controlled evaluation of a breastfeeding intervention consisting of 570 Jewish and Muslim postcesarean women who had delivered healthy, term infants at an Israeli hospital. Women in the control group (n = 264) received standard hospital care and women in the intervention group (n = 306) received early, culturally sensitive, postcesarean breastfeeding guidance. Surveys regarding breastfeeding duration practices were conducted at 10 and 16 weeks postpartum. Overall and exclusive 4-month breastfeeding duration rates were significantly higher for the intervention group as compared to the control group for the Jewish women at 10 and 16 weeks postpartum. Since few Muslim women ceased breastfeeding, only exclusive breastfeeding rates were evaluated. At 10 and 16 weeks, significantly more Muslim women in the intervention group were exclusively breastfeeding as compared to the control group, although rates dramatically declined by 16 weeks. Despite the challenges to breastfeeding posed by cesarean delivery, early and appropriate breastfeeding guidance facilitated successful outcomes for both Jewish and Muslim women.
To assess the relative efficacy and incidence of side effects of a single injection versus a continuous infusion of epidural morphine sulfate (MS) in the postcesarean population, the authors report a prospective, randomized, double-blind study. Thirty-one patients received either a 5-mg MS bolus and subsequent saline infusion (n = 13) or a 2.6-mg MS bolus and subsequent MS infusion at 0.1 mg/hour (n = 18), such that after 24 hours both groups had received a total MS dose of 5 mg. No statistically significant differences were found between the two groups in overall satisfaction with analgesia, verbal pain scores, level of activity, need for supplemental opioids, or incidence of sedation during the 24-hour study period. The authors conclude that in this population, continuous epidural morphine infusion offers no obvious advantage over single morphine bolus therapy. However, the theoretical merits of continuous opioid infusion therapy are discussed.
The efficacy of epidurally administered hydromorphone for postcesarean analgesia was evaluated in a prospective, randomized, double-blind study. Patients in group H (N = 26) received 1.0 mg of hydromorphone in preservative-free saline (total volume = 10 mL), administered epidurally. Patients in group B (N = 26) received 10 mL of 0.25% bupivacaine, administered epidurally. Both groups subsequently received intramuscular injections of hydromorphone as needed. There were significant differences between the two groups in pain score, patient assessment of analgesia quality, time to first analgesic intervention, and total dosage of hydromorphone during the first 24 hours. Nausea/vomiting and pruritus occurred more frequently in group H. No patient had a respiratory rate less than or equal to 10. There were no statistically significant differences between groups in mean times to first ambulation, first void, first passage of flatus, or hospital discharge.
With the current clinical popularity of patient-controlled analgesia pumps (PCAP) in postoperative pain management, it is prudent to be aware of the possible risk of adynamic ileus formation from intravenous narcotic administration. We hypothesized that prolonged PCAP exposure could delay bowel motility and increase post-operative morbidity. After stringent exclusionary parameters were met, we retrospectively analyzed 170 postcesarean patients who received PCAP medication and compared data with 171 postcesarean patients who received traditional intramuscular (IM) administration. The degree of adynamic ileus formation of moderate and severe intensity was higher in PCAP users (21.8%) vs. IM users (13.5%), P = .02. There was no significant difference in the average cumulative amount of analgesic administered during the first 24 postoperative hours for PCAP (442.2 mg) vs. IM (397.7 mg), reflecting that the mode of narcotic delivery is responsible for ileus formation rather than the dosage. Type of postoperative diet and speed of diet advancement were also factored into the analysis and did not statistically influence the results. We conclude that PCAP usage may increase the morbidity risk for adynamic ileus formation, and that usage should be accompanied with close monitoring of bowel motility.