A new type of surgical sealant is being used to reduce the risk of infection during cesarean deliveries.
This article on the subject focuses on the practice being employed by Dr Jacques Moritz, director of gynecology at St. Luke’s-Roosevelt Hospital in Manhattan, following positive results in clinical trials:
Research
The 'sealant has been shown to seal and immobilize harmful pathogens including MRSA, S. epidermis and E. coli. The sealant is applied to the skin after surgery prep and before the incision is made. The sealant is non-irritating and does not need to be removed in order to close the incision. After surgery, the sealant wears off naturally within a few days. Doctors say the sealant should not be used in surgical procedures involving mucous membranes or the eyes, on patients with hypersensitivity or on skin with active signs of infections.'
Dr Moritz says that, while 'there is no such thing as true sterilization of the skin', this sealant 'gives new moms an added layer of protection.'
It's certainly something worth asking your doctor about ahead of your planned surgery...?
Showing posts with label Risks for mothers. Show all posts
Showing posts with label Risks for mothers. Show all posts
Wednesday, December 9, 2009
Wednesday, April 8, 2009
Hysterectomy risk with multiple cesarean deliveries
The fact that risks increase with multiple cesarean deliveries is well documented, and it is important that anyone considering choosing a planned cesarean delivery in preference to a trial of labor is aware of these increased risks. In fact, this is why the NIH, ACOG and others all stress that CDMR is not recommended for women planning large families.
One of the risks often cited with multiple surgeries is the chance of needing an emergency hysterectomy, and a recent Irish news article has highlighted this risk:
The Sunday Times' 'Caesarean link to surge in hysterectomies', on April 5, reports:
"The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans. Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births."
It is similar to an article that appeared in January 2008 in Australia's The Age, 'Caesars raise risk of losing womb', which reported on research from the University of Oxford:
"For most women giving birth normally for the first time, a hysterectomy is rare - only one in 30,000 will need surgery to remove their womb because of bleeding complications. But the risk of having to undergo surgery to remove the womb rises in the subsequent pregnancy for those who had a caesarean. One in 1300 women who have had one previous caesarean will have a hysterectomy. If the woman has had two or more previous caesareans, the risk rises to one in 220. Researchers estimate that more than 80 women a year have been forced to have a hysterectomy in Britain as a result of having a caesarean. But with the popularity of the procedure on the rise this figure is likely to increase. The study of 775,000 women who gave birth in Britain between February 2005 and February 2006 also found that women with twin pregnancies, older mothers and those who already had three or more children were also at higher risk of needing a hysterectomy."
Limitations of the research
The main problem with the research cited above is that the nature of the primary cesarean deliveries (that occurred prior to the subsequent surgery in which the hysterectomy is required) are not specified.
In fact, all cesarean delivery types tend to be pooled together and then the health outcomes of their subsequent pregnancies are looked at together. This means that primary cesareans that may have been an emergency delivery (which has greater morbidity risks than a planned delivery) are treated the same as planned deliveries.
Therefore, healthy women choosing a planned primary cesarean delivery should not be criticized or deterred from making their valid decision on the basis of mixed data outcomes. Yes, they should be informed of the risk of subsequent placenta complications, but every effort should be made to evaluate how many hysterectomies occur in cesarean deliveries that follow primary planned surgeries - not primary emergency surgeries.
One of the risks often cited with multiple surgeries is the chance of needing an emergency hysterectomy, and a recent Irish news article has highlighted this risk:
The Sunday Times' 'Caesarean link to surge in hysterectomies', on April 5, reports:
"The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans. Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births."
It is similar to an article that appeared in January 2008 in Australia's The Age, 'Caesars raise risk of losing womb', which reported on research from the University of Oxford:
"For most women giving birth normally for the first time, a hysterectomy is rare - only one in 30,000 will need surgery to remove their womb because of bleeding complications. But the risk of having to undergo surgery to remove the womb rises in the subsequent pregnancy for those who had a caesarean. One in 1300 women who have had one previous caesarean will have a hysterectomy. If the woman has had two or more previous caesareans, the risk rises to one in 220. Researchers estimate that more than 80 women a year have been forced to have a hysterectomy in Britain as a result of having a caesarean. But with the popularity of the procedure on the rise this figure is likely to increase. The study of 775,000 women who gave birth in Britain between February 2005 and February 2006 also found that women with twin pregnancies, older mothers and those who already had three or more children were also at higher risk of needing a hysterectomy."
Limitations of the research
The main problem with the research cited above is that the nature of the primary cesarean deliveries (that occurred prior to the subsequent surgery in which the hysterectomy is required) are not specified.
In fact, all cesarean delivery types tend to be pooled together and then the health outcomes of their subsequent pregnancies are looked at together. This means that primary cesareans that may have been an emergency delivery (which has greater morbidity risks than a planned delivery) are treated the same as planned deliveries.
Therefore, healthy women choosing a planned primary cesarean delivery should not be criticized or deterred from making their valid decision on the basis of mixed data outcomes. Yes, they should be informed of the risk of subsequent placenta complications, but every effort should be made to evaluate how many hysterectomies occur in cesarean deliveries that follow primary planned surgeries - not primary emergency surgeries.
Saturday, January 31, 2009
Cesarean complications rise in line with changes in mothers
A number of studies have been published recently, which, if read in the context and knowledge of other applicable studies, would inform women more accurately than many media reports have managed to do.
Take for example this week's highly publicized U.S. report, 'Severe Obstetric Morbidity in the United States: 1998-2005', by EV Kuklina et al. They found that the "prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998-1999 to 0.81% (n=68,433) in 2004-2005." And that
Perception of risk - actual increase versus percentage increase
Clearly, these numbers in real terms - especially when you consider that they take into account ALL delivery complications (including emergency cesareans) - are relatively small (less than 1%), but what many media reports concentrated on was the '% increase' number, which of course looks a lot higher - and riskier - when reported without the 'per 1000' figures.
For example, renal failure increased "by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57).
The authors conclude that: "Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery.
But is cesarean surgery the reason for greater severe morbidity - or are other factors to blame?
Adding to a growing body of evidence on this subject, a Scottish review this month by A Poobalan et al, 'Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies' tells us that cesarean delivery "risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI."
And in 2003, KS Joseph et al's Canadian study, 'Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery', which set out to "estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates", concluded that "Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery."
Specifically, the researchers noted a 14% increase in cesarean deliveries for dystocia, 24% for breech, 21% for suspected fetal distress, 47% for hypertension, and 73% for miscellaneous indications between 1988 and 2000. Importantly: "Adjustment for maternal characteristics reduced the temporal increase" in cesarean rates from 21% to 2% [and] Additional adjustment for obstetric practice factors further reduced period effects."
The future of cesarean rates
A review by Rebecca Simmons, MD., 'Perinatal Programming of Obesity', published in the U.S. in October 2008, reminds us that the prevalence of obesity "has risen dramatically over the last decade [and a] number of epidemiological studies have shown that there is a direct relationship between birth weight and BMI in childhood and in adult life." I would suggest that with no sign of a decline in obesity rates (in fact, quite the opposite) and with women continuing to have their babies later and later in life, we are not going to see any significant reduction in primary cesarean rates at all, and we need to be very careful about implementing strategies to drastically reduce them since this will result in greater morbidity and mortality for these women and their babies.
Take for example this week's highly publicized U.S. report, 'Severe Obstetric Morbidity in the United States: 1998-2005', by EV Kuklina et al. They found that the "prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998-1999 to 0.81% (n=68,433) in 2004-2005." And that
Perception of risk - actual increase versus percentage increase
Clearly, these numbers in real terms - especially when you consider that they take into account ALL delivery complications (including emergency cesareans) - are relatively small (less than 1%), but what many media reports concentrated on was the '% increase' number, which of course looks a lot higher - and riskier - when reported without the 'per 1000' figures.
For example, renal failure increased "by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57).
The authors conclude that: "Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery.
But is cesarean surgery the reason for greater severe morbidity - or are other factors to blame?
Adding to a growing body of evidence on this subject, a Scottish review this month by A Poobalan et al, 'Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies' tells us that cesarean delivery "risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI."
And in 2003, KS Joseph et al's Canadian study, 'Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery', which set out to "estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates", concluded that "Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery."
Specifically, the researchers noted a 14% increase in cesarean deliveries for dystocia, 24% for breech, 21% for suspected fetal distress, 47% for hypertension, and 73% for miscellaneous indications between 1988 and 2000. Importantly: "Adjustment for maternal characteristics reduced the temporal increase" in cesarean rates from 21% to 2% [and] Additional adjustment for obstetric practice factors further reduced period effects."
The future of cesarean rates
A review by Rebecca Simmons, MD., 'Perinatal Programming of Obesity', published in the U.S. in October 2008, reminds us that the prevalence of obesity "has risen dramatically over the last decade [and a] number of epidemiological studies have shown that there is a direct relationship between birth weight and BMI in childhood and in adult life." I would suggest that with no sign of a decline in obesity rates (in fact, quite the opposite) and with women continuing to have their babies later and later in life, we are not going to see any significant reduction in primary cesarean rates at all, and we need to be very careful about implementing strategies to drastically reduce them since this will result in greater morbidity and mortality for these women and their babies.
Monday, January 26, 2009
New research on cesarean surgery techniques
Hypotension and Nausea during surgey
When I saw this new study from Canada by M Tanaka et al, 'ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery', it reminded me of my own experience during the birth of my daughter in 2007. The anesthetist had warned me prior to the start of surgery that I may experience some nausea, and to let him know if I did as he would be able to administer something for it. Well, I did, and he did, and in truth, I have no idea what the drug was, but I felt better almost immediately.
For those of who would like to be able to discuss this occurence of nausea and its treatment during your cesarean surgery in more detail (with your OBGYN or anesthetist), you might find this study interesting. It set out to "determine the 95% effective dose (ED95) of phenylephrine by intermittent i.v. bolus, to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery" and involved 50 patients undergoing elective cesarean delivery under spinal anesthesia.
The study results
"The ED95 of phenylephrine was estimated as 159 mug (95% confidence interval: 122-371 mug), although the largest dose given in the study was only 120 mug. Hypertension (systolic blood pressure >120% of baseline) was observed in 14 cases, immediately after intrathecal injection and prophylactic phenylephrine administration in all cases." The authors conclude that the "safety of this dose warrants further studies."
Blood loss following surgery
This second study from Iran, 'Efficacy of tranexamic acid in reducing blood loss after cesarean section' by L Sekhavat et al, was conducted on 90 primiparas divided into two groups who underwent cesarean delivery. "The study group, 45 women, received tranexamic acid immediately before CS, whereas the control group, 45 women received placebo" and then blood loss volume for each group was measured from the end of surgery to 2 hours postpartum.
Study conclusions
The authors conclude that: "Tranexamic acid statistically reduces blood loss from end to 2 h after CS and its use was not associated with any side effects or complications. Consequently, tranexamic acid can be used safely and effectively to reduce bleeding resulting from CS." My second baby is due shortly, and a cesarean delivery is planned, so I will certainly be asking my doctor about whether the findings in this study are relevant to my potential recovery experience.
When I saw this new study from Canada by M Tanaka et al, 'ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery', it reminded me of my own experience during the birth of my daughter in 2007. The anesthetist had warned me prior to the start of surgery that I may experience some nausea, and to let him know if I did as he would be able to administer something for it. Well, I did, and he did, and in truth, I have no idea what the drug was, but I felt better almost immediately.
For those of who would like to be able to discuss this occurence of nausea and its treatment during your cesarean surgery in more detail (with your OBGYN or anesthetist), you might find this study interesting. It set out to "determine the 95% effective dose (ED95) of phenylephrine by intermittent i.v. bolus, to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery" and involved 50 patients undergoing elective cesarean delivery under spinal anesthesia.
The study results
"The ED95 of phenylephrine was estimated as 159 mug (95% confidence interval: 122-371 mug), although the largest dose given in the study was only 120 mug. Hypertension (systolic blood pressure >120% of baseline) was observed in 14 cases, immediately after intrathecal injection and prophylactic phenylephrine administration in all cases." The authors conclude that the "safety of this dose warrants further studies."
Blood loss following surgery
This second study from Iran, 'Efficacy of tranexamic acid in reducing blood loss after cesarean section' by L Sekhavat et al, was conducted on 90 primiparas divided into two groups who underwent cesarean delivery. "The study group, 45 women, received tranexamic acid immediately before CS, whereas the control group, 45 women received placebo" and then blood loss volume for each group was measured from the end of surgery to 2 hours postpartum.
Study conclusions
The authors conclude that: "Tranexamic acid statistically reduces blood loss from end to 2 h after CS and its use was not associated with any side effects or complications. Consequently, tranexamic acid can be used safely and effectively to reduce bleeding resulting from CS." My second baby is due shortly, and a cesarean delivery is planned, so I will certainly be asking my doctor about whether the findings in this study are relevant to my potential recovery experience.
Friday, January 16, 2009
0.5% risk of deep vein thrombosis with cesarean delivery
A new North American study by Winnie Siaa et al, 'The incidence of deep vein thrombosis in women undergoing cesarean delivery', set out to determine the incidence of deep vein thrombosis (DVT) post cesarean delivery since venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States and Canada, and cesarean delivery is a known risk factor.
The autors found an incidence proportion of DVT post cesarean delivery of 0.5% and say this is the largest study to date that uses Doppler compression ultrasound to diagnose DVT in women after cesarean deliveries.
Study highlights
The research is certainly worth a read, but I've highlighted some of the interesting points made by the researchers in the 'Comment' section of their presentation:
The autors found an incidence proportion of DVT post cesarean delivery of 0.5% and say this is the largest study to date that uses Doppler compression ultrasound to diagnose DVT in women after cesarean deliveries.
Study highlights
The research is certainly worth a read, but I've highlighted some of the interesting points made by the researchers in the 'Comment' section of their presentation:
*A Swedish prospective study found an incidence of DVT post cesarean delivery at 1.8% using impedance plethysmography, which is known to have high false positive rate compared to Doppler ultrasound. However, four other studies using Doppler ultrasound did not find any DVT in their cesarean delivery population... [many more studies are cited]
*This incidence of post cesarean delivery DVT is much lower than that reported among general surgical patients... This disparity between general surgical patients and patients undergoing CD may be due to many factors. First, patients undergoing CD are generally younger. This is still true even though 20% of our population would be described as “advanced maternal age” for being over 35 years old. Age is both an independent risk factor of VTE and is associated with increased likelihood of co-morbidities. Second, most cesarean deliveries are now performed under regional anesthesia, which is known to have a lower risk of postoperative DVT compared with general anesthesia. Third, postpartum mothers are more likely to be out of bed early and frequently (because of the needs of their newborn) as compared to patients who have undergone other abdominal surgeries.
*It is interesting to note that while our study population appears to have few VTE risk factors, 78% would have warranted thromboprophylaxis after cesarean delivery per RCOG guideline. The preeclampsia rate of nearly 10% in our study is higher than that of the general obstetric population likely because preeclampsia increases the risk of cesarean delivery and our participants all had cesarean deliveries.
Epidural risk lower than thought
A BBC News article on the 12th January reports on a study by researchers at Bath's Royal United Hospital, which suggests that the "risk of epidurals and spinal anaesthetics to expectant mothers and patients undergoing surgery may be being overstated."
The researchers analysed the complications from the 700,000 pain-killing injections given each year and "found the risk of harm was at least as low as one in 23,000 - 10 times less than tends to be estimated. Experts said it was important patients were told about the true risk."
You can read the article in full here, but it continues: "Researchers said expectant mothers, in particular, should not be overly concerned as their risk of permanent harm was as low a one in 80,000."
Spinal anesthesia
Spinal anesthesia rather than an epidural is often used in planned cesarean deliveries today, but this research is worth being aware of for both cesarean and vaginal delivery risk information.
The researchers analysed the complications from the 700,000 pain-killing injections given each year and "found the risk of harm was at least as low as one in 23,000 - 10 times less than tends to be estimated. Experts said it was important patients were told about the true risk."
You can read the article in full here, but it continues: "Researchers said expectant mothers, in particular, should not be overly concerned as their risk of permanent harm was as low a one in 80,000."
Spinal anesthesia
Spinal anesthesia rather than an epidural is often used in planned cesarean deliveries today, but this research is worth being aware of for both cesarean and vaginal delivery risk information.
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