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PubMed2006

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section.

OBJECTIVE: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). METHODS: For 6 months, we prospectively studied women undergoing a CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, then bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% top-ups according to patient request. Sixteen millilitres of lidocaine 2%, 1 ml of bicarbonate, and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. RESULTS: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient's age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index (BMI) at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio 4.39, P = 0.005). CONCLUSION: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor, having a higher VAS in the 2 h before CS are at risk of inability to extend labor epidural analgesia to epidural anesthesia for CS.

Adult↗

PubMed1984

Cesarean section and intraoperative surgical complications.

The incidence of surgical complications associated with cesarean section (CS) was studied prospectively in 1319 patients undergoing CS during the years 1978, 1979 and 1980 (18% of all deliveries). The overall complication rate was 11.6% (9.5% patients with minor complications and 2.1% with major complications). The complication rate for emergency operations was 18.9% and for elective CS, 4.2%--a highly significant difference. (p less than 0.001). Six risk factors were associated with the occurrence of surgical complications in emergency cases: Station of the presenting part of the fetus in relation to the spinal plane (p less than 0.001), labor prior to surgery (p less than 0.001), low gestational age (less than 32 weeks) (p less than 0.001), rupture of fetal membranes (with labor) prior to surgery (p less than 0.01), previous CS (p less than 0.01), and skill of the operator (p less than 0.05). However, no such risk factors were found in the elective group. The clinical relevance of these findings is summarized in two conclusions. Firstly, the proportion of emergency operations needs to be reduced, either in favor of elective procedures, or by allowing more patients to give birth by the vaginal route. Secondly, emergency CS requires great skill on the part of the surgeon, and should therefore not be entrusted to young, inexperienced obstetricians.

Cesarean Section↗

PubMed1989

Breech extraction versus cesarean section for the remaining second twin.

All second twins delivered by cesarean section (CS) after vaginal birth of the first twin (n = 38) and all breech-extracted second twins (n = 282) in Sweden during 1973-81 were identified. Data from the medical records of all CS second twins were extracted and compared with breech-extracted second twins from the same departments born within 2 years of the CS twin (n = 25). Second twins delivered after maternal general anesthesia had lower 5-min Apgar scores, irrespective of mode of delivery. Maternal morbidity was substantial in the CS group. The results encourage the use of breech extraction under local anesthesia rather than CS when there is a need for a quick delivery of the second twin and when both alternatives are available.

Anesthesia, Obstetrical↗

PubMed2004

Spinal anesthesia for Cesarean section in a parturient with long QT syndrome.

PURPOSE: To report the first use of spinal anesthesia for Cesarean section (CS) in a parturient with a long QT syndrome (LQTS) and an automatic implantable cardiac defibrillator (AICD). Although both general and epidural anesthesia have been described for CS in patients with LQTS, there are no previous case reports on the use of spinal anesthesia. The clinical features, diagnosis, treatment and anesthetic management of LQTS are discussed. CLINICAL FEATURES: A 31-yr-old woman, gravida 2 para 1 known to have LQTS and an AICD, presented in labour at 35 weeks gestation, three weeks before her scheduled CS. Her previous delivery by CS under spinal anesthesia at our institution was uneventful. On this occasion, we elected to administer spinal anesthesia because she was asymptomatic (no arrhythmia or cardiac arrest) for the last few years, was hemodynamically stable, and had received uneventful spinal anesthesia before. CONCLUSION: Spinal anesthesia was used safely for CS in this parturient with LQTS.

Adult↗

PubMed2002

Value of subcutaneous drainage system in obese females undergoing cesarean section using pfannenstiel incision.

OBJECTIVE: To determine whether closed subcutaneous drainage systems were efficacious in reducing the rate of wound breakdown of Pfannenstiel incision after cesarean section (CS) in obese females. DESIGN: Prospective controlled clinical trial. PARTICIPANTS: 118 obese pregnant females with a body mass index >32 undergoing CS were divided into two groups: group I (n = 78) with closed subcutaneous drainage system and group II (n = 40) without drainage system. Incision closure technique was standardized. Prophylactic antibiotics were given routinely to both groups. OUTCOME MEASURES: Primary outcomes were the incidence of wound breakdown in both groups together with rate of hematoma formation and occurrence of fever. Secondary outcomes were amount of fluid drained, need for redressing. RESULTS: Wound breakdown occurred in 9 cases in group I (11.5%), while it happened in 5 cases in group II (12.5%) (p > 0.05). Relative risk was 0.92 (95% CI 0.26-3.75). Hematoma formation was observed in only 1 case in the nondrainage group (group II). Fever was observed in 18 cases in group I (23.1%) in the first 24 h postoperative while in group II, 13 cases developed fever (32.5%) (p > 0.05). The need for redressing within the first 24 h was only in 2.5% of cases in group I while it was 17.9% in group II (p < 0.05). CONCLUSION: We found no significant benefit in using a subcutaneous drain as a prophylactic measure against wound breakdown in obese pregnant females undergoing CS as long as they received a prophylactic antibiotic.

Adipose Tissue↗

PubMedDate not supplied

Cesarean section odds ratios.

Cesarean section (CS) rates for primiparas, multiparas with and without previous CS were investigated in seven obstetrical settings. Despite the great diversity of global CS rates (5.3 to 17.4%), common CS odds ratios of 3.0 and 37 have been found for primiparas and multiparas with previous CS, respectively. Internal links between CS odds ratios have also been investigated for some anomalies associated with CS (fetal distress, non-vertex presentation, hypertension, dystocia, small for dates new born and prematurity), suggesting that perinatal services may be evaluated on CS aspects according to a single general interventionist/conservative clinical attitude. Data from two additional obstetrical settings were used to verify the findings in terms of perinatal evaluation.

Cesarean Section↗

PubMed1988

The Northwestern University Triplet Study. III: Neonatal outcome.

Limited data suggest that cesarean section (CS) may be the preferred method of delivery for triplets. Despite this, it is also felt that the third triplet is at great risk at delivery. We reviewed our experience of 14 triplet pregnancies at Northwestern University between 1981 and 1985. All deliveries were attended by neonatal teams in sufficient number to resuscitate each infant. Of the 14 pregnancies, two ended in previable loss. Thirty-six infants were born from 12 pregnancies of a mean gestational age of 33 weeks (28-38 weeks). The overall survival was 97.3%. Two women delivered vaginally. While the first was successful, the second resulted in vaginal delivery of the first two triplets followed by emergency CS for the third. That infant had a cord blood pH of 6.96 (BE-19), was resuscitated and survived. All 10 CS were successful. The mean cord blood gas tensions and pH were normal. In addition, Apgar scores, the requirement for mechanical ventilation or supplemental oxygen, and mortality did not differ between the first and third-born triplet. These observations suggest that CS was beneficial. Our very low mortality rate supports the concept that CS delivery and aggressive neonatal resuscitation and therapy greatly enhances survival.

Birth Order↗

PubMed2006

Reframing birth: a consequence of cesarean section.

AIM: This paper is a report of a study to describe the childbirth expectations, influences and knowledge of a group of Western Australian women who experienced a cesarean section (CS) and would prefer a CS in a subsequent pregnancy. BACKGROUND: Evidence suggests that a previous CS is not an indication for an elective CS in a subsequent pregnancy, but western world data indicate high probability of repeat CS. METHODS: Community advertisements invited women who had experienced a CS to participate in a telephone interview. The thematic analysis presented in this paper is derived from data collected during 2003/2004 from 49 participants who had initially expected to birth vaginal but had a CS and who had planned a CS in a subsequent pregnancy or stated that they would choose this option in a future pregnancy. FINDINGS: Before the first CS most women expected and wanted to give birth normally. After having a CS, however, many reframed vaginal birth as uncertain, unsafe and unachievable. For this group of women, the medical discourse that promoted CS as the safest option was a major influence on their decisions. As a result, they reconstructed CS as an acceptable alternative that was safer for them and their babies, allowed them to be better prepared, and was convenient. CONCLUSION: In the present climate, enabling women to keep birth 'fear' in perspective may be an important strategy if we are to improve the uptake of vaginal birth after CS and the quality of care offered to women during the normal, but major, life event of childbirth.

Attitude of Health Personnel↗

PubMed1986

Cesarean section: a controversial feature of modern obstetric practice.

Cesarean section (CS) has been an integral part of modern obstetrics during the last decades. As safety has increased, so too has the range of problems that CS is used to solve, to a degree that it must cause medical concern. There is a great danger in the blind faith that CS is the only way out in every difficult obstetric situation. The problem can always be easily solved by CS in an acute difficult obstetrical situation. However, CS is a major abdominal surgery and it may present any complication that besets major surgery including severe intraoperative and postoperative complications, a much greater risk for maternal death compared to vaginal delivery and also late complications, i.e. secondary involuntary infertility. Therefore, CS should never be undertaken lightly and without serious consideration of the justifications, preparations and all ancillary support.

Abortion, Induced↗

PubMed1989

Use of cefuroxime in preventing postcesarean infection in high-risk patients.

Prophylactic antibiotic therapy is accepted for prevention of postceasarean infection in certain risk groups. Of the antibiotic regimens presented none appears superior. Patients having a cesarean section (CS) more than 6 h after membrane rupture were given three doses of cefuroxime (1.5 g every 8th hour) in a prospective study. This prophylaxis was as efficacious as a 7-day treatment with cefuroxime and cefadroxil. The infection rate was 21% which should be compared to approximately 50% when no prophylaxis was given. Patients with membrane rupture of less than 6 h and having a most urgent CS received the same 24-hour prophylaxis. No postoperative infection was recorded. Women having a CS with an ongoing uterine infection were treated with cefuroxime alone or combined with metronidazole. All but one (91%) had an uneventful recovery.

Bacterial Infections↗

PubMed1998

Fertility in anovulatory patients after primary cesarean section.

OBJECTIVE: To evaluate the fertility potential after primary cesarean section (CS) in anovulatory patients treated for ovulation induction with gonadotropins. STUDY DESIGN: A controlled, prospective study was conducted on 97 anovulatory patients who delivered a neonate either abdominally or vaginally after ovulation induction with human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG). After four cycles of hMG/hCG therapy, cumulative pregnancy rates and abortions were observed. In both groups, patients who did not conceive underwent hysterosalpingography to evaluate uterine and tubal patency. RESULTS: The cumulative pregnancy rate in the anovulatory, post-cesarean section patients treated with hMG/hCG was 61.9%, as compared to 59.6% in the control group (statistically nonsignificant). The abortion rate was similar in both groups. CONCLUSION: The risk of uterine or tubal infertility is probably not substantially increased in patients on whom uncomplicated cesarean sections have been performed. Anovulatory patients who conceive after treatment with gonadotropins and deliver abdominally should be referred for medical treatment before evaluation of any uterine or tubal infertility.

Adult↗

PubMed1980

Cesarean section: a contemporary assessment.

A one-year retrospective study of cesarean section (CS) at Women and Infants Hospital of Rhode Island is reported. There were 5,467 women delivered, including 1,011 who delivered by CS, yielding a total CS rate of 18.5% and a primary rate of 13.4%. The four leading indications for primary CS were: dystocia (38.8%), breech presentation (14.9%), malposition (11.9%) and fetal distress (11.3%). Sepsis was responsible for 75% of the complications. The incidence of low-birth-weight infants was 14.2% for primary CS and 6.7% for repeat CS. The perinatal death rate was 21.2% per 1,000. The relationship of these findings to changing obstetric practice is discussed.

Adolescent↗

PubMed1999

ST-segment depression and myocardial contractility during cesarean section under spinal anesthesia.

PURPOSE: To evaluate myocardial contractility during ST segment depression in healthy parturients during Cesarean section (CS). METHODS: Forty-seven consecutive term parturients undergoing elective CS under spinal anesthesia were studied. The ST segment was recorded continuously on leads II and V5 using a Holter monitor. Myocardial performance was evaluated by measuring cardiac index (CI), heart rate (HR), pre-ejection period (PEP), ventricular ejection time (VET), systolic time ratio (STR, PEP/VET), and ejection fraction (EF) with an impedance cardiograph. RESULTS: Fourteen patients (30%) developed ST segment depression within 15 min after delivery and the remaining 33 (70%) did not (controls). Seven patients developed a 1 mm change, five patients a 2 mm change and the remaining two a 3 mm change in the ST segment. Compared with pre-anesthesia values, the mean HR increased from 103 +/- 10 to 116 +/- 10 (ISD) bpm (P = 0.001), CI from 4.7 +/- 0.7 to 5.6 +/- 1.7 L.min-1 (P = 0.01), EF from 0.58 +/- 0.08 to 0.66 +/- 0.05 (P = 0.01) and STR decreased from 0.26 +/- 0.06 to 0.2 +/- 0.04 (P = 0.01) during ST segment depression. At this time, CI, HR and EF were greater and STR smaller than values obtained 15 min after delivery in the control subjects. CONCLUSION: ST-segment depression occurring during CS is associated with a hyperkinetic myocardial contractile state.

Adolescent↗

PubMed1991

Delayed neurological adaptation in infants delivered by elective cesarean section and the relation to catecholamine levels.

We have studied the effect of mode of delivery and catecholamine (CA) surge at birth on neurobehaviour 1, 2 and 5 days after birth. Fifteen full-term infants were delivered by elective cesarean section (CS) and 15 full-term control infants were born vaginally. Infants born after elective CS were less excitable and had significantly reduced number of optimal responses during the first 2 days after delivery, compared to the controls. On the 5th day no significant neurological differences were found between the groups. Adrenaline and noradrenaline (NA) in umbilical arterial plasma were analysed in all infants. The mean values of NA were lower in the CS infants as compared to the vaginally delivered infants. Statistically significant correlations were found between low CA levels and poor muscle tone and/or lower grade of excitability in the CS infants. These results suggest that the high CA surge at birth might be of importance for the neurological adaptation after birth.

Adaptation, Physiological↗

PubMedDate not supplied

Recurrence of carcinoma cervix in the scar of previous cesarean section: a case report.

Although rare, reports of carcinoma cervix recurring in abdominal incision, episiotomy scars, laparoscopic port sites, and drain sites are available. However, recurrence in the scar of a previous cesarean section (CS) is unreported. A 49-year-old female with a diagnosis of keratinizing squamous cell carcinoma (SCC) of cervix, stage IIB, was treated by radical radiotherapy. She had undergone CS, through midline abdominal incision, for three previous deliveries. Twenty months later, she presented with a nodule of size 2.5 x 2 cm(2) on the 26-year-old abdominal CS scar. Infiltration of the skin and extension into the deeper structures of the abdominal wall was present in an area of 5 x 4 cm(2). There was no evidence of disease on the cervix. A fine-needle aspiration cytologic examination from the nodule revealed keratinizing SCC. Ultrasonography and computerized tomography scan revealed a mass lesion along the abdominal CS scar with subcutaneous nodule and peritoneal extension. Multiple metastatic lesions were present in the liver. She was treated with chemotherapy and radiotherapy. The patient has lived for more than 12.5 months. The first report of recurrence of carcinoma cervix in a CS scar is presented. Literature on surgical scar recurrence in carcinoma cervix is reviewed.

Adenocarcinoma↗

PubMed2000

[Clinical analysis of 318 cases of new-mode cesarean section].

OBJECTIVES: To study types of new mode cesarean section (CS) and its clinical value. METHODS: Four hundred and sixty-eight pregnant women with operative indications were randomly divided into three groups: the new mode CS group whose peritoneum was not sewed, the new mode CS group whose peritoneum was sewed, and the lower segmental CS group. The duration of operation, bleeding volume, morbidity after operation, and B type ultrasound for examining the incision were observed. RESULTS: There were significant difference in the duration of operation, bleeding volume, and morbidity after operation between the lower segmental CS and the two types of the new mode CS (P < 0.05). There was no significant differences in the bleeding volume and morbidity after operation between the two types of the new mode CS (P > 0.05), but there were significant difference in the duration of operation and the incision examined by B type ultrasound (P < 0.05). CONCLUSION: The new mode CS has shorter operative period, less bleeding, weak pain, faster recovery of peristalsis, and lower incidence of post-operative morbidity.

Cesarean Section↗

PubMed2006

Effects of the DRG-based prospective payment system operated by the voluntarily participating providers on the cesarean section rates in Korea.

This study explored the effects of the diagnosis-related group (DRG)-based prospective payment system (PPS) operated by voluntarily participating organizations on the cesarean section (CS) rates, and analyzed whether the participating health care organizations had similar CS rates despite the varied participation periods. The study sample included delivery claims data from the Korean national health insurance program for the year 2003. Risk factors were identified and used in the adjustment model to distinguish the main reason for CS. Their risk-adjusted CS rates were compared by the reimbursement methods, and the organizations' internal and external environments were controlled. The final risk-adjustment model for the CS rates meets the criteria for an effective model. There were no significant differences of CS rates between providers in the DRG and fee-for-service system after controlling for organizational variables. The CS rates did not vary significantly depending on the providers' DRG participation periods. The results provide evidence that the DRG payment system operated by volunteering health care organizations had no impact on the CS rates, which can lower the quality of care. Although the providers joined the DRG system in different years, there were no differences in the CS rates among the DRG providers. These results support the future expansion of the DRG-based PPS plan to all health care services in Korea.

Adolescent↗

PubMed2001

Maternal complications associated with cesarean section.

OBJECTIVE: To assess the prevalence of cesarean section (CS) related maternal complications and to evaluate post-CS complications in relationship with relative risk factors. METHOD: 3010 patients who had a CS in the University Hospital of Bari during the period 1988-98 were retrospectively included into the study and 1007 women delivered vaginally at the same institution and in the same period of time, were randomly selected as the control group. For each single patient delivered by CS, the following risk factors were taken into account: age, parity, pre-pregnancy body mass index (BMI), and any disease antedating pregnancy or diagnosed during pregnancy. Additionally, therapeutic procedures such as blood transfusion, number of days in hospital, and admission into intensive care were followed. The prevalence of puerperal complications was assessed for vaginal deliveries and CS by Student's t-test and a correlation of CS complications with risk factors was performed by multivariate analysis. RESULTS: In the cohort of abdominal delivery, puerperal complications were significantly more frequent compared with those following vaginal delivery (p < 0.05). In the group of CS, obese women have higher prevalence of maternal complications, particularly hypertension and intestinal complications (p < 0.05). CONCLUSION: Compared with vaginal delivery, CS delivery carries a higher number of postpartum complications, and the higher rate is mainly related to obesity.

Adult↗