Intrauterine cleaning after placental delivery at cesarean section: a randomized controlled trial

Objective: The objective of this study is to evaluate whether omission of intrauterine cleaning increases intraoperative and postoperative complications among women who deliver via cesarean section.

Methods: We randomized 206 women undergoing primary elective cesarean deliveries to intrauterine cleaning or omission of cleaning. Postpartum endomyometritis rates across groups were the primary outcome. We also examined secondary outcomes. To detect a 20% difference in infection rate between the cleaned and the non-cleaned groups (two-tailed [alpha]?=?0.05, [beta]?=?0.2), 103 women were required per group. Analysis was by intention-to-treat.

Results: Two hundred and six were randomized as follows: 103 to intrauterine cleaning and 103 to omission of cleaning after placental delivery. There were no statistically significant differences in the rate of endomyometritis between the two groups (2.0% versus 2.9%, RR =0.60; 95% CI 0.40–1.32). There were no statistically significant differences in postpartum hemorrhage rates (5.8% versus 7.7%, RR 0.75; 95% CI 0.6–1.2), hospital readmission rates (2.9 versus 3.8%, RR 0.75; 95% CI 0.5–1.6), time to return of gastrointestinal function, need for repeat surgery, or quantitated blood loss between the two groups.

Conclusions: Our randomized controlled trial provides evidence suggesting that omission of intrauterine cleaning during cesarean deliveries in women at low risk of infection does not increase intraoperative or postoperative complications.     

The effect of intraabdominal irrigation at cesarean delivery on maternal morbidity: a randomized trial

To determine if intraabdominal irrigation with normal saline at cesarean delivery is associated with increased maternal morbidity.One hundred ninety-six women undergoing routine cesarean delivery at at least 37 weeks' gestation were prospectively randomized to receive 500-1000 mL of normal saline intraabdominal irrigation versus no irrigation after closure of the uterine incision, but before abdominal wall closure. Data were collected for comparison of demographic factors, intrapartum and postpartum complication rates, and maternal and neonatal outcomes. The primary outcome measure was the combined incidence of maternal morbidity, defined as at least one of the following: postoperative infectious morbidity, postpartum hemorrhage, severe anemia, and urinary retention.Ninety-seven patients were randomized to the irrigation group and 99 to the control group. The demographic characteristics of the two groups were similar. Thirteen patients (13.1%) in the control group and 14 patients (14.4%) in the irrigation group experienced maternal morbidity (P =.84). There were no statistically significant differences between the groups in estimated blood loss, operating time, incidence of intrapartum complications, hospital stay, return of gastrointestinal function, incidence of infectious complications, or neonatal outcomes.Routine intraabdominal irrigation at cesarean delivery in a low-risk population does not reduce intrapartum or postpartum maternal morbidity.     

A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage

Objective

The purpose of this study was to determine whether postcesarean section administration of ketorolac tromethamine reduces pain and narcotic usage.

Study design

A double-blinded randomized, placebo-controlled trial of ketorolac tromethamine was performed. Patients were randomly assigned to receive either ketorolac tromethamine or placebo. Patient-controlled analgesia (PCA) was used for pain control. Visual analog scales (VAS) were administered postoperatively to assess pain levels. Morphine equivalents and attempts were recorded.

Results

There were 22 patients in each arm of the study. There was no significant difference between patient demographics, blood loss, and type of anesthesia. Pain scores were significantly different at 2, 3, 4, 6, 12, and 24 hours by analysis of variance (ANOVA) (P = .033). There was a significant decrease in pain medication usage (P = .008) in the study group.

Conclusion

Ketorolac tromethamine is efficacious in reducing postoperative pain and narcotics usage after cesarean section.     

The effect of placental removal method on perioperative hemorrhage at cesarean delivery; a randomized clinical trial

Purpose

The aim of this prospective randomized clinical study is to compare whether the removal methods of placenta during cesarean section have an impact on perioperative hemorrhage.

Methods

One hundred women with singleton term pregnancies undergoing elective cesarean section through lower segment transverse incision under general anesthesia were included in this study. They were randomly allocated to two groups according to the type of removal of the placenta from the uterus after childbirth; manually or spontaneously. The main outcome measures were change in hemoglobin levels after cesarean section. The secondary outcomes were operative time, required transfusions and postcesarean endometritis.

Results

Fifty patients were randomized to the manual removal group and 50 to the spontaneous group. The demographic characteristics of the two groups were similar. There were no difference in terms of change in hemoglobin levels after cesarean section between two groups (1.6 ± 1.0 and 1.5 ± 1.0, respectively; P = 0.711). In addition, none of the patients required blood transfusion and showed postpartum infections.

Conclusion

There is not an association between the method of removal of the placenta and postpartum blood loss in cesarean section deliveries.     

The effect of placental removal method at cesarean delivery on perioperative hemorrhage: a randomized clinical trial ISRCTN 49779257

OBJECTIVES: To evaluate whether the method of placental removal during cesarean section has an impact on perioperative hemorrhage and maternal infectious morbidity. STUDY DESIGN: Three hundred and two patients admitted for abdominal delivery were recruited in a prospective randomized clinical intention-to-treat trial. Participants were assigned to have their placenta removed either manually or spontaneously. The drop in hematocrit was the primary outcome; postpartum maternal infectious morbidity was also assessed. RESULTS: Two patients were excluded for incomplete data. One-hundred-fifty-one were randomized to the manual removal group and 149 to the spontaneous group. The demographic characteristics of the two populations were similar. The mean drop (%) in the manual removal group was greater than in the spontaneous group (5.57+/-3.86 and 2.65+/-2.67, respectively; P<0.01). the incidence of postpartum infectious morbidity was also significantly greater in the manual group (RR 15.8, 95% CI 2.19-117.5). CONCLUSION: Routine manual removal of placenta at cesarean section significantly increases perioperative blood loss and postpartum maternal infectious morbidity.     

Chlorhexidine gluconate versus povidone iodine at cesarean delivery: a randomized controlled trial

Background/Aims: To compare the prevalence of positive bacterial cultures at the cesarean delivery (CD) incision site in patients with pre-operative application of chlorhexidine gluconate (CG) versus povidone iodine (PI).

Methods: Women undergoing a scheduled CD at ≥36 gestational weeks were randomly assigned to receive CG or PI. A swab of the incision site was performed at 3?min after disinfectant application and at 18 post-operative hours, and the prevalence of cultures with any detected bacterial growth was compared for the two groups.

Results: Of the 60 participants, 33 (55.0%) were in the PI group. There were no differences detected at 3?min, with 9.1% positive in the PI group versus 0% positive in the CG group (p?=?0.2499). However, at 18?h, women in the PI group were seven times more likely than women in the CG group to have a positive culture (16/33 [48.5%] versus 3/27 [11.1%], OR?=?7.53 [95% CI 1.67–38.83], p?=?0.0023). Multivariate logistic regression demonstrated similar results: OR?=?7.33 (95% CI 1.77–30.35), p?=?0.0060.

Conclusion: The prevalence of positive bacterial cultures obtained at the site of the skin incision 18?h after CD was higher in the PI versus the CG group.     

Comparison of local and intra venous dexamethasone on post operative pain and recovery after caeseream section. A randomized controlled trial

Objective

To compare the effect of local infiltration and intravenous dexamethasone on postoperative pain and recovery after Cesarean Section (CS).

Neonatal impact of elective repeat cesarean delivery at term: a comment on patient choice cesarean delivery

OBJECTIVE: The object of this study was to compare neonatal outcomes of term uncomplicated pregnancies delivered by scheduled repeat cesarean with outcomes of babies born to mothers intending to deliver vaginally. STUDY DESIGN: This retrospective cohort study describes neonatal outcomes of term uncomplicated pregnancies. Neonates of mothers intending to deliver vaginally (n = 3134) are compared with neonates born by elective repeat cesarean delivery prior to labor (n = 117). RESULTS: Neonates born by elective repeat cesarean are more frequently admitted to advanced care nurseries than infants born to mothers intending to deliver vaginally (risk ratio 3.58, 95% confidence interval 3.35-3.58). CONCLUSION: The decision to undergo scheduled cesarean delivery appears to negatively impact immediate neonatal outcomes.     

Yoga during pregnancy: The effects on labor pain and delivery outcomes (A randomized controlled trial)

ObjectiveTo investigate the effects of an antenatal yoga program on perceived maternal labor pain and delivery outcomes. Material & Methods: This randomized control trial was conducted with sixty primiparous women, aged 18–35 years old, who were randomly assigned to either an antenatal yoga program or control groups. Labor pain and discomfort level of the participants were measured using a Visual Analogue Scale at cervical dilatation of 3–4 c and at 2 and 4 h after the initial measurement. Demographic and obstetrical information were collected. The antenatal yoga program consisted of a 1-h supervised yoga class, three times a weekly, starting at 26 weeks gestation. .ResultsParticipants in control group reported higher pain intensity compared to experimental group at 3–4 cm of dilatation (p = 0.01) and at 2 h after the first and the second measurements (p = 0.000). Mothers in the antenatal intervention group that completed the yoga class required a decreased frequency of labor induction in comparison with control group (p = 0.008). In addition, mode of delivery of the intervention group resulted in a lower percentage of cesarean section than control group (p = 0.002). Lastly, the intervention group experienced a shorter duration of the second and third stages of labor. Interval level data was analyzed by using an independent t-test and chi-square.ConclusionYoga during pregnancy may contribute to a reduction pain of labor and improved adequacy of childbirth.     

The timing of antibiotics at cesarean: a randomized controlled trial

We compared maternal and neonatal outcomes in women who received prophylactic antibiotics prior to skin incision to those who received antibiotics at cord clamp. We performed a randomized clinical trial at two sites. Eligible women included those undergoing nonemergency cesarean at 36 weeks' gestation or greater. Subjects were randomized (permuted blocks) into one of two treatments: "preoperative antibiotics" (cefazolin 1 g given <30 minutes prior to skin incision) or "intraoperative antibiotics" (cefazolin 1 g at cord clamping). Patients who reported an allergy to penicillin received clindamycin 900 mg. The trial primary outcome was a composite of maternal infectious morbidities, defined as having any one of the following: (1) postoperative fever (defined as oral temperature >38°C on two separate occasions more than 6 hours apart, after the initial 24-hour postoperative period); (2) wound infection (defined as purulent discharge from the incision); (3) endomyometritis (defined as fundal tenderness and fever malodorous lochia, fever); (4) urinary tract infection (defined as fever, positive urine culture). We enrolled a total of 434 subjects in this study, with 217 in each group. Overall, we found no difference in composite maternal infectious morbidity between those who received antibiotics preoperatively and those who received antibiotics at cord clamp (relative risk = 1.2, 95% confidence interval 0.7 to 1.5). Neonatal outcomes were also similar between the two intervention arms. The rate of suspected sepsis was similar between the two groups. There were no cases of antibiotic resistance in the neonates. Either preoperative antibiotic therapy or antibiotic administration after cord clamp is a reasonable clinical method for reducing the risk of postcesarean infectious morbidity.     

Manual removal versus spontaneous delivery of the placenta at cesarean section in developing countries: a randomized controlled trial and review of literature

Purpose: Cesarean section (CS) rates have increased; this is especially concerning in developing countries. The mode of placental delivery contributes to morbidity associated with CS and determines blood loss during CS. We aimed to compare manual removal versus spontaneous delivery of the placenta at CS.

Methods: In a randomized controlled trial, 574 women admitted for primary or repeat elective CS were randomized into two groups. In group A, the placenta was manually removed, whereas in group B, the placenta was left for spontaneous delivery. Blood loss, operative and postoperative data were recorded.

Results: Blood loss was 875.2?±?524.2?ml in group A versus 731.8?±?426.7?ml in group B (p?=?.001), with a significant drop in postoperative HB (p?=?.015) and HCT (p?=?.031). In group A, odds ratios for blood loss (>1000?ml), HB drop (>?4g/dl), postpartum hemorrhage and blood transfusion were 2.581, 2.850, 2.614 and 1.665, respectively. However, the total operative time (p?=?.326), duration of hospital stay (p?=?.916) and intensive care unit (ICU) admission (p?=?.453) were not statistically different between the two groups.

Conclusions: Manual removal of the placenta at CS is associated with a higher risk of blood loss, postpartum hemorrhage and blood transfusion, with no decrease in operative time.     

Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis

This study reviewed maternal morbidity following trial of labor (TOL) after cesarean section, compared with elective repeat cesarean delivery (ERCS). Articles were pooled to compare women planning vaginal birth after cesarean (VBAC) with those undergoing ERCS with regard to maternal morbidity (MM), uterine rupture/dehiscence (UR/D), blood transfusion (BT), and hysterectomy. The former group was subdivided into successful VBAC (S-VBAC) and failed TOL (F-TOL). VBAC was successful in 17,905 of 24,349 patients (73%). MM, BT, and hysterectomy were similar in women planning VBAC or ERCS, whereas UR/D was different (1.3%; 0,4%). MM, UR/D, BT and hysterectomy were more common after F-TOL (17%, 4.4%, 3%; 0.5%) than after S-VBAC (3.1%, 0.2%, 1.1%; 0.1%) or ERCS (4.3%, 0.4%, 1%; 0.3%). Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.     

Placental drainage of fetal blood at cesarean delivery and feto maternal transfusion: a randomized controlled trial

OBJECTIVE: To assess the efficacy of placental drainage of fetal blood at the time of cesarean delivery on the incidence of feto-maternal transfusion. METHODS: This randomized trial includes 86 gravid women who underwent cesarean delivery. Forty-four women were assigned to the placental drainage group and 42 to the no-drainage group. Placental drainage was accomplished by cutting and milking the umbilical cord until no further blood flow occurred. All placentas were spontaneously expelled. The primary outcome variable, as assessed by preoperative and postoperative Kleihauer-Betke tests, was the amount of fetal blood (greater than or equal to 0.5 mL) in the maternal circulation. RESULTS: The group having placental drainage of fetal blood before placental delivery showed a significantly lower incidence (3 of 44, 6.8%) of feto-maternal transfusion (P=.003) as compared with the undrained group (14 of 42, 33%; relative risk 0.20, 95% confidence interval 0.065-0.65; number needed to treat=4). CONCLUSION: Placental drainage of fetal blood before spontaneous placental delivery at the time of cesarean delivery significantly reduces the incidence of feto-maternal transfusion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00470899 LEVEL OF EVIDENCE: I.