Implementation of the Four-Category Classification of Cesarean Section Urgency in Clinical Practice. A Prospective Study.

PURPOSE: This study is aimed at investigating the clinical efficacy of the 4-category classification of urgent cesarean section. METHODS: Women giving birth from September 2012 to December 2014 were prospectively investigated. Urgency C-section categories were color-coded: red - maternal/fetal life threat; yellow - maternal/fetal compromise, not life-threatening; and green - early delivery necessary. Results were audited. RESULTS: A total of 4,754 women gave birth in the period considered, 1,313 (27.6%) with C-section of which 867 were urgent. The code was red in 0.98% of women, and 91.5% of newborns were delivered ≤30'; yellow in 5.1%; and green in 11.7%. The mean decision-to-delivery interval (DDI) ± SD was 19.6 ± 9.5 min, 36.6 ± 15.3 (p < 0.01), and 80.3 ± 52.8 (p < 0.01), respectively; and mean umbilical pH was 7.24 ± 0.10, 7.29 ± 0.08 (p < 0.05), and 7.33 ± 0.04 (p < 0.01) in the red, yellow, and green groups, respectively. Two (4.2%) red and 4 (2.2%) yellow newborns were acidotic. Mean DDI ± SD decreased from 21.7 ± 9.7 min in the period September 2012 to February 2013 to 17.4 ± 9.7 min in the period February to December 2014 (p = NS). CONCLUSIONS: Four-category classification led to achieving the target time in >90% of category 1 emergency C-sections, and stratified newborns with significantly different acidosis levels.

Femoral nerve injury complicating surgery for gynecologic cancer.

OBJECTIVE: The aim of this study was to report the incidence, severity, and factors associated with femoral nerve injury during gynecologic cancer surgery. METHODS: All patients who underwent abdominal surgery for gynecologic cancer entered the study. A retrospective review of the medical records was carried out for patients operated on from 2003 to April 2011. After this analysis, the use of the Bookwalter retractor was modified and the data were prospectively recorded. RESULTS: In the first period, femoral nerve injury was observed in 11 (2.7%) of 406 patients, occurring with a significantly higher frequency when the Bookwalter retractor was used (5.1% vs 0%, P < 0.01) and when pelvic lymphadenectomy was performed (5.1% vs 0.9%, P < 0.01). The analysis of the 212 patients (52.2%) in the Bookwalter group showed higher frequency of nerve injury in the patients undergoing pelvic lymphadenectomy (7.8% vs 2.0%, P = 0.05). In the second period, femoral nerve injury was observed in 1 (0.7%) of 132 patients operated on and in 1 (2.3%) of 43 patients (32.6%) in the Bookwalter group. When comparing the 2 periods, the lesser use of the Bookwalter retractor and the reduced time of maximal traction of the pelvic blades decreased the nerve injury rate from 2.7% to 0.7% and, in the Bookwalter group, from 5.1% to 2.3%. These results, although not statistically significant, are clinically relevant. CONCLUSIONS: Femoral nerve injury during gynecologic cancer surgery was associated with the Bookwalter retractor. The pelvic blades of the retractor may exert a compression on the nerve. The weakened muscles suggest that the nerve compression occurred intrapelvically over the iliacus muscle. Shortening the time of maximal traction of the pelvic blades reduced the incidence of femoral nerve injury. When performing gynecologic surgery with the use of the Bookwalter retractor, care must taken with the placement of the pelvic blades.