Evaluation of adjunctive analgesia with intrathecal fentanyl along with hyperbaric bupivacaine in spinal anesthesia for elective cesarean section

Background: Cesarean section (CS) is one of the most common surgical procedures in female patients. Authors aimed to evaluate the postoperative analgesic efficacy of adding intrathecal fentanyl to bupivacaine, and its effect on the onset and duration of spinal anesthesia along with its effect on mother and neonate.Methods: Study was performed on 60 cesarean section parturients divided into two groups. Group F received 2 ml of 0.5% hyperbaric bupivacaine (10 mg) plus 0.4 ml fentanyl (20 µg), and Group B received 2 ml of 0.5% hyperbaric bupivacaine (10 mg) plus 0.4 ml of normal saline. The parameters taken into consideration were pain scores, analgesic requirement, hemodynamic stability and side effects.Results: It was found that duration of sensory block was prolonged in fentanyl group (111 minutes vs 86 minutes, p<0.001). Duration of effective analgesia (174.36 minutes vs 127.81; p value <0.001) were also found to be prolonged in Group F with requirement of fewer postoperative analgesics (1.02 vs 2.76, p=0.03). There was not much difference in the occurrence of side effects in both the groups.Conclusions: Addition of fentanyl to intrathecal bupivacaine for cesarean section increases the duration of postoperative analgesia without increasing maternal or neonatal side effects.

A study of maternal outcome in term premature rupture of membranes in a tertiary care hospital

Background: Premature rupture of membranes (PROM) remains a subject of great clinical relevance. The present study was conducted to study maternal morbidity and its relationship with PROM-delivery interval in patients with term PROM as compared to patients without PROM.Methods: A prospective case control study was conducted in the department of obstetrics and gynecology, Kasturba Hospital, New Delhi. 100 pregnant patients presenting to the labor room with features of PROM at term (POG>37 weeks) were taken as cases and 100 term pregnant women (age and parity matched) with intact membranes were taken as controls and compared in terms of maternal outcome.Results: This study reported maternal morbidity rate of 21% in term PROM cases which was significantly higher than in control group (5%). The major cause was febrile morbidity which occurred in 16% of cases indicating ascending infection. Other complications were abdominal and episiotomy wound infection (4%), chorioamnionitis (2%), postpartum hemorrhage (2%) and puerperal sepsis (1%). There was an increased rate of operative delivery in the case group (33%) as compared to 18% in patients without PROM. Duration of PROM-delivery interval had a significant direct proportional impact on the maternal morbidity. The duration of combined hospital stay of mother and neonate was also increased.Conclusions: Patients with term PROM have significant maternal morbidity which was mainly due to infection. The duration of the hospital stay was also significantly increased.

Effectiveness of modified mattress suture closing technique over conventional lower segment caesarean section closing technique

Background: The objective of this study was to compare the thickness of the scar and relative thinning of the uterinewall following conventional LSCS closing technique versus new closing technique (modified mattress Suture) and any additional surgical procedure in each group.Methods: A total of sixty patients undergoing primary caesarean for obstetric indications and who were willing for the study were included. In 30 patients uterus was closed by conventional double layer technique (the first layer is suturing with absorbable suture in a continuous running fashion. After first layer is complete, a second continuous stitch is used to invert the first layer, inverting stitch may be horizontal or vertical using same suturing material) and in 30 patient uterus was closed by new modified mattress technique. In both groups same suture material (vicryl 1-0) was used. Measurement of the thickness of scar site and corresponding posterior wall thickness was done following 6 months of caesarean section.Results: The possible parameters of better technique i.e., the mean scar thickness is more and relative as well as percentage thinning is less with this new technique of uterine closure although statistically not significant. Conclusions: Modified mattress suture technique is a single step procedure and gives the feel of double layer uterine closure. Hence the time taken, material. Used and the cost involved will be less along with excellent hemostasis.

Study of caesarean section at tertiary care centre: a retrospective study

Background: Caesarean section (C-section) is one of the most widely performed surgical procedure in obstetrics worldwide. The WHO guidelines revised in 1994 states that the proportion of C-section birth should range between 5-15% but both in developed and developing countries C-section rate is on the rise. This study was conducted to analyse the frequency and indications for C-section and associated maternal morbidity and mortality.Methods: This retrospective study was conducted over a period from January 2018 to May 2019 at the department of obstetrics and gynecology, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Hingna, Nagpur, Maharashtra, India. Data of patients who delivered by C-section in our hospital during the defined study period were studied and statistically analysed according to various parameters namely, the frequency of caesarean section, its indications, age, parity and gestational age of the patient.Results: The total number of women delivered over the study period were 2811. Out of which C-sections were done in 1461 women (51.97%). Previous C-section was the leading indication in 35.72% women followed by fetal distress 14.09%, failure of induction 12.93%, arrest of labour 7.93%, PIH 7.18%, oligo/IUGR 6.50%, breech 4.44%, refusal of vaginal birth 4.24%, CPD 1.71%, bad obstetrics history (BOH) 1.43%, malpresentation 1.30%, prematurity 1.23%,  and multifetal gestation in 1.09% women. Two women had classical C-section 0.07. 14.09% women had various complications. There was no maternal mortality.Conclusions: A high rate of caesarean deliveries was observed. Individualization of the indication and careful evaluation, following standardized guidelines can help us to limit C-section. Audit and feedback are the best way to judge clinical practice and to reduce the frequency of caesarean section in any tertiary setup.

A study comparing non-gestational diabetes mellitus and gestational diabetes mellitus in antenatal patients in a tertiary care center

Background: Gestational diabetes mellitus is defined as any glucose intolerance with the onset or first recognition during pregnancy. Objectives of this study were to diagnose cases of GDM by screening with DIPSI criteria at less than 28 weeks. And observation and comparison of maternal and perinatal outcome in women diagnosed of GDM in less than 20 weeks and at 24-28 weeks.Methods: This was the prospective analytical study conducted in the department of obstetrics and gynecology for one year in Muzaffarnagar medical college and Hospital. After history taking, clinical and obstetrics examination 1503 antenatal patients of less than 28 weeks were enrolled underwent screening with DIPSI criteria. Out of which 80 patients with abnormal OGTT of gestational age less than 20 weeks and 69 patients with abnormal OGTT of gestational age 24 -28 weeks.Results: In early diagnosed GDM group alive and healthy babies were slightly lower as compared with late diagnosed GDM group.Conclusions: The diagnosis of GDM gives us an opportunity in identifying individuals who will be benefitted by early therapeutic intervention with diet, exercise, and normalizing the weight to delay or prevent the onset of the disease.

Trends of caesarean section: an analytical overview of indications

Background: Caesarean section is one of the commonly performed surgical procedures in obstetrics. An increasing trend has been observed in both primary and repeat caesarean sections. The reasons for its increase are multifaceted. So, this study was carried out to compare the rates of caesarean delivery and to analyse various indications contributing to it.Methods: This retrospective study was conducted over a period of three year from 1st January 2016 to 31st December 2018 at the department of obstetrics and gynaecology, tertiary care hospital Pune, Maharashtra, India. All caesarean delivery (primary and repeat) taken place during the study period. The rate and indications of caesarean section was calculated over the study period to find out the trends in caesarean delivery. The data so collected was presented with graphical representation. Statistical analysis was performed with SPSS software and t-test was used for continuous data and pearson chi square test for discrete data.Results: There were a total of 12373 deliveries during the study period out of which, 3701 had delivered via Caesarean Section. So, the rate of caesarean section in the study was found to be 29.91%.Conclusions: Being a tertiary care hospital, a high rate of caesarean deliveries was observed, Individualization of the indication and careful evaluation, following standardized guidelines, practice of evidenced-based obstetrics and audits in the institution, can help us limit caesarean section rates.

A root cause analysis of increasing caesarean section rates in a tertiary care private hospital in North India

Background: Increase in the incidence of caesarean section is a matter of concern worldwide. Robson’s criteria which is universally accepted now as a way for calculating caesarean rates takes into account only the obstetrical consideration, however, it is noteworthy that many socioeconomic and cultural factors also have a role to play. This study takes into account both Robson’s criteria and common socio-cultural factors which lead to increased caesarean rates with an attempt to suggest ways to curtail this trend.Methods: The study was a hospital based cross-sectional study at a private tertiary care hospital in New Delhi. 1200 consecutive live births after 34 weeks of gestation were analysed over a period of one year.Results: LSCS was the most common mode of delivery 733 (61.1%). 329 (27.4%) had induced labour of which 260 (76.2%) had LSCS. 333 women had elective LSCS. Rates of CDMR were 185 (25.2%) which is very significant. As per Robson’s criteria maximum number of women (318) were in group 2, of which 226 (71.1%) underwent caesarean section.Conclusions: High caesarean rates can be attributed to a multitude of factors. Robson’s criteria are an effective way for analysis of obstetric indications. Other added factors include comorbidities, CDMR, fear of litigations, etc which were analysed.

Associated comorbidities with obesity in pregnancy and its feto-maternal outcome

Background: Obesity is an evolving risk factor in the modern day - a rising global epidemic reported to cause many problems in the pregnant woman - causing ill effects to both the mother and the fetus. Managing the comorbidities associated with obesity is a challenge in obstetric care.Methods: This prospective observational cohort study was conducted at a tertiary care institute over a period of 2 years. 50 antenatal patients fulfilling the inclusion criteria were studied after taking informed consent. The various maternal, fetal and neonatal outcomes were noted to examine the magnitude and significance of the effect of BMI.Results: Obese women have a higher prevalence of infertility and are considered a high-risk state because pregnancy is associated with a higher risk of pre-eclampsia, gestational diabetes mellitus, preterm labour, increased operative and caesarean deliveries, post-partum haemorrhage, post-partum infectious morbidities and a higher incidence of anesthetic and post-operative complications in these deliveries. Neonatal complications include congenital anomalies, fetal macrosomia leading to birth injuries, preterm births and still births. Technical difficulties are faced by the obstetricians while operating and by the anesthesiologists while induction.Conclusions: Considering the adverse effects of obesity on pregnancy outcomes, pre-pregnancy counseling should be done for all overweight and obese females planning conception signifying the negative impact of obesity on maternal and fetal outcome.

Indications and foeto-maternal outcome of emergency cesarean sections in rural Mewar region

Background: In the 21st century caesarean section is the most common operation in modern obstetrics but its indications have been changed in elective and emergency cases. The aim of the present study was to find out the incidence, indication of caesarean, foeto-maternal outcome in patients who came in emergency from rural areas.Methods: This retrospective study was conducted at Pannadhai Mahila Hospital, R. N. T. Medical College, Udaipur from September 2017 to February 2018. All the women who were unbooked, belonged to rural Mewar region and underwent emergency caesarean section.Results: Total no. of deliveries conducted were 1560 in the emergency labour room out of which 462 were emergency caesarean sections. The mean age of the participants was 27 years. Foetal distress was the most common indication (17.75%) followed by prolonged labour/ failed induction 14.5%. Post-partum haemorrhage and adhesions were the commonly encountered complications.Conclusions: LSCS due to maternal and foetal indications is inevitable. Timely performed LSCS decreases the morbidity and mortality. The government of India has also taken initiative in making caesarean deliveries more acceptable, affordable to patients belonging to rural areas. The government is also enhancing primary and community health centers.

Vaginal Birth After One Previous Lower Segment Caesarean Section Puja Puri, Mary Abraham, Seema Grover.

To find out the incidence and factors favorable for vaginal delivery after previous one lower segment CS and to document maternal and fetal complications if any in these women.It was a three year study (two year retrospective and one year prospective) and a total of 205 women with previous one lower segment CS for non recurrent indication were included in the study. Case selection for trial of vaginal delivery was done as per the ACOG guidelines.Out of 205 women who were given trial of labor, 56.1% had a vaginal birth after Caesarean section (VBAC) and 43.9% required emergency repeat CS. There was no maternal or neonatal mortality and also no case of uterine rupture.A trial of vaginal delivery after previous one LSCS in selected patients can eliminate the need for a large proportion of repeat CS. This can significantly decrease the incidence of postpartum morbidity, anesthetic and operative risks and financial liabilities.

Conjunctivitis in the newborn- A comparative study.

Background: Conjunctivitis of the newborn is defined as hyperemia and eye discharge in the neonates and is a common infection occurring in the neonates in the first month of life. In the United States, the incidence of neonatal conjunctivitis ranges from 1-2%, in India, the prevalence is 0.5-33% and varies in the world from 0.9-21% depending on the socioeconomic status. Aim: To study the organisms causing conjunctivitis of the newborn and to correlate the etiology with the mode of delivery. Design: Single center, prospective, observational study. Materials and Methods: A total of 300 mothers and their newborns, born over a period of one year, were included in the study. Of these 200 newborns were delivered through vaginal route (Group A) and 100 (Group B) delivered by lower segment caesarean section (LSCS). At the time of labour, high vaginal swabs were taken from the mothers. Two conjunctival swabs each from both eyes of the newborn were collected at birth and transported to Microbiology department in a candle jar immediately. Results: Eight babies in Group A, developed conjunctivitis at birth. None of the babies in Group B developed conjunctivitis, this difference was statistically highly significant (P<0.000). The organisms found in the conjunctiva of the newborns in Group A were Coagulase negative Staphylococcus, α hemolytic Streptococcus, Escherichia coli and Pseudomonas spps. However, the commonest organism leading to conjunctivitis in the newborn in this study was Coagulase negative Staphylococcus. It was observed that the mothers of 5 out of 8 babies (60%) developing conjunctivitis gave history of midwife interference and premature rupture of membranes so the presence of risk factors contribute to the occurrence of conjunctivitis in the newborn. Conclusions: It is inferred that the mode of delivery and the presence of risk factors is responsible for conjunctivitis in the newborn.