Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries.
To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery.
A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan–Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used.
From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes.
In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.
We present a rare case of uterine artery pseudoaneurysm (UAP) following an emergency cesarean section, which led to severe vaginal bleeding and subcutaneous hematoma. The patient, a 40-year-old woman with no history of hemophilia or hemostasis disorders, presented with sudden profuse vaginal bleeding and multiple subcutaneous hematomas at the site of the cesarean scar ten days postoperation. Ultrasound and CT scan confirmed the presence of a pseudoaneurysm in the right uterine artery. Due to the unavailability of radiological embolization, surgical ligation of the right internal iliac artery was performed. Postoperative follow-up showed successful resolution of the pseudoaneurysm and cessation of bleeding. This case highlights the importance of considering UAP in the differential diagnosis of postpartum hemorrhage and demonstrates the efficacy of surgical intervention when embolization is not available.
National guidance conflicts regarding the use of RhD immune globulin administration <12w. Recent Society for Maternal Fetal Medicine (SMFM) guidelines suggest liberal use of this product while other guidelines, including Society of Family Planning and the World Health Organization, propose a more conservative approach. Medicine is not practiced in a vacuum, and potential harms must include not only individual but communal and public health effects. We aim to critically examine the practical implications of the new SMFM guidelines with a focus on equity and access.
Family planning programs are foundationally important to public health, but like any medical intervention, contraception has drawbacks in addition to its benefits. Knowledge of these drawbacks in addition to benefits is essential for informed choice. Despite a general consensus among family planning researchers and providers that contraceptive counseling should be unbiased, little quantitative research has assessed the extent of bias in contraceptive counseling, and in people's contraceptive knowledge more broadly.
To understand the extent to which women report being told more about the advantages of contraception than the disadvantages—a concept we call “asymmetry” in contraceptive counseling, at two research sites in Burkina Faso.
We use data from a cross-sectional population-based survey of 3,929 women residing in the catchment areas of the Ouagadougou (urban) and the Nouna (rural) Health and Demographic Surveillance Systems in Burkina Faso. We use descriptive statistics to explore asymmetry in knowledge of the benefits/advantages and risks/disadvantages of contraceptive use overall, as well as method-specific asymmetry among current method users regarding their counseling experience.
Results show substantial asymmetry in knowledge of advantages/benefits of contraception compared to disadvantages/risks. 86% of respondents said they could name any advantage of family planning, while half of that proportion (43%) could name any disadvantage. We find a similarly stark asymmetry in method-specific results among contraceptive users, especially for hormonal/biomedical methods. We also find substantial variation between research sites, with urban respondents much less likely to self-report complete family planning knowledge than their rural counterparts.
Our results suggest that family planning messaging in Burkina Faso may place an emphasis on the advantages without a commensurate focus on disadvantages. Family planning programs worldwide must ensure that people can make informed choices based on balanced, accurate information about both the benefits and the disadvantages of contraception.
Despite Vietnam's overall progress on maternal health indicators, marginalized ethnic minorities in remote areas face lower access to antenatal care and higher maternal mortality rates relative to the Kinh (majority ethnic group). Last year, we conducted fieldwork for 2 qualitative research projects that aimed to address maternal health inequities among pregnant ethnic minority women in rural Northern Vietnam. Although not the focus of our research, the use of ultrasonography services at for-profit private clinics was ubiquitous in participants’ healthcare-seeking accounts. Ultrasound scans from for-profit clinics were a major component of ethnic minority women's antenatal care: many purchased 8 to 10 scans during pregnancy at $6.15 US dollars per scan, despite their limited agricultural income of $120 to $205 per month. Women were unaware of how many scans were recommended and their medically indicated scheduling, but purchased frequent scans to assuage pregnancy anxieties and access what they experienced as the highest-quality antenatal service. In tandem, for-profit ultrasonography providers offered broader opening hours, immediate results, and rich technological scans, which seemed to deliver poor families the most tangible “value” for their hard-earned money.
Previous literature documented the concerning overuse of ultrasonography among Kinh women in urban Vietnam: What are the implications of this trend extending to affect rural-dwelling ethnic minority women who face lower education, economic marginalization, and a 4-fold higher maternal mortality rate? Our findings raise concerns related to safety, financial vulnerability and provider-induced demand, and broader health policy questions regarding healthcare commodities in low-resource settings. Critically, there is no evidence of the effect of obstetrical ultrasound on reducing maternal mortality in low- and middle-income countries, and its excess use could burden available resources and detract from evidence-based services.
Our findings suggest that health system gaps are driving poor women toward frequent purchases of a single insufficient maternal health commodity: this will not improve their pregnancy outcomes or health equity for marginalized ethnic minorities. We argue that addressing this overuse of ultrasonography due to provider-induced demand requires a multipronged response that meets women's growing expectations. Our findings highlight the need for investment in health education, health promotion, and reliable high-quality public maternal healthcare for ethnic minority communities in Vietnam.
Port-site herniation (PSH) is a rare complication observed postlaparoscopic surgery, typically associated with port sizes of 10 mm or larger, commonly occurred at umbilicus. While occurrences of extra-umbilicus with port size smaller than 10 mm are rare, we present a case detailing a lateral 7 mm PSH diagnosed on the 8th day following a total laparoscopic hysterectomy. The patient exhibited clinical symptoms indicative of partial small bowel obstruction, which became apparent on the third postoperative day. Computed tomography revealed significant small bowel dilatation and herniation through the previously employed 7 mm trocar site. Notably, this trocar site had been utilized with uterine screw. Prompt laparoscopic repair successfully addressed the herniation. The patient demonstrated satisfactory recovery and was subsequently discharged. While current practice recommends fascial incision closure for port size ≥10 mm. In light of our case, we propose considering fascial closure for small-size trocar subjected to any use of a manipulator.
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