A cross-sectional study exploring the incidence of and indications for second-stage cesarean delivery over three decades.

OBJECTIVE: To observe the incidence of, indications for, and complications associated with second-stage cesarean delivery in 10-year intervals over 30 years. METHODS: The present analysis of prospectively collected data compared cesarean deliveries during 1976, 1986, 1996, and 2006 at John Radcliffe Hospital in Oxford, UK (n=3222). Pregnancy, delivery, and neonatal details were reviewed. RESULTS: The proportion of deliveries by cesarean in the second stage of labor increased from 0.5% (22/4464) in 1976 to 2.1% (124/5998) in 2006 (P<0.001). The proportion of cesarean deliveries during the second stage because of failed instrumental delivery also increased over the study period from 59.1% (13/22) in 1976 to 71.0% (88/124) in 2006. Compared with cesareans at other stages, uterine trauma (P<0.001), blood loss greater than 1000 mL (P=0.002), and blood transfusion (P=0.001) were more frequent in second-stage cesarean delivery. Neonates delivered by second-stage cesarean had lower Apgar scores (P<0.001 for 1-min and 5-min scores) and cord arterial pH values (P<0.001) than did those delivered by cesarean earlier in labor. A trend towards an increase in neonatal trauma with second-stage cesarean compared with cesarean delivery before labor or during the first stage did not reach statistical significance. CONCLUSION: The proportion of deliveries by cesarean in the second stage of labor increased; these deliveries were associated with greater maternal and neonatal morbidity, but were not influenced by the indication for cesarean.

Retrospective study to investigate the possible relationship between excess blood loss at caesarean section and reduced intra-operative oxytocin dose.

OBJECTIVE: To investigate a possible relationship between the oxytocin dose at caesarean section and blood loss. STUDY DESIGN: Retrospective analysis of computerised data for all caesarean sections in a UK maternity unit delivering 6000 women annually during 1995-2009 and thus for seven years before and after the 2001 recommended change in oxytocin dose. Validation of computerised and hand-checked clinical data for 1996 and 2006 was performed and annual frequency of blood loss >1000 ml was observed. RESULTS: Validation showed most variables recorded were similar for both acquisition methods. For 17,405 (98.9%) caesarean sections with blood loss recorded, excess or severe loss occurred in 127 (1.6%) of 7177 cases during 1995-2001 compared with 362 (4.0%) of 9035 during 2003-2009 (OR 2.317, CI 1.888-2.843). It was significantly more frequent with multiple than singleton pregnancies (OR 1.946, CI 1.417-2.673), with general than neuraxial anaesthesia (OR 4.296, CI 3.479-5.305) and with non-longitudinal than longitudinal fetal lie (OR 1.942, CI 1.501-2.512). Excluding these three groups, excess blood loss was still more frequent during 2003-2009 than 1995-2001 (OR 3.181, CI 2.374-4.263). Oxytocin given during labour did not influence the frequency of excess blood loss. CONCLUSIONS: The increased rate of excess blood loss at caesarean section during the latter period could be the result of the reduced oxytocin dose. If similar observations are made by others, this possible relationship should be investigated with appropriate objective randomised studies.

Factors that influence the incision-delivery interval at caesarean section and the impact on the neonate: a prospective cohort study.

OBJECTIVE: To determine the range of, and influences on, the incision-delivery interval (IDI) and the impact on neonatal condition at delivery. STUDY DESIGN: Analysis of prospectively collected cohort data from all women delivered by caesarean section over 12 months in an obstetric unit delivering 6000 women per year. Prospective data were collected from clinical records, with factors that influence IDI and relationship to neonatal condition at birth as the main outcome measures. RESULTS: IDI was recorded for 1379 (93%) caesarean sections and ranged between 1 and 37min; median (IQR) was 6 (5-8)min, and for 3% the interval was longer than 15min. Category 1 and 2 caesarean sections had shorter IDI than categories 3 and 4 and intrapartum operations had significantly shorter IDI at 5 (3-8)min than antepartum at 7 (5-9)min (P<0.0001). Factors associated with longer IDI included previous delivery by caesarean section, increased maternal body mass index (BMI), regional anaesthesia, larger neonatal birthweight and technical problems including intraperitoneal adhesions, but did not include fetal malpresentation, multiple pregnancy, grade of surgeon or stage of labour. IDI had no impact on neonatal condition at birth. CONCLUSIONS: Prolonged IDI does not adversely affect neonatal outcome, but factors associated with prolonged IDI should be acknowledged when assessing decision-to-delivery interval target times.

Target decision to delivery intervals for emergency caesarean section based on neonatal outcomes and three year follow-up.

OBJECTIVE: To investigate current target decision to delivery intervals (DDIs) for 'emergency' caesarean section. STUDY DESIGN: Prospective observational cohort study in a teaching hospital providing district and tertiary maternity services delivering 6000 babies per annum. RESULTS: 68% Category 1 deliveries were achieved within 30min and 66% Category 2 within 75min (26% for antepartum Category 2 deliveries). Category 1 deliveries were quicker using general rather than regional anaesthesia (21 vs. 29min, odds ratio [OR] for delivery <30min 4.2, 95%CI 1.3-14.2). 8% Category 1 and 4% Category 2 neonates were acidotic or asphyxiated. The risk of acidosis was not reduced by delivery within 30min for Category 1 (OR 0.56; 0.11-2.81), or within 75min for Category 2 (OR 2.72; 0.6-25.1). Three babies were registered with developmental impairment by three years of age; none were Category 1 deliveries. CONCLUSIONS: Our data suggest that clinical triage is effective, with the more compromised fetus delivered more rapidly using general anaesthesia. For Category 1 deliveries a 30min target DDI is appropriate, although those born after longer DDI did not show developmental impairment. For Category 2 caesarean sections performed for acute fetal distress or concerns, failed instrumental delivery, failure to progress or placental bleeding, a 75min DDI may be an appropriate target but did not protect against acidosis, asphyxia or developmental impairment. Longer DDIs did not result in unfavourable outcomes for other Category 2 indications.

Arterial stiffness is associated with regional ventricular systolic and diastolic dysfunction: the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: The pathophysiology of left ventricular (LV) dysfunction, particularly in the setting of a preserved ejection fraction (EF), remains unclear. Few studies have investigated the relationship between arterial compliance and LV function in humans, and none used cardiovascular MRI. METHODS AND RESULTS: We sought to determine whether arterial compliance is related to regional myocardial function among participants of the Multi-Ethnic Study of Atherosclerosis (MESA). Arterial compliance was assessed using carotid ultrasound measurements to calculate the distensibility coefficient (DC) and Young's modulus (YM). Circumferential systolic (SR(S)) and diastolic (SR(E)) strain rates were calculated by harmonic phase (HARP) from tagged MRI. Associations between arterial compliance and indices of ventricular function were adjusted for cardiovascular risk factors. We found a significant association between arterial compliance and SR(S) in all myocardial regions (P<0.05); arterial compliance was also associated with SR(E) in the lateral and septal wall regions (P<0.05). Multiple linear regression analyses demonstrated a direct linear relationship between the carotid artery DC and SR(S) across all LV segments and slices, even after adjustment for cardiovascular risk factors and LV mass. In regression analyses, a significant relationship between arterial compliance and SR(E) in the septal and antero-apical walls was also found and remained significant after multivariable adjustment. CONCLUSIONS: Arterial stiffness is associated with early and asymptomatic impairment of systolic as well as diastolic myocardial function. Further studies are needed to elucidate role of vascular compliance in the development of ventricular dysfunction and failure.

Tacrolimus and pimecrolimus: from clever prokaryotes to inhibiting calcineurin and treating atopic dermatitis.

Tacrolimus ointment, a topical inhibitor of the phosphatase calcineurin, has recently been approved in the United States for use in the treatment of atopic dermatitis. It is the first topical immune suppressant that is not one of the hydrocortisone derivatives, important allies in dermatology for nearly 50 years. Although tacrolimus is less able to penetrate thick skin than glucocorticoids, it does not cause dermal atrophy, an important advantage over the hydrocortisone class. Pimecrolimus (ASM 981), a newer calcineurin inhibitor closely related to tacrolimus, is also being developed for atopic dermatitis therapy. Pimecrolimus has an altered skin penetration profile but the same mechanism of action as tacrolimus. In this review we chronicle the discovery of the calcineurin inhibitors, their presumed evolutionary role as a bacterial "smart bomb" against fungi, molecular and cellular mechanisms of action in the immune system, systemic and topical side effects, efficacy in atopic dermatitis, and future applications within the specialty of dermatology. Particular attention is given to the issues of systemic absorption of tacrolimus, the conditions in which absorption can become a concern, efficacy relative to glucocorticoids, and the choice of 0.03% or 0.1% tacrolimus ointment for use in adults and children.