Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101576
A. Dhanya Mackeen MD, MPH , Maranda V. Sullivan DO , Vincenzo Berghella MD
The goal of standardizing the technique of the routine, uncomplicated cesarean delivery (CD) is to decrease maternal morbidity while optimizing neonatal outcomes. During the procedure, a family-oriented CD is recommended. The low transverse cesarean skin incision (created with either scalpel or diathermy) is preferred with either the Joel-Cohen or Pfannenstiel methods being acceptable. For patients with obesity (BMI > 35kg/m2), surgeons may also elect either the Cohen (including supraumbilical) or Pfannenstiel (infraumbilical or infrapannus) technique as there are similar outcomes, however the Cohen approach has been associated with lower Apgar scores and decreased surgeon satisfaction related to the feasibility of the incision. Diathermy may be preferred for subcutaneous tissue opening as compared to sharp dissection. Though postoperative recovery outcomes may be improved with an extraperitoneal approach to CD, a transperitoneal technique is the current standard of care. The initial fascial incision is made sharply, further extension can be carried out either sharply or bluntly. Inferior dissection of the rectus muscle can be omitted and routine cutting of the muscles is not needed. If necessary, a Maylard modification is acceptable. Though based on limited data, blunt peritoneal entry and extension should be considered. With regards to uterine entry and delivery: bladder flap creation should be omitted, a low transverse hysterotomy is recommended with blunt cephalo-caudad expansion, and manual delivery of the fetal head should be performed. If the fetal head is impacted, then reverse breech extraction may be preferred for maternal benefit. Delayed cord clamping is recommended for at least 30 seconds and up to 120 seconds (recommended for preterm deliveries) with either routine or selected umbilical cord gas collection being considered. In areas where available, carbetocin is more effective in prevention of postpartum hemorrhage (PPH). Otherwise, the combination of oxytocin plus either misoprostol or methergine should be utilized. There is insufficient evidence regarding the effectiveness of uterine massage for PPH prevention. Spontaneous removal of the placenta with gentle cord traction is recommended.
{"title":"Evidence-based cesarean delivery: intraoperative management from skin incision until placental delivery (Part 8)","authors":"A. Dhanya Mackeen MD, MPH , Maranda V. Sullivan DO , Vincenzo Berghella MD","doi":"10.1016/j.ajogmf.2024.101576","DOIUrl":"10.1016/j.ajogmf.2024.101576","url":null,"abstract":"<div><div>The goal of standardizing the technique of the routine, uncomplicated cesarean delivery (CD) is to decrease maternal morbidity while optimizing neonatal outcomes. During the procedure, a family-oriented CD is recommended. The low transverse cesarean skin incision (created with either scalpel or diathermy) is preferred with either the Joel-Cohen or Pfannenstiel methods being acceptable. For patients with obesity (BMI <u>></u> 35kg/m<sup>2</sup>), surgeons may also elect either the Cohen (including supraumbilical) or Pfannenstiel (infraumbilical or infrapannus) technique as there are similar outcomes, however the Cohen approach has been associated with lower Apgar scores and decreased surgeon satisfaction related to the feasibility of the incision. Diathermy may be preferred for subcutaneous tissue opening as compared to sharp dissection. Though postoperative recovery outcomes may be improved with an extraperitoneal approach to CD, a transperitoneal technique is the current standard of care. The initial fascial incision is made sharply, further extension can be carried out either sharply or bluntly. Inferior dissection of the rectus muscle can be omitted and routine cutting of the muscles is not needed. If necessary, a Maylard modification is acceptable. Though based on limited data, blunt peritoneal entry and extension should be considered. With regards to uterine entry and delivery: bladder flap creation should be omitted, a low transverse hysterotomy is recommended with blunt cephalo-caudad expansion, and manual delivery of the fetal head should be performed. If the fetal head is impacted, then reverse breech extraction may be preferred for maternal benefit. Delayed cord clamping is recommended for at least 30 seconds and up to 120 seconds (recommended for preterm deliveries) with either routine or selected umbilical cord gas collection being considered. In areas where available, carbetocin is more effective in prevention of postpartum hemorrhage (PPH). Otherwise, the combination of oxytocin plus either misoprostol or methergine should be utilized. There is insufficient evidence regarding the effectiveness of uterine massage for PPH prevention. Spontaneous removal of the placenta with gentle cord traction is recommended.</div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101576"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142824646","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101533
Christina Maxey MD, John Hayden MD, Rebecca Schneyer MD, Kacey M. Hamilton MD, Gabriel Levin MD, Matthew T. Siedhoff MD, Kelly N. Wright MD, Raanan Meyer MD
{"title":"The impact of obstetrics and gynecology journal podcasts on the dissemination of featured articles","authors":"Christina Maxey MD, John Hayden MD, Rebecca Schneyer MD, Kacey M. Hamilton MD, Gabriel Levin MD, Matthew T. Siedhoff MD, Kelly N. Wright MD, Raanan Meyer MD","doi":"10.1016/j.ajogmf.2024.101533","DOIUrl":"10.1016/j.ajogmf.2024.101533","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101533"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142644065","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101547
Raneen Abu Shqara MD , Aya Binenbaum MD , Sari Nahir Biderman MA , Inshirah Sgayer MD , Riva Keidar BA , Nadir Ganim MD , Lior Lowenstein MD , Susana Mustafa Mikhail MD
Background
Various interventions have been applied to reduce perineal trauma and obstetric anal sphincter injuries (OASIS). The efficacy of warm compresses during the second stage of labor for reducing the occurrence of perineal tears is controversial.
Objective
We aimed to compare rates of spontaneous perineal tears requiring suturing, between women who received warm compresses plus perineal massage vs perineal massage alone.
Study design
Women admitted to a single tertiary university-affiliated hospital between June 2023 and January 2024 were randomized to receive warm compresses and perineal massage (n=206) or perineal message only (n=206) during the second stage of labor. Excluded were women with a history of third-degree perineal tear, nut allergy, fetal death, Crohn's disease with perineal involvement, or delivery number >5. Participant allocation was concealed until the second stage of labor. The allocated perineal management was implemented at the time of active fetal descent and when the participant felt the need to push. During active maternal pushing, gentle perineal massage with almond oil was performed in both study groups. In 1 group, warm compresses were applied between contractions, for a minimum of 10 minutes and a maximum of 30. The temperature of the warm compresses was kept in the range of 45°C to 59°C. The perineum was protected during delivery with a hands-on technique. After delivery, the perineum was assessed by an intervention-blinded senior midwife and rectal examination was performed for ruling out OASIS. The primary outcome was the rate of perineal tears requiring suturing. Secondary outcomes included the rates of OASIS and episiotomies. A sub-analysis according to parity and an intention-to-treat analysis were performed.
Results
Similar proportions of women treated and not treated with warm compresses had spontaneous perineal tears requiring suturing: 43.7% vs 45.1%, P value=.766. The groups did not differ in the proportions with first-degree tears, 22.8% vs 21.4%, P value=.722; second-degree tears, 21.4% vs 23.8%, P value=.566; and OASIS rates, 0.5% in each. In a sub-analysis according to parity, the proportion with perineal tears did not differ between the 2 groups.
Conclusion
For women treated during the second stage of labor with warm compresses and perineal massage, compared to perineal massage alone, the rate of spontaneous perineal tears requiring suturing was similar.
El resumen está disponible en Español al final del artículo.
{"title":"Does combining warm perineal compresses with perineal massage during the second stage of labor reduce perineal trauma? A randomized controlled trial","authors":"Raneen Abu Shqara MD , Aya Binenbaum MD , Sari Nahir Biderman MA , Inshirah Sgayer MD , Riva Keidar BA , Nadir Ganim MD , Lior Lowenstein MD , Susana Mustafa Mikhail MD","doi":"10.1016/j.ajogmf.2024.101547","DOIUrl":"10.1016/j.ajogmf.2024.101547","url":null,"abstract":"<div><h3>Background</h3><div>Various interventions have been applied to reduce perineal trauma and obstetric anal sphincter injuries (OASIS). The efficacy of warm compresses during the second stage of labor for reducing the occurrence of perineal tears is controversial.</div></div><div><h3>Objective</h3><div>We aimed to compare rates of spontaneous perineal tears requiring suturing, between women who received warm compresses plus perineal massage vs perineal massage alone.</div></div><div><h3>Study design</h3><div>Women admitted to a single tertiary university-affiliated hospital between June 2023 and January 2024 were randomized to receive warm compresses and perineal massage (n=206) or perineal message only (n=206) during the second stage of labor. Excluded were women with a history of third-degree perineal tear, nut allergy, fetal death, Crohn's disease with perineal involvement, or delivery number >5. Participant allocation was concealed until the second stage of labor. The allocated perineal management was implemented at the time of active fetal descent and when the participant felt the need to push. During active maternal pushing, gentle perineal massage with almond oil was performed in both study groups. In 1 group, warm compresses were applied between contractions, for a minimum of 10 minutes and a maximum of 30. The temperature of the warm compresses was kept in the range of 45°C to 59°C. The perineum was protected during delivery with a hands-on technique. After delivery, the perineum was assessed by an intervention-blinded senior midwife and rectal examination was performed for ruling out OASIS. The primary outcome was the rate of perineal tears requiring suturing. Secondary outcomes included the rates of OASIS and episiotomies. A sub-analysis according to parity and an intention-to-treat analysis were performed.</div></div><div><h3>Results</h3><div>Similar proportions of women treated and not treated with warm compresses had spontaneous perineal tears requiring suturing: 43.7% vs 45.1%, <em>P</em> value=.766. The groups did not differ in the proportions with first-degree tears, 22.8% vs 21.4%, <em>P</em> value=.722; second-degree tears, 21.4% vs 23.8%, <em>P</em> value=.566; and OASIS rates, 0.5% in each. In a sub-analysis according to parity, the proportion with perineal tears did not differ between the 2 groups.</div></div><div><h3>Conclusion</h3><div>For women treated during the second stage of labor with warm compresses and perineal massage, compared to perineal massage alone, the rate of spontaneous perineal tears requiring suturing was similar.</div><div>El resumen está disponible en Español al final del artículo.</div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101547"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142644087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101544
Justine M. Keller MD , Noor Al-Hammadi PhD, MBChB, MPH , Sabel Bass MBChB, MPH , Niraj R. Chavan MD, MPH, MSMS
Background
Substance use disorder (SUD) is a disease characterized by behavior patterns of substance use leading to dysfunction in cognition, mood, and quality of life. The prevalence of perinatal SUD in the United States continues to rise and has adverse effects on the maternal-infant dyad. Mirroring the rise in SUD is an increasing prevalence of severe maternal morbidity (SMM). However, this relationship needs further examination.
Objective(s)
The primary objective of this study was to evaluate the association between perinatal SUD and SMM. We hypothesized that SUD would predict a significantly increased risk for SMM events, both as a composite and individually, in adjusted multivariable regression analyses.
Study Design
We conducted a cross-sectional analysis of inpatient pregnancy hospitalizations from the Healthcare Cost and Utilization Project National Inpatient Sample from 2016 to 2020. ICD-10 codes were used to identify patients with an SUD and/or a SMM event. SUD was defined as a composite. Our primary outcome was rate of SMM as defined by the Centers for Disease Control and Prevention. Multivariable logistic regression analyses were performed to predict the likelihood of SMM among pregnancy hospitalizations with and without SUD as well as to predict the likelihood of SMM for each individual type of SUD in a subgroup of hospitalizations with SUD and SMM.
Results
Of the 3672,932 inpatient pregnancy hospitalizations included in the analyses, 6.27% (230,110/3,672,932) had SUD diagnosis and 2.10% (77,021/3,672,932) had an SMM diagnosis. The prevalence of SMM was significantly higher among patients with SUD (7357/230,110%–3.20%) vs without SUD (69,664/3442,822–2.02%, P<.0001). Patients with SUD were 1.5 times more likely to have a SMM event as compared to those without SUD (aOR 1.52; 95% CI 1.48–1.56). In subgroup analyses based on SUD type—the likelihood of SMM was strongest for stimulants (aOR 3.86; 95% CI 3.61–4.13) and sedatives (aOR 3.82; 95% CI 3.08–4.75). In subgroup analyses based on SMM event, SUD was a strong positive predictor for acute myocardial infarction (aOR 3.63; 95% CI 2.78–4.74) and aneurysm (aOR 6.28; 95% CI 2.77–14.21).
Conclusion(s)
Pregnant patients with SUD carry significantly increased risk of experiencing an SMM event. These events occur more readily in patients with certain patterns of SUD use—most notably sedatives and stimulants. Patients with SUD were most likely to experience a cardiovascular-related SMM event, thus informing care.
背景：物质使用障碍（SUD）是一种以使用物质的行为模式导致认知、情绪和生活质量功能障碍为特征的疾病。在美国，围产期药物使用障碍的发病率持续上升，并对母婴关系产生不利影响。与药物滥用症发病率上升相对应的是，严重孕产妇发病率（SMM）也在不断上升。然而，这种关系还需要进一步研究：本研究的主要目的是评估围产期 SUD 与 SMM 之间的关系。我们假设，在调整后的多变量回归分析中，SUD 将预测 SMM 事件风险的显著增加，包括综合风险和单独风险：我们对 2016 年至 2020 年医疗成本与利用项目（HCUP）全国住院患者样本（NIS）中的妊娠住院患者进行了横断面分析。采用ICD-10编码来识别患有SUD和/或SMM事件的患者。SUD 被定义为一个复合体。我们的主要结果是疾病预防控制中心定义的 SMM 发生率。我们进行了多变量逻辑回归分析，以预测有 SUD 和无 SUD 的妊娠住院患者发生 SMM 的可能性，并预测有 SUD 和 SMM 的住院患者亚群中每种 SUD 类型发生 SMM 的可能性：在纳入分析的 3,672,932 例住院孕妇中，6.27%（230,110 例/3,672,932 例）被诊断为 SUD，2.10%（77021 例/3,672,932 例）被诊断为 SMM。有药物滥用史的患者（7 357/230 110 - 3.20%）与无药物滥用史的患者（69 664/3 442 822 - 2.02%，P）相比，SMM 的患病率明显更高：患有 SUD 的孕妇发生 SMM 事件的风险明显增加。这些事件更容易发生在使用某些药物滥用模式的患者身上，尤其是镇静剂和兴奋剂。患有药物依赖性疾病的患者最有可能发生与心血管相关的 SMM 事件，从而为护理提供参考。
{"title":"Substance use disorder and severe maternal morbidity: is there a differential impact?","authors":"Justine M. Keller MD , Noor Al-Hammadi PhD, MBChB, MPH , Sabel Bass MBChB, MPH , Niraj R. Chavan MD, MPH, MSMS","doi":"10.1016/j.ajogmf.2024.101544","DOIUrl":"10.1016/j.ajogmf.2024.101544","url":null,"abstract":"<div><h3>Background</h3><div>Substance use disorder (SUD) is a disease characterized by behavior patterns of substance use leading to dysfunction in cognition, mood, and quality of life. The prevalence of perinatal SUD in the United States continues to rise and has adverse effects on the maternal-infant dyad. Mirroring the rise in SUD is an increasing prevalence of severe maternal morbidity (SMM). However, this relationship needs further examination.</div></div><div><h3>Objective(s)</h3><div>The primary objective of this study was to evaluate the association between perinatal SUD and SMM. We hypothesized that SUD would predict a significantly increased risk for SMM events, both as a composite and individually, in adjusted multivariable regression analyses.</div></div><div><h3>Study Design</h3><div>We conducted a cross-sectional analysis of inpatient pregnancy hospitalizations from the Healthcare Cost and Utilization Project National Inpatient Sample from 2016 to 2020. ICD-10 codes were used to identify patients with an SUD and/or a SMM event. SUD was defined as a composite. Our primary outcome was rate of SMM as defined by the Centers for Disease Control and Prevention. Multivariable logistic regression analyses were performed to predict the likelihood of SMM among pregnancy hospitalizations with and without SUD as well as to predict the likelihood of SMM for each individual type of SUD in a subgroup of hospitalizations with SUD and SMM.</div></div><div><h3>Results</h3><div>Of the 3672,932 inpatient pregnancy hospitalizations included in the analyses, 6.27% (230,110/3,672,932) had SUD diagnosis and 2.10% (77,021/3,672,932) had an SMM diagnosis. The prevalence of SMM was significantly higher among patients with SUD (7357/230,110%–3.20%) vs without SUD (69,664/3442,822–2.02%, <em>P</em><.0001). Patients with SUD were 1.5 times more likely to have a SMM event as compared to those without SUD (aOR 1.52; 95% CI 1.48–1.56). In subgroup analyses based on SUD type—the likelihood of SMM was strongest for stimulants (aOR 3.86; 95% CI 3.61–4.13) and sedatives (aOR 3.82; 95% CI 3.08–4.75). In subgroup analyses based on SMM event, SUD was a strong positive predictor for acute myocardial infarction (aOR 3.63; 95% CI 2.78–4.74) and aneurysm (aOR 6.28; 95% CI 2.77–14.21).</div></div><div><h3>Conclusion(s)</h3><div>Pregnant patients with SUD carry significantly increased risk of experiencing an SMM event. These events occur more readily in patients with certain patterns of SUD use—most notably sedatives and stimulants. Patients with SUD were most likely to experience a cardiovascular-related SMM event, thus informing care.</div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101544"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142591663","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101577
Antonio F. Saad MD, MBA , Eunice Yang MD , Andrew H. Nguyen DO , Garima Sharma MD, MBBS, FACC , Scott A. Sullivan MD , George L. Maxwell MD , Luis D. Pacheco MD , George R. Saade MD
{"title":"A practical approach to diagnosing and managing long QT syndrome from pregnancy through postpartum","authors":"Antonio F. Saad MD, MBA , Eunice Yang MD , Andrew H. Nguyen DO , Garima Sharma MD, MBBS, FACC , Scott A. Sullivan MD , George L. Maxwell MD , Luis D. Pacheco MD , George R. Saade MD","doi":"10.1016/j.ajogmf.2024.101577","DOIUrl":"10.1016/j.ajogmf.2024.101577","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101577"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142824642","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101584
Anna R. Whelan MD
{"title":"Bridging personal and professional: the impact of birth trauma on a maternal-fetal medicine specialist's empathy and practice","authors":"Anna R. Whelan MD","doi":"10.1016/j.ajogmf.2024.101584","DOIUrl":"10.1016/j.ajogmf.2024.101584","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101584"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142824643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101540
Alissa Paudel MD, Rachel A. Tinius PhD, Kimberly B. Fortner MD, Linda M. Szymanski MD, PhD, Nikki B. Zite MPH, MD, Jill M. Maples PhD
{"title":"Physician recommendations for physical activity and lifestyle changes in pregnancies with fetal growth restriction: a survey","authors":"Alissa Paudel MD, Rachel A. Tinius PhD, Kimberly B. Fortner MD, Linda M. Szymanski MD, PhD, Nikki B. Zite MPH, MD, Jill M. Maples PhD","doi":"10.1016/j.ajogmf.2024.101540","DOIUrl":"10.1016/j.ajogmf.2024.101540","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101540"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142591657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101549
A. Dhanya Mackeen MD, MPH , Maranda V. Sullivan DO , Whitney Bender MD , Daniele Di Mascio MD , Vincenzo Berghella MD
<div><div>The following review focuses on routine postoperative care after cesarean delivery (CD), including specific Enhanced Recovery After Cesarean recommendations as well as important postpartum counseling points. Following CD, there is insufficient evidence to support administration of prophylactic multi-dose antibiotics to all patients. Additional antibiotic doses are indicated for the following scenarios: patients with obesity who did not receive preoperative azithromycin, CD lasting ≥4 hours since prophylactic dose, blood loss >1500 mL, or those with an intra-amniotic infection. An oxytocin infusion for prevention of postpartum hemorrhage should be continued post-CD. While initial measures to prevent postoperative pain occur in the intraoperative period, with the consideration of 1 g intravenous (IV) acetaminophen and IV or intramuscular nonsteroidal anti-inflammatory medications (eg, 30 mg IV ketorolac), the focus postoperatively continues with this multimodal approach with scheduled acetaminophen per os (PO, 650 mg every 6 hours) and nonsteroidal agents (ketorolac 30 mg IV every 6 hours for 4 doses followed by ibuprofen 600 mg PO every 6 hours) being recommended. Short-acting opioids should be reserved for breakthrough pain. Low-risk patients should receive mechanical thromboprophylaxis until ambulation with chemoprophylaxis being reserved for patients with additional risk factors. When an indwelling bladder catheter was placed intraoperatively for scheduled CD, it should be removed immediately postoperatively. Chewing gum to aid in return of bowel function and early oral intake of solid food can occur immediately after CD and within 2 hours, respectively. For prevention of postoperative nausea and vomiting, administration of 5HT<sub>3</sub> antagonists with the addition of either a dopamine antagonist or a corticosteroid is recommended based on noncesarean data. Early ambulation after CD starting 4 hours postoperatively is encouraged and should be incentivized by pedometer. For patients that receive a dressing over the CD skin incision, limited evidence supports leaving it in place for 48 hours. Adjunct nonpharmacologic interventions for postoperative recovery discussed in this review are acupressure, acupuncture, aromatherapy, coffee, ginger, massage, reiki, and transcutaneous electrical nerve stimulation. In the low-risk patient, hospital discharge may occur as early as 24 to 28 hours if close (ie, 1–2 days) outpatient neonatal follow-up is available due to the potential for neonatal jaundice; otherwise, patients should be discharged at 48 to 72 hours postoperatively. Upon discharge, the multimodal pain control recommendations of acetaminophen and ibuprofen should be continued. If short-acting opioids are necessary, the prescribing practices should be individualized based upon the inpatient opioid requirements. Other portions of postoperative/postpartum counseling during the inpatient stay include the optimal interpregnancy interv
{"title":"Evidence-based cesarean delivery: postoperative care (part 10)","authors":"A. Dhanya Mackeen MD, MPH , Maranda V. Sullivan DO , Whitney Bender MD , Daniele Di Mascio MD , Vincenzo Berghella MD","doi":"10.1016/j.ajogmf.2024.101549","DOIUrl":"10.1016/j.ajogmf.2024.101549","url":null,"abstract":"<div><div>The following review focuses on routine postoperative care after cesarean delivery (CD), including specific Enhanced Recovery After Cesarean recommendations as well as important postpartum counseling points. Following CD, there is insufficient evidence to support administration of prophylactic multi-dose antibiotics to all patients. Additional antibiotic doses are indicated for the following scenarios: patients with obesity who did not receive preoperative azithromycin, CD lasting ≥4 hours since prophylactic dose, blood loss >1500 mL, or those with an intra-amniotic infection. An oxytocin infusion for prevention of postpartum hemorrhage should be continued post-CD. While initial measures to prevent postoperative pain occur in the intraoperative period, with the consideration of 1 g intravenous (IV) acetaminophen and IV or intramuscular nonsteroidal anti-inflammatory medications (eg, 30 mg IV ketorolac), the focus postoperatively continues with this multimodal approach with scheduled acetaminophen per os (PO, 650 mg every 6 hours) and nonsteroidal agents (ketorolac 30 mg IV every 6 hours for 4 doses followed by ibuprofen 600 mg PO every 6 hours) being recommended. Short-acting opioids should be reserved for breakthrough pain. Low-risk patients should receive mechanical thromboprophylaxis until ambulation with chemoprophylaxis being reserved for patients with additional risk factors. When an indwelling bladder catheter was placed intraoperatively for scheduled CD, it should be removed immediately postoperatively. Chewing gum to aid in return of bowel function and early oral intake of solid food can occur immediately after CD and within 2 hours, respectively. For prevention of postoperative nausea and vomiting, administration of 5HT<sub>3</sub> antagonists with the addition of either a dopamine antagonist or a corticosteroid is recommended based on noncesarean data. Early ambulation after CD starting 4 hours postoperatively is encouraged and should be incentivized by pedometer. For patients that receive a dressing over the CD skin incision, limited evidence supports leaving it in place for 48 hours. Adjunct nonpharmacologic interventions for postoperative recovery discussed in this review are acupressure, acupuncture, aromatherapy, coffee, ginger, massage, reiki, and transcutaneous electrical nerve stimulation. In the low-risk patient, hospital discharge may occur as early as 24 to 28 hours if close (ie, 1–2 days) outpatient neonatal follow-up is available due to the potential for neonatal jaundice; otherwise, patients should be discharged at 48 to 72 hours postoperatively. Upon discharge, the multimodal pain control recommendations of acetaminophen and ibuprofen should be continued. If short-acting opioids are necessary, the prescribing practices should be individualized based upon the inpatient opioid requirements. Other portions of postoperative/postpartum counseling during the inpatient stay include the optimal interpregnancy interv","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101549"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142669017","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101514
Vincenzo Berghella MD , Emily S. Miller MD, MPH , Molly Stout MD, MS , Adam K. Lewkowitz MD, MPHS , Terri-Ann Bennett MD , Karin A. Fox MD, MEd , American Journal of Obstetrics & Gynecology MFM Editors
{"title":"How the history of midwifery and obstetrics still affects what you do today in pregnancy care: the American Journal of Obstetrics & Gynecology MFM starts a new “Obstetrical history” series","authors":"Vincenzo Berghella MD , Emily S. Miller MD, MPH , Molly Stout MD, MS , Adam K. Lewkowitz MD, MPHS , Terri-Ann Bennett MD , Karin A. Fox MD, MEd , American Journal of Obstetrics & Gynecology MFM Editors","doi":"10.1016/j.ajogmf.2024.101514","DOIUrl":"10.1016/j.ajogmf.2024.101514","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101514"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142781393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.ajogmf.2024.101578
William W. Hurd MD
{"title":"Myometrial shortening stimulates contractility: a biomechanical hypothesis for labor onset and progression","authors":"William W. Hurd MD","doi":"10.1016/j.ajogmf.2024.101578","DOIUrl":"10.1016/j.ajogmf.2024.101578","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"7 1","pages":"Article 101578"},"PeriodicalIF":3.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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