Postcesarean hysterectomy for hemorrhage due to placenta accreta associated with placenta previa. Report of a case.
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Cesarean Section↗
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Experience with early postcesarean hospital dismissal.
OBJECTIVE: Our purpose was to assess early postcesarean hospital dismissal. STUDY DESIGN: A retrospective review was performed of all women receiving cesarean delivery over the most recent 6-month period in a busy private obstetrics practice that routinely dismisses its cesarean patients on postoperative day 2. Women who meet certain criteria (uncomplicated pregnancy, Pfannenstiel incision, uncomplicated surgery, no febrile morbidity, stable vital signs, ability to ambulate without assistance, ability to urinate without assistance, and auscultation of active bowel sounds) on postoperative day 2 are dismissed from the hospital. Outcomes were compared against women undergoing cesarean delivery during the 6 months immediately before the institution of the early dismissal program. RESULTS: Among 147 women undergoing cesarean deliveries, 117 (80%) met the criteria for early dismissal. When compared with controls (n = 93), there was no difference in outcomes. No one in the early dismissal group required readmission to the hospital. CONCLUSION: Among properly selected candidates, early postcesarean hospital admission is a reasonable option.
Adult↗
Epidural fentanyl for postcesarean delivery pain management.
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Analgesics, Opioid↗
Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial.
OBJECTIVE: To estimate the efficacy of preoperative administration of intravaginal metronidazole for the prevention of postcesarean endometritis. METHODS: This double-masked, placebo-controlled randomized trial included patients of at least 24 weeks' gestation undergoing cesarean deliveries for various indications. Patients were randomized to receive either 5 g of metronidazole gel intravaginally or matching placebo before the initiation of the cesarean. All patients underwent surgical cleansing of the abdomen, and most received prophylactic antibiotics after cord clamping. Patients with chorioamnionitis and/or suspected allergy to metronidazole were excluded. For a two-sided alpha of 0.05 and beta of 0.20 (80% power), 120 subjects were required in each group. The main outcome variable was the incidence of postcesarean endometritis. Secondary outcome variables included presence of febrile morbidity, wound infection, days on antibiotics, and length of postpartum hospitalization. Neonatal outcomes included birth weight, Apgar scores less than 7 at 5 minutes, umbilical arterial pH less than 7.16, admission and length of stay in the neonatal intensive care unit, and length of hospital stay. RESULTS: Of 112 patients receiving metronidazole, eight (7%) developed postcesarean endometritis, compared with 19 of 112 (17%) of those receiving placebo gel (relative risk 0.42, 95% confidence interval 0.19, 0.92). No significant differences were noted between treatment groups with respect to the other outcome variables. CONCLUSION: The preoperative administration of 5 g of intravaginal metronidazole gel appears to reduce the incidence of postcesarean endometritis.
Administration, Intravaginal↗
Anesthesia in pregnant women with HELLP syndrome.
OBJECTIVE: Our purpose was to determine the types of anesthesia and neurologic or hematologic complications found in pregnancy with HELLP syndrome providing analgesia for cesarean section. METHODS: This is a retrospective study. For the period of 1 July 1996, through 30 June 2000, we reviewed the charts of all patients with HELLP syndrome who had cesarean section. RESULTS: During the period of study 119 patients had HELLP syndrome. Eighty-five patients had cesarean delivery and 34 had vaginal delivery. Seventy-one patients had diagnosed HELLP syndrome previous to the anesthesia and 14 postcesarean delivery; the range platelet count was 19000-143000/microl. Of these 71, 58 had an epidural anesthesia, 9 had general anesthesia and 4 had spinal anesthesia. There were no neurologic complications or bleeding in the epidural space. CONCLUSION: We found no documentation of any neurologic or hematologic complications of women with HELLP syndrome and neuraxial anesthesia.
Anesthesia, Epidural↗
The role of epidural morphine in the postcesarean patient: efficacy and effects on bonding.
This study was designed to determine in postcesarean patients whether in addition to superior analgesic effects, epidural morphine administration results in secondary benefits in maternal well-being and maternal-infant interaction. Following elective cesarean section with bupivacaine epidural anesthesia, 40 healthy mothers received 5 mg preservative-free morphine sulfate in 10 ml of saline, either by the epidural (Group 1, n = 20) or the intravenous (Group 2, n = 20) route, in a randomized, double-blind fashion. Each received a simultaneous injection of saline by the alternate route. Analgesia in Group 1 lasted significantly longer (16.1 +/- 8.8 vs. 4.4 +/- 2.4 h, mean +/- SD; P less than 0.001), and morphine requirements in the first 24 h were significantly less (12.5 +/- 20 mg vs. 36 +/- 21 mg, P less than 0.001) than in Group 2. Seventy-four per cent of patients who received epidural morphine reported excellent analgesia, compared with only 32% of those who received intravenous morphine (P less than 0.05). Although Group 1 mothers ambulated 6 h earlier than those in Group 2 (P less than 0.02), there was no difference between the groups in time of first voiding, number of hours mothers slept, or duration of hospital stay. Mothers in both groups interacted with their infants equally well and for the same duration of time. Itching occurred in 58% of Group 1 patients and only 16% of Group 2 patients (P less than 0.01); the incidences of nausea, vomiting, and urinary retention were not statistically different between the groups. No respiratory depression was observed. Benefits of epidural morphine in this patient population appear limited to the provision of improved analgesia and earlier mobility.
Adult↗
The effect of volume of epidural morphine on postoperative analgesia in patients undergoing cesarean section.
Ninety paturients undergoing elective cesarean section were included in this randomized study to compare the influence of the injected volume of epidural morphine (EM) on postoperative analgesia. Three similar groups of patients (n = 30 each) received 2 mg EM in 2 ml, 10 ml, and 20 ml saline respectively one hour after the last dose of 2% lidocaine. Pain scores (0-10) at rest (including uterine contraction pain) at the 2nd, 4th, 8th, 12th, 18th, and 24th h were compared among the three groups. There were no statistically significant differences of pain score among the three groups although lower pain score was present in the 20 ml group since the 8th h and thereafter. Regarding the number of patients who requested additional meperidine for pain relief 3 in 2 ml group, 2 in 10 ml group and 1 in 20 ml group respectively. The result may suggest that the influence of the injected volume of EM on postcesarean analgesia is not obvious.
Adult↗
Routine postcesarean urine culture. A cost-effectiveness analysis.
Paired urinalysis and urine culture reports on 302 postcesarean patients were studied to determine whether screening postcesarean urinalyses could be useful in predicting positive urine cultures. A positive culture was predicted with a specificity of 97.5% and a sensitivity of 90.4%. The screening urinalysis had a positive predictive value of 73.1% and a negative predictive value of 99.3%. Routine postcesarean urine cultures were not found to be cost effective.
California↗
Effects of placental delivery method and intraoperative glove changing on postcesarean febrile morbidity.
This study was designed to evaluate the effects of the placental delivery methods and intraoperative glove changing on postcesarean febrile morbidity. In this randomized controlled trial, consenting patients were randomized to one of four management protocols: Group A (n = 26)--no glove change with manual placental delivery; Group B (n = 27)--no glove change with expressed placental delivery; Group C (n = 27)--glove change with manual placental delivery; and Group D (n = 28)--glove change with expressed placental delivery. Glove change was performed by removal of a second glove after delivery of the fetal head. Variables examined included febrile morbidity, endometritis, maximums and durations of elevated temperatures, as well as other demographic, intrapartum, and postpartum variables. Febrile morbidity and endometritis rates were not significantly different between the four groups. When the groups were combined so as to compare no glove change versus glove change (Groups A and B vs. C and D) and manual versus expressed placental delivery (Groups A and C vs. B and D), there were no significant differences in either febrile morbidity (relative risk: 0.7, 95% CI: 0.3-1.4 and relative risk: 1.4, 95% CI: 0.6-3.5) or endometritis (relative risk: 1.2, 95% CI: 0.5-2.8 and relative risk: 1.5, 95% CI: 0.6-3.6), respectively. There were no statistically significant differences in measures of postcesarean febrile morbidity based on placental delivery method or intraoperative glove change.
Cesarean Section↗
A retrospective study of the effect of postoperative indomethacin rectal suppositories on the need for narcotic analgesia in patients who had a cesarean delivery while they were under regional anesthesia.
OBJECTIVE: This study was undertaken to assess the efficacy of rectal indomethacin as an analgesic after cesarean delivery, comparing narcotic usage in patients receiving indomethacin with patients who received only standard narcotic analgesics. STUDY DESIGN: A retrospective study of patient records consisting of 297 women who underwent cesarean delivery while they were under regional anesthesia in a medium-sized community hospital from February 1996 through December 1999. Narcotic usage was determined as morphine equivalents whereby 10 mg morphine sulfate equals 30 mg oxycodone equals 50 mg hydrocodone equals 75 mg meperidine. Indomethacin was administered as 50-mg rectal suppositories. Statistical analysis was done by Pearson correlation and independent Student t test analysis. RESULTS: Narcotic usage was reduced by an average of 16 morphine equivalents (28%) in the indomethacin group. Pearson correlation revealed correlation at the.01 level; independent Student t test analysis revealed a P value of.001. Thus the mean amount of narcotic analgesic administered was significantly less in patients treated with indomethacin rectal suppositories. CONCLUSION: In this uncontrolled trial the use of indomethacin rectal suppositories resulted in a significant reduction in narcotic use in the postcesarean hospital recovery period as measured in morphine equivalents.
Analgesia↗
Pain control after cesarean birth. Efficacy of patient-controlled analgesia vs traditional therapy (IM morphine).
A clinical trial compared the efficacy of a mechanical device to deliver patient-controlled analgesia (PCA) (n = 25) with intramuscularly administered morphine (n = 17) for postcesarean pain management. Hypotheses were: (1) patient-controlled administration of narcotics will be superior (increased satisfaction, reduced pain, decreased sedation, increased ambulation, decreased length of stay), and (2) functional vital capacity will increase post-operatively with PCA. No differences in demographic variables were identified (P = less than or equal to .001). Differences in satisfaction (greater in PCA group, P = less than or equal to .05), ambulation (greater in PCA group, P = less than or equal to .001), amount of medication used (greater in PCA group, P = less than or equal to .001), and sedation level (less in PCA group, P = less than or equal to .05) were identified. No differences in vital capacity were identified. The hypothesis related to the superiority of PCA was accepted, while the association between PCA and increased vital capacity was not supported. The use of mechanical PCA devices provides an effective and safe means of managing postcesarean pain.
Analgesics↗
Postcesarean endometritis: a brief review and comparison of three antibiotic regimens.
Three different antibiotic regimens (trospectomycin plus azteonam, clindamycin plus azteonam, and triple antibiotics-ampicillin plus clindamycin plus gentamicin) were all effective in treating patients with postcesarean endometritis. Patients are frequently cured clinically despite the fact that the offending organisms may be isolated in post-treatment cultures. Treatment of postcesarean endometritis without obtaining endometrial cultures is acceptable gynecologic practice. Obtaining post-treatment cultures is clearly not cost effective nor clinically beneficial. Drug treatment efficacy should be evaluated by clinical response. This communication is the first to report the new antibiotic, trospectomycin, in the treatment of postcesarean endometritis. Further clinical trials are currently underway.
Anti-Bacterial Agents↗
Emphysema of the abdominal wall obscuring postcesarean volvulus. A case report.
BACKGROUND: Emphysema of the abdominal wall occurs after infection with gas-forming organisms or when intraabdominal gas has a mechanical pathway to the retroperitoneum. CASE: Emphysema of the abdominal wall associated with volvulus developed after cesarean delivery. CONCLUSION: Postcesarean abdominal pathology may be associated with emphysema of the abdominal wall.
Abdominal Wall↗
Decreasing infectious morbidity in cesarean delivery by changing gloves.
OBJECTIVE: To assess whether changing the entire surgical team's gloves intraoperatively, after delivery of the placenta, would reduce the rate of postcesarean wound infection. STUDY DESIGN: Women who underwent cesarean delivery were randomized to a group where the surgical team changed the surgical gloves after delivery of the placenta or to a control group, where surgical gloves were not changed during the cesarean procedure. RESULTS: Ninety-two patients were randomized to 2 groups of 46 patients each. The group where the surgical team changed their gloves had significantly less serosanguineous drainage 24 hours after surgery (3 vs. 8 patients, 8.3% vs. 22.2%, P = .2, RR 2.7, CI 0.7, 12.4) and fewer wound infections (2 vs. 9 women, 5.5% vs. 25%, P = .05, RR 4.5, CI 0.982, 29.8). CONCLUSION: Obstetricians may decrease the number of postcesarean wound infections by having the entire team change surgical gloves after delivery of the placenta.
Adult↗
[Effects of continuous epidural administration of fentanyl and morphine on postcesarean pain].
We studied the effects of continuous epidural administration of fentanyl and morphine with bupivacaine for management of postcesarean pain. Eighteen patients received either bolus epidural administration of fentanyl 100 micrograms or morphine 3 mg with 0.5% bupivacaine 4 ml, followed by continuous infusion of fentanyl 33 micrograms.ml-1 with 0.17% bupivacaine or morphine 0.21 mg.ml-1 with 0.17% bupivacaine for 48 hours, respectively. Pain score was assessed at 0 h, 12h, 24h and 48h after leaving the operating room. Pain score increased significantly and progressively in the fentanyl group. In all cases pruritus was noted. Severe pruritus was observed in the morphine group significantly more than in the fentanyl group. The current results indicate that morphine may be preferable to fentanyl for postcesarean pain control using the present opioid doses.
Adult↗
Vaginal birth after cesarean section. Acceptance and outcome at a rural hospital.
A retrospective review of all pregnant women with a history of cesarean section was conducted at an isolated military hospital. During the two-year period 1988-1989, 62 patients were initially considered eligible for attempting vaginal birth after cesarean section (VBAC). Seventy-nine percent (49/62) of the patients initially requested a trial of labor, and 14 of them ultimately did not meet American College of Obstetricians and Gynecologists criteria. Three patients reversed their decision late in pregnancy. Eighty-eight percent (28/32) of those undergoing a trial of labor delivered vaginally. The three patients with more than one prior cesarean section all delivered vaginally. The four failures occurred in patients who had a history of well-documented cephalopelvic disproportion. Perinatal morbidity consisted of intrauterine fetal demise prior to the onset of labor at 40 weeks' gestation. Maternal morbidity included postcesarean endometritis (n = 1) and vaginal sidewall laceration (n = 1). These results indicate that in a rural hospital VBAC was well accepted by patients and was safe; however, further study is required.
Decision Making↗
Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses.
Obstetric hemorrhage is still a potential cause of maternal mortality and morbidity. Angiographic embolization techniques have been described in cases of postcesarean bleeding, vaginal wall hematomas, cervical ectopic pregnancies, and postpartum bleeding to control persistent bleeding from pelvic vessels. We describe two cases of pregnancy complicated with placenta percreta. Balloon occlusion and embolization of the hypogastric arteries were performed during the cesarean section and hysterectomy, resulting in a remarkable reduction in intraoperative blood loss. Balloon occlusion and embolization of the internal iliac arteries significantly reduce intraoperative blood losses.
Adult↗
Combination of low-dose epidural morphine and intramuscular diclofenac sodium in postcesarean analgesia.
Epidural morphine is used for postcesarean analgesia, and nonsteroidal antiinflammatory drugs are frequently administered to relieve uterine cramps after vaginal delivery. To assess the efficacy of a combination of low-dose epidural morphine and intramuscular diclofenac sodium in postcesarean analgesia, a double-blind, randomized study was conducted. Epidural anesthesia was given to 120 parturients who were randomly allocated into four treatment groups: group A received normal saline solution, 10 mL epidurally and 3 mL intramuscularly (IM); group B received 10 mL of epidural saline solution and 75 mg (3 mL) of diclofenac IM; group C received 2 mg of morphine in 10 mL of epidural saline solution and 3 mL of saline solution IM; and group D received 2 mg of morphine in 10 mL of epidural saline solution and 75 mg of diclofenac IM. Epidural injections were given after delivery of the placenta, and IM injections were given on arrival in the recovery room. Verbal analogue pain scores were recorded at 2, 4, 8, 12, 18, and 24 h after epidural injection. Subjective scores of overall pain relief were also recorded at 24 h. Results showed that scores of overall pain relief were significantly better in group D compared with group A, B, or C (P less than 0.05). Groups A and B required more supplemental meperidine than groups C and D. None of the subjects in group D requested supplemental analgesia. Compared with the other three groups, group D experienced a better analgesic effect for both wound pain and uterine cramping pain from 4 to 18 h (P less than 0.05). Incidence of nausea or vomiting, or both, and pruritus occurred more frequently in groups C and D compared with group A or B (P less than 0.05). No bradypnea was observed during the study period. Diclofenac alone was not effective in postcesarean analgesia.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗