Cesarean Section Technique: What’s New in the Evidence Base? No Disclosures Marya G. Zlatnik, MD, MMS Maternal Fetal Medicine UCSF Hamano, Teisuke. 1880. Kainin no kokoroe (Information on pregnancy). Japanese Woodblock Print Collection, Archives & Special Collections, UCSF Library & Center for Knowledge Management. Cesarean Rates Continue to Rise Learning Objectives • Review new techniques & literature re: C/S – “Gentle” cesarean – Infection prevention – (Pain control) – Hemorrhage – Sutures • Evidence-base (according to me) 1 Family-Centered or “Gentle” Cesarean UCSF Family-Centered Cesarean • Buy in from OB, Peds, Nursing, Anesthesia • Clear double drapes • Staffing (extra RN) • UCSF Protocol created by Dr. Robyn Lamar Is “family-centered” or “gentle” A. Yes, we docesarean this at my hospitala good idea? B. Yes, we’re working on it C. We do it only because patients ask D. No, I’m worried about infection & E. What isdisruption it? in the OR UCSF Family-Centered Cesarean • 27% • Mother may choose music to be played in OR • Double drape (with clear window) used 23% • Anesthesia places ECG leads away from mother’s chest 42% • Mother’s chest warmed prior to skin-to-skin with instant hot pack Elevate head of bed, to facilitate viewing the birth & skin-to-skin • Yes, we do this at my hos... • After delivery of head, OB delivers body slowly 5% Yes, we’re working on it • After delivery of head, drape dropped if mother desires to see birth 3% • Consider delayed cord clamping for 30-60 seconds We do it only because pa... Pediatricians receive the baby as usual; 1 min APGAR on warmer; goal to be No, I’m worried about in... • back to mom by 5 minutes for skin-to-skin After close, while drapes are removed & mother is cleaned, partner may help What is it? • with weighing baby & observe other routine care Once mother is on recovery bed, baby placed skin-to-skin again & the dyad transported together to recovery +Ev +Ev +Ev 2 Family-Centered or “Gentle” Cesarean Contraindications: • Prematurity • Emergency cesarean • Anticipated resuscitation (ex: anomalies, nonreassuring Protocol inappropriate in some situations & clinical FHR) judgment always takes precedent •Ex: with vasa previa, slow delivery of body inadvisable •Ex: increased BMI, elevating the head of the bed may impact surgical visualization •Ex: insufficient nursing staff to remain with baby in OR Pre-incision Atbx: Decreased SSI vs After Cord Clamp 8 p= 0.002 6 What are your routine prophylactic antibiotics? (no PCN-allergy) 4 SSI (%) A. Any agent given after cord clamp 2 B. Ampicillin pre-incision 12 0 p= 0.014 C. Cephalosporin (cefazolin) pre- Overall Endometritis Cellulitis D. Cefazolinincision + azithromycin 2005-2006 n= 800 E. Other pre-incision After 2006 n= 516 p= 0.020 Kaimal SMFM 2008 Prophylactic Atbx—Extended 77% Spectrum Regimens 2% 11% • RCT adding metronidazole vag gel Any agent given after co.. Ampicillin pre-incision – 224 pts; vaginal gel vs placebo gel 9% Ceph lo or n c az i . – Less endometritis (7 vs 17%), trend towards less a sp i ( ef ol n. Cefazolin + azithromycin 1% fever; no difference in wound infxn, LOS • Ureasplasma increases risk for C/S SSI Other pre-incision – Cephalosporin doesn’t cover – Post-cord-clamp cefotetan plus placebo or doxy+azithro Pitt 2001 Andrews 2003 3 Extended spectrum Prophylaxis • UAB studies over 14 years – In 2000, IV cefotetan or cefazolin & IV azithro at cord clamp 14 – Decreased endometritis – Decreased wound infections Extended spectrum Prophylaxis? • UCSF baseline rate much lower (<1%) • Hesitant to extend atbx spectrum for all C/S pts Tita Tita Concerns– re: atbx resistance, messing up ObGyn Extended spectrum Prophylaxis • Selectively extend atbx spectrum AJOG microbiome 2009 2008 eg,– pt w/ DM/obesity Cefazolin– 2-3g IV preop + azithro 500mg IV after 17 cord clamp (mix in 250mL/give over 1 hr ) • Multicenter RCT: C/SOAP Trial 2013– pts, C/S in labor or ROM (chorio excluded) 15 – Ave BMI 35 (>60% had BMI >30) – Std atbx + Azithro prior to incision – Fewer SSIs, fevers, PP readmits Do you prep the vagina prior to C/S? A. Yes, every case B. Yes, if ruptured membranes C. Yes, if chorio D. No, never Tita NEJM 2016 E. Not sure 18 66% 13% 8% Yes, every case Yes, if ruptured membranes 1% Yes, if chorio 11% No, never Not sure 4 ZMG2 ZMG2 Vaginal Prep prior to C/S Vaginal Cleansing prior to C/S • Povidone-iodine prep -> decreased • New meta-analysis Sept 2017 endometritis, esp w/ ROM • Povidone-iodine prep -> decreased • No difference in fever or wound complications endometritis, fever, esp w/ labor/ROM • ? benefit if already chorio • No difference in wound complications • Possible effect on neonatal thyroid studies • Only 6 of 16 specified pre-incision atbx • Risk of vaginal lac • ? benefit if already chorio • Dahlke gives a “B” – Caissutti ObGYN 2017 – Cochrane 2010, Reid 2001, Rouse 1997, Starr 2005 CORONIS Trial Lancet 2016 • International, pragmatic trial 2x2x2x2x2 • 19 sites in S. America, Africa, India, Pakistan • 1st or 2nd C/S, follow up at 3 yrs • 15,633 women studied: – Blunt vs. sharp abdominal entry – Repair of uterus in or out – 1 vs. 2 layer closure of uterus – Closure vs. non-closure of peritoneum – Chromic vs. polyglactin-910 for uterus • Outcomes of subsequent pregnancies, pain 5 Incision Type, Uterine Repair, Etc. Placental Delivery – CORONIS Trial 2016 Uterine Exteriorization Incision Type, Uterine Repair, Etc. • No differences CORONIS Trial 2016 6 Management of Hemorrhage Uterine repair • CMQCC hemorrhage toolkit V2.0 (revised March 2015) https://www.cmqcc.org/resources-tool- kits/toolkits/ob-hemorrhage-toolkit Photo courtesy of CMQCC and David Lagrew, MD NPR.org CMQCC OB Hemorrhage Obstetric Hemorrhage Emergency Management Plan: Table Chart Format version 2.0 Assessments Meds/Procedures Blood Bank Stage 0 Every woman in labor/giving birth Emergency Management · Assess every woman Active Management · If Medium Risk: T & Scr Management of Hemorrhage Stage 0 focuses for risk factors for 3rd Stage: · If High Risk: T&C 2 U on risk hemorrhage · Oxytocin IV infusion or · If Positive Antibody assessment and · Measure cumulative 10u IM Screen (prenatal or active quantitative blood · Fundal Massage- current, exclude low level management of loss on every birth vigorous, 15 seconds min. anti-D from Plan the third stage. RhoGam):T&C 2 U Blood loss: > 500ml vaginal or >1000 ml Cesarean, or Stage 1 VS changes (by >15% or HR ³110, BP £85/45, O2 sat <95%) Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014 · Activate OB · IV Access: at least 18gauge · T&C 2 Units PRBCs Follow appropriate workups, planning, preparing Hemorrhage Protocol (if not already done) Identify patients with special consideration: · Increase IV fluid (LR) and Pre- Placenta previa/accreta, Bleeding disorder, or of resources, counseling and notification Stage 1 is short: and Checklist Oxytocin rate, and repeat Admission those who decline blood products Verify Type & Screen on prenatal activate · Notify Charge nurse, fundal massage record; Low Risk: Draw blood and hold specimen if positive antibody screen on prenatal hemorrhage OB/CNM, Anesthesia · Methergine 0.2mg IM (if Time of Screen All Admissions for hemorrhage risk: Medium Risk: Type & Screen, Review Hemorrhage Protocol or current labs (except low level anti-D protocol, initiate · VS, O2 Sat q5’ not hypertensive) Low Risk, Medium Risk and High Risk High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage from Rhogam), Type & Crossmatch 2 preparations and · Record cumulative May repeat if good admission Protocol Units PBRCs give Methergine blood loss q5-15’ response to first dose, BUT nd IM. · Weigh bloody materials otherwise move on to 2 Ongoing Cumulative Blood Loss rd · Careful inspection with level uterotonic drug (see Stage 0 All women receive active management of 3 stage Evaluation: >500 ml Vag; >1000 ml CS NO Standard Postpartum below) Oxytocin IV infusion or 10 Units IM, 10-40 U infusion Quantification of >15% Vital Sign change -or- Management good exposure of All Births blood loss and HR ≥ 110, BP ≤ 85/45 Fundal Massage vaginal walls, cervix, · Empty bladder: straight cath vital signs O2 Sat <95%, Clinical Sx uterine cavity, placenta or place foley with urimeter INCREASED BLEEDING Blood Loss: YES >500 ml Vaginal Increase IV Oxytocin Rate Stage 2 Continued bleeding with total blood loss under 1500ml Methergine 0.2 mg IM (if not hypertensive) Activate Hemorrhage Protocol nd >1000 ml CS OB back to bedside (if 2 Level Uterotonic Drugs: · Notify Blood Bank of Vigorous Fundal massage; Empty Bladder; Keep Warm CALL FOR EXTRA HELP Stage 1 not already there) · Hemabate 250 mcg IM or OB Hemorrhage Administer O2 to maintain Sat >95% Increased nd Activate Rule out retained POC, laceration or hematoma NO Postpartum · Extra help: 2 OB, · Misoprostol 800 mcg SL · Bring 2 Units PRBCs Continued heavy Stage 2 is nd Hemorrhage Order Type & Crossmatch 2 Units PRBCs if not already done Rapid Response Team 2 IV Access (at least to bedside, transfuse bleeding Surveillance focused on Protocol (per hospital), assign 18gauge) per clinical signs – do YES sequentially Blood Loss: Vaginal Birth: roles Bimanual massage not wait for lab values CALL FOR EXTRA HELP advancing Bimanual Fundal Massage · VS & cumulative Vaginal Birth: (typical order) · Use blood warmer for 1000-1500 ml Give Meds: Hemabate 250 mcg IM -or- through Retained POC: Dilation and Curettage blood loss q 5-10 min · Move to OR transfusion Misoprostol 600-800 SL or PO medications and Stage 2 Lower segment/Implantation site/Atony: