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Frontiers in Medicine 2022Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World...
BACKGROUND
Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World Health Organization (WHO), advocate for the selective use of episiotomy. Episiotomy rates, on the other hand, have remained high in developing countries, while declining in developed countries. As a result, the current study sought to determine the overall prevalence of episiotomy in Africa as well as the risk factors associated with its practice.
METHODS
Articles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 14 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. A random-effects meta-analysis model was used to determine the pooled prevalence of episiotomy. A heterogeneity test was conducted using I-Squared ( ) statistics. Egger's test and funnel plots were conducted to detect publication bias. Subgroup analysis was also conducted. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).
RESULT
A total of 21 studies with 40,831 participants were included in the systematic review and meta-analysis. The pooled prevalence of episiotomy practice was 41.7% [95% CI (36.0-47.4), = 99.3%, < 0.001). Primiparity [OR: 6.796 (95% CI (4.862-9.498)), < 0.001, : 95.1%], medical doctors- assisted delivery [OR: 3.675 (95% CI (2.034-6.640)), < 0.001, : 72.6%], prolonged second stage of labor [OR: 5.539 (95% CI (4.252-7.199)), < 0.001, : 0.0%], using oxytocin [OR: 4.207 (95% CI (3.100-5.709)), < 0.001, : 0.0%], instrument -assisted vaginal delivery [OR: 5.578 (95% CI (4.285-7.260)), < 0.001, : 65.1%], and macrosomia [OR: 5.32 (95% CI (2.738-10.339)), < 0.001, : 95.1%] were factors associated with episiotomy practice.
CONCLUSION
In this review, the prevalence of episiotomy among African parturients was high. A selective episiotomy practice should be implemented to reduce the high episiotomy rates.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021293382, identifier: CRD42021293382.
PubMed: 35865171
DOI: 10.3389/fmed.2022.905174 -
The Cochrane Database of Systematic... Jun 2023Epidural analgesia is often used for pain relief during labour and childbirth, and involves administration of local anaesthetics (LA) into the epidural space resulting... (Review)
Review
BACKGROUND
Epidural analgesia is often used for pain relief during labour and childbirth, and involves administration of local anaesthetics (LA) into the epidural space resulting in sensory blockade of the abdomen, pelvis, and perineum. Epidural opioids are often co-administered to improve analgesia. Administration of epidural medications can be accomplished by basal infusion (BI) or automated mandatory bolus (AMB). With BI, medications are administered continuously, while AMB involves injecting medications at set time intervals. Patient-controlled epidural analgesia (PCEA) on top of AMB or BI enables patients to initiate additional boluses of epidural medications. The superior method of delivering epidural medications would result in lower incidence of pain requiring anaesthesiologist intervention (breakthrough pain). Also, it should be associated with lower incidence of epidural-related adverse effects including caesarean delivery, instrumental delivery (use of forceps or vacuum devices), prolonged duration of labour analgesia, and LA consumption. However, clear evidence of the superiority of one technique over the other is lacking. Also, differences in the initiation of epidural analgesia such as combined spinal-epidural (CSE) (medications given into the intrathecal space in addition to the epidural space) compared to epidural only, and medications used (types and doses of LA or opioids) may not have been accounted for in previous reviews. Our prior systematic review suggested that AMB reduces the incidence of breakthrough pain compared to BI with no significant difference in the incidence of caesarean delivery or instrumental delivery, duration of labour analgesia, and LA consumption. However, several studies comparing AMB and BI have been performed since then, and inclusion of their data may improve the precision of our effect estimates.
OBJECTIVES
To assess the benefits and harms of AMB versus BI for maintaining labour epidural analgesia in women at term.
SEARCH METHODS
We searched CENTRAL, Wiley Cochrane Library), MEDLINE, (National Library of Medicine), Embase(Elseiver), Web of Science (Clarivate), the WHO-ICTRP (World Health Organization) and ClinicalTrials.gov (National Library of Medicine) on 31 December 2022. Additionally, we screened the reference lists of relevant trials and reviews for eligible citations, and we contacted authors of included studies to identify unpublished research and ongoing trials.
SELECTION CRITERIA
We included all randomised controlled studies that compared bolus dosing AMB with continuous BI during epidural analgesia. We excluded studies of women in preterm labour, with multiple pregnancies, with fetal malposition, intrathecal catheters, those that did not use automated delivery of medications, and those where AMB and BI were combined.
DATA COLLECTION AND ANALYSIS
We used standard methodology for systematic review and meta-analysis described by Cochrane. Primary outcomes included: incidence of breakthrough pain requiring anaesthesiologist intervention; incidence of caesarean delivery; and incidence of instrumental delivery. Secondly, we assessed the duration of labour; hourly LA consumption in bupivacaine equivalents, maternal satisfaction after fetal delivery, and neonatal Apgar scores. The following subgroup analyses were chosen a priori: epidural alone versus CSE technique; regimens that used PCEA versus those that did not; and nulliparous versus combination of nulli- and multi-parous women. We used the GRADE system to assess the certainty of evidence associated with our outcome measures.
MAIN RESULTS
We included 18 studies of 4590 women, of which 13 enrolled healthy nulliparous women and five included healthy nulli- and multiparous women. All studies excluded women with preterm or complicated pregnancies. Techniques used to initiate epidural analgesia differed between the studies: seven used combined spinal epidural, 10 used epidural, and one used dural puncture epidural (DPE). There was also variation in analgesics used. Eight studies utilised ropivacaine with fentanyl, three used ropivacaine with sufentanil, two utilised levobupivacaine with sufentanil, one used levobupivacaine with fentanyl, and four utilised bupivacaine with fentanyl. Most of the studies were assessed to have low risk of randomisation, blinding, attrition, and reporting biases, except for allocation concealment where eight studies were assessed to have uncertain risk and three with high risk. Our results showed that AMB was associated with lower incidence of breakthrough pain compared to BI (risk ratio (RR) 0.71; 95% confidence interval (CI) 0.55 to 0.91; I = 57%) (16 studies, 1528 participants), and lower hourly LA consumption in bupivacaine equivalents (mean difference (MD) -0.84 mg/h; 95% CI -1.29 to -0.38, I = 87%) (16 studies, 1642 participants), both with moderate certainty. AMB was associated with an estimated reduction in breakthrough pain incidence of 29.1% (incidence 202 per 1000, 95% CI 157 to 259), and was therefore considered clinically significant. The incidence of caesarean delivery (RR 0.85; 95% CI 0.69 to 1.06; I = 0%) (16 studies, 1735 participants) and instrumental delivery (RR 0.85; 95% CI 0.71 to 1.01; I = 0%) (17 studies, 4550 participants) were not significantly, both with moderate certainty. There was no significant difference in duration of labour analgesia (MD -8.81 min; 95% CI -19.38 to 1.77; I = 50%) (17 studies, 4544 participants) with moderate certainty. Due to differences in the methods and timing of outcome measurements, we did not pool data for maternal satisfaction and Apgar scores. Results reported narratively suggest AMB may be associated with increased maternal satisfaction (eight studies reported increased satisfaction and six reported no difference), and all studies showed no difference in Apgar scores. WIth the exception of epidural alone versus CSE which found significant subgroup differences in LA consumption between AMB and BI, no significant differences were detected in the remaining subgroup analyses.
AUTHORS' CONCLUSIONS
Overall, AMB is associated with lower incidence of breakthrough pain, reduced LA consumption, and may improve maternal satisfaction. There were no significant differences between AMB and BI in the incidence of caesarean delivery, instrumental delivery, duration of labour analgesia, and Apgar scores. Larger studies assessing the incidence of caesarean and instrumental delivery are required.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Analgesia, Epidural; Analgesics; Analgesics, Opioid; Breakthrough Pain; Levobupivacaine; Ropivacaine; Sufentanil; United States
PubMed: 37276327
DOI: 10.1002/14651858.CD011344.pub3 -
Women's Health (London, England) 2022An episiotomy is one of the most commonly performed obstetrics surgeries indicated in emergencies during the second stage of labor like fetal distress, dystocia, and... (Meta-Analysis)
Meta-Analysis
An episiotomy is one of the most commonly performed obstetrics surgeries indicated in emergencies during the second stage of labor like fetal distress, dystocia, and tight perineum. As a result, this systematic review and meta-analysis aimed to assess the prevalence of episiotomy practice and associated factors in Ethiopia. Ten cross-sectional studies with a total population of 3718 were included in this study. The search was done using online databases like PubMed, HINARI, Web of Science, other gray, and online repositories of Universities. All the included papers were extracted and appraised using the standard extraction sheet format of JOANNA Briggs Institute. The Cochran Q-test and statistics test were used to test the heterogeneity of studies. To detect the publication bias of the included studies, a funnel plot and Egger's test were used. The pooled prevalence of episiotomy practice and the odds ratio with a 95% confidence interval were presented using forest plots. The overall pooled prevalence of episiotomy practice was 45.11% (95% CI; 37.04-53.18; = 96.3%). Prolonged second stage of labor (OR: 4.79, 95% CI: 3.03, 7.57), face presentation (OR: 4.26, 95% CI: 1.21, 15.07), birth weight > 4000 g (OR: 6.71, 95% CI: 3.14-14.33), instrumental delivery (OR: 4.26, 95% CI 2.95, 6.14), and primiparity (OR: 3.70, 95% CI: 1.90, 7.2) were factors associated with episiotomy practice. The overall prevalence of episiotomy practice was higher in Ethiopia compared to studies conducted in other countries. The prolonged second stage of labor, face presentation, birth weight > 4000 g, instrumental delivery, and primiparity of women were the factors associated with episiotomy practice. Therefore, efforts should be made to prevent routine episiotomy practice through creating awareness, adjusting national guidelines, affecting the World Health Organization episiotomy policy, and monitoring the activities of the health care facilities in executing the protocols.
Topics: Birth Weight; Cross-Sectional Studies; Episiotomy; Ethiopia; Female; Humans; Pregnancy; Prevalence
PubMed: 35435068
DOI: 10.1177/17455057221091659 -
International Journal of Gynaecology... Jul 2022Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence.
OBJECTIVE
We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.
SEARCH STRATEGY
Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.
SELECTION CRITERIA
Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.
DATA COLLECTION AND ANALYSIS
Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model.
MAIN RESULTS
The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery.
CONCLUSION
Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.
Topics: Anal Canal; Delivery, Obstetric; Fecal Incontinence; Female; Humans; Obstetric Labor Complications; Perineum; Pregnancy; Risk Factors
PubMed: 34559892
DOI: 10.1002/ijgo.13950 -
The Cochrane Database of Systematic... Jan 2021Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative vaginal births (ventouse or forceps-assisted births). This is an update of a review last published in 2013.
OBJECTIVES
To determine the efficacy of a single administration of paracetamol (acetaminophen) used in the relief of acute postpartum perineal pain.
SEARCH METHODS
For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (9 December 2019), and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised controlled trials (RCTs), including cluster-RCTs, comparing paracetamol to placebo. We excluded quasi-RCTs and cross-over trials. Data from abstracts would be included only if authors had confirmed in writing that the data to be included in the review had come from the final analysis and would not change.
DATA COLLECTION AND ANALYSIS
Two review authors assessed each study for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. We assessed the certainty of the evidence using the GRADE approach.
MAIN RESULTS
This update identified no new trials so the results remain unchanged. However, by applying the GRADE assessment of the evidence, the interpretation of main results differed from previous version of this review. We identified 10 studies involving 2044 women, but all these studies involved either three or four groups, looking at differing drugs or doses. We have only included the 1301 women who were in the paracetamol versus placebo arms of the studies. Of these, five studies (482 women) assessed 500 mg to 650 mg and six studies (797 women) assessed 1000 mg of paracetamol. One study assessed 650 mg and 1000 mg compared with placebo and contributed to both comparisons. We used a random-effects meta-analysis because of the clinical variability among studies. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context. The certainty of the evidence for the two primary outcomes on which data were available was assessed as low, downgraded for overall unclear risk of bias and for heterogeneity (I² statistic 60% or greater). More women may experience pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89; 10 trials, 1279 women), and fewer women may need additional pain relief with paracetamol compared with placebo (average RR 0.34, 95% CI 0.21 to 0.55; 8 trials, 1132 women). However, the certainty of the evidence was low, downgraded for unclear overall risk of bias and substantial heterogeneity. One study used the higher dose of paracetamol (1000 mg) and reported maternal drug adverse effects. There may be little or no difference in the incidence of nausea (average RR 0.18, 95% CI 0.01 to 3.66; 1 trial, 232 women; low-certainty evidence), or sleepiness (average RR 0.89, 95% CI 0.18 to 4.30; 1 trial, 232 women; low-certainty evidence). No other maternal adverse events were reported. None of the studies assessed neonatal drug adverse effects.
AUTHORS' CONCLUSIONS
A single dose of paracetamol may improve perineal pain relief following vaginal birth, and may reduce the need for additional pain relief. Potential adverse effects for both women and neonates were not appropriately assessed. Any further trials should also address the gaps in evidence concerning maternal outcomes such as satisfaction with postnatal care, maternal functioning/well-being (emotional attachment, self-efficacy, competence, autonomy, confidence, self-care, coping skills) and neonatal drug adverse effects.
Topics: Acetaminophen; Acute Pain; Episiotomy; Female; Humans; Infant, Newborn; Perineum; Postpartum Period; Pregnancy
PubMed: 34559424
DOI: 10.1002/14651858.CD008407.pub3 -
The Cochrane Database of Systematic... Mar 2020Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017.
OBJECTIVES
To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both.
SEARCH METHODS
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies.
SELECTION CRITERIA
All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium).
DATA COLLECTION AND ANALYSIS
Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach.
MAIN RESULTS
Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials.
AUTHORS' CONCLUSIONS
Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.
Topics: Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Antibiotic Prophylaxis; Cefotetan; Endometritis; Episiotomy; Extraction, Obstetrical; Female; Humans; Length of Stay; Obstetrical Forceps; Perineum; Pregnancy; Puerperal Infection; Randomized Controlled Trials as Topic; Surgical Wound Infection; Vacuum Extraction, Obstetrical; Vaginal Diseases
PubMed: 32215906
DOI: 10.1002/14651858.CD004455.pub5 -
The Cochrane Database of Systematic... Aug 2020Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the...
BACKGROUND
Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones, and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake are usually encouraged. Although laxatives are commonly used in relieving constipation, the effectiveness and safety of available interventions for preventing postpartum constipation should be ascertained. This is an update of a review first published in 2015.
OBJECTIVES
To evaluate the effectiveness and safety of interventions for preventing postpartum constipation.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth's Trials Register, and two trials registers ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019), and screened reference lists of retrieved trials.
SELECTION CRITERIA
We considered all randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo, or no intervention in postpartum women. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions). Quasi-randomised trials and cluster-RCTs were eligible for inclusion; none were identified. Trials using a cross-over design were not eligible.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the results of the search to select potentially relevant trials, extracted data, assessed risk of bias, and the certainty of the evidence, using the GRADE approach. We did not pool results in a meta-analysis, but reported them per study.
MAIN RESULTS
We included five trials (1208 postpartum mothers); three RCTs and two quasi-RCTs. Four trials compared a laxative with placebo; one compared a laxative plus a bulking agent versus the same laxative alone, in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported, and four of the five trials were published over 40 years ago. We judged the risk of bias to be unclear for most domains. Overall, we found a high risk of selection and attrition bias. Laxative versus placebo We included four trials in this comparison. Two of the trials examined the effects of laxatives that are no longer used; one has been found to have carcinogenic properties (Danthron), and the other is not recommended for lactating women (Bisoxatin acetate); therefore, we did not include their results in our main findings. None of the trials included in this comparison assessed our primary outcomes: pain or straining on defecation, incidence of postpartum constipation, or quality of life; or many of our secondary outcomes. A laxative (senna) may increase the number of women having their first bowel movement within 24 hours after delivery (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75; 1 trial, 471 women; low-certainty evidence); may have little or no effect on the number of women having their first bowel movement on day one after delivery (RR 0.94, 95% CI 0.72 to 1.22; 1 trial, 471 women; very low-certainty evidence); may reduce the number of women having their first bowel movement on day two (RR 0.23, 95% CI 0.11 to 0.45; 1 trial, 471 women; low-certainty evidence); and day three (RR 0.05, 95% CI 0.00 to 0.89; 1 trial, 471 women; low-certainty evidence); and may have little or no effect on the number of women having their first bowel movement on day four after delivery (RR 0.22, 95% CI 0.03 to 1.87; 1 trial, 471 women; very low-certainty evidence), but some of the evidence is very uncertain. Adverse effects were poorly reported. Low-certainty evidence suggests that the laxative (senna) may increase the number of women experiencing abdominal cramps (RR 4.23, 95% CI 1.75 to 10.19; 1 trial, 471 women). Very low-certainty evidence suggests that laxatives taken by the mother may have little or no effect on loose stools in the baby (RR 0.62, 95% CI 0.16 to 2.41; 1 trial, 281 babies); or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82; 1 trial, 281 babies). Laxative plus bulking agent versus laxative only Very low-certainty evidence from one trial (147 women) suggests no evidence of a difference between these two groups of women who underwent surgical repair of third degree perineal tears; only median and range data were reported. The trial also reported no evidence of a difference in the incidence of postpartum constipation (data not reported), but did not report on quality of life. Time to first bowel movement was reported as a median (range); very low-certainty evidence suggests little or no difference between the two groups. A laxative plus bulking agent may increase the number of women having any episode of faecal incontinence during the first 10 days postpartum (RR 1.81, 95% CI 1.01 to 3.23; 1 trial, 147 women; very low-certainty evidence). The trial did not report on adverse effects of the intervention on babies, or many of our secondary outcomes.
AUTHORS' CONCLUSIONS
There is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives for preventing postpartum constipation. The evidence in this review was assessed as low to very low-certainty evidence, with downgrading decisions based on limitations in study design, indirectness and imprecision. We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo, and one that examined laxatives versus laxatives plus stool bulking agents. Further, rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials should assess educational and behavioural interventions, and positions that enhance defecation. They should report on the primary outcomes from this review: pain or straining on defecation, incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention, such as: nausea or vomiting, pain, and flatus.
Topics: Adult; Constipation; Defecation; Dietary Fiber; Female; Humans; Laxatives; Perineum; Postpartum Period; Puerperal Disorders; Randomized Controlled Trials as Topic; Time Factors
PubMed: 32761813
DOI: 10.1002/14651858.CD011625.pub3 -
JPRAS Open Sep 2022This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding... (Review)
Review
BACKGROUND
This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions.
METHODS
A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery.
RESULTS
The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review.
CONCLUSIONS
Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.
PubMed: 35812356
DOI: 10.1016/j.jpra.2022.05.006 -
Plastic Surgery (Oakville, Ont.) Nov 2020Necrotizing fasciitis (NF) is a life-threatening infection that involves spreading necrosis of the subcutaneous tissue and fascia that affects the extremities, abdominal... (Review)
Review
PURPOSE
Necrotizing fasciitis (NF) is a life-threatening infection that involves spreading necrosis of the subcutaneous tissue and fascia that affects the extremities, abdominal wall, and perineum. Primary infection of the breast is a rare occurrence. Shah et al described the first case of primary breast NF and recommended radical "pseudotumor" excision and delayed skin closure months after resolution. Numerous other cases reported were successfully managed with different strategies. We aimed to summarize management options for primary breast NF through a systematic review of the literature.
METHODS
A systematic review of English literature was performed using PubMed. A total of 58 abstracts were reviewed. Data were abstracted from 25 cases that met inclusion criteria.
RESULTS
A total of 25 cases of primary NF of the breast without an inciting event were found within the literature. Common initial operations included total mastectomy (36.0%), excisional debridement (32.0%), and partial mastectomy (12.0%). A total or radical mastectomy was completed for definitive source control in 13 (52.0%) cases. A total of 18 cases underwent reconstruction. Split-thickness skin grafts (44.4%) and delayed primary closures (33.3%) were the most common methods of reconstruction.
CONCLUSION
Majority of cases with primary breast NF are managed with a total mastectomy to gain source control. Reconstruction using split-thickness skin grafts was most common. Other options included delayed primary closure, full thickness skin grafts, local tissue rearrangement, and pedicle flap reconstruction. Reconstruction should be patient dependent, but the whole arsenal of the reconstructive ladder may be used.
PubMed: 33215036
DOI: 10.1177/2292550320928557 -
American Journal of Obstetrics and... Aug 2022We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair.
DATA SOURCES
MEDLINE, Embase, CINAHL, EmCare, the Cochrane Library, and Trip Pro databases were searched from inception to February 2021.
STUDY ELIGIBILITY CRITERIA
We included observational clinical studies reporting the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. Case series and reports were excluded. Conference articles and observational study abstracts were included if they contained enough information regarding study design and outcome data.
METHODS
Data were analyzed as incidence (percentage) with 95% confidence intervals. Moreover, the prediction intervals were calculated to provide a predicted range for the potential incidence of wound complications when applied to an individual study setting. Study quality and risk of bias were assessed using the relevant tool from the Joanna Briggs Institute.
RESULTS
Of 956 studies found, 39 were selected for full-text review. Moreover, 10 studies (n=4767 women) were eligible and included in the meta-analysis. All 10 studies were conducted in high-income countries (Denmark [n=1], the United Kingdom [n=3], and the United States [n=6]). The incidences of wound infection (n=4593 women) and wound dehiscence (n=3866 women) after primary obstetric anal sphincter injury repair ranged between 0.1% to 19.8% and 1.9% to 24.6%, respectively. The overall incidences were 4.4% (95% confidence interval, 0.4-8.4) for wound infection and 6.9% (95% confidence interval, 1.6-12.2) for wound dehiscence. The prediction intervals were wide and suggested that the true incidences of wound infection and dehiscence in future studies could lie between 0.0% to 11.7% and 0.0% to 16.4%, respectively. Overall, 8 studies had a high or unclear risk of bias across ≥1 assessed element. None of the studies used the same set of clinical parameters to define wound infection or dehiscence. Furthermore, microbiological confirmation with wound swabs was never used as a diagnostic measure.
CONCLUSION
This was a systematic review and meta-analysis of wound infection and dehiscence incidences after primary obstetric anal sphincter injury repair. The incidence estimates from this review will be useful for clinicians when counseling women with obstetric anal sphincter injury and when consenting them for primary surgical repair.
Topics: Anal Canal; Delivery, Obstetric; Fecal Incontinence; Female; Humans; Incidence; Observational Studies as Topic; Obstetric Labor Complications; Perineum; Pregnancy; United Kingdom; Wound Infection
PubMed: 35550375
DOI: 10.1016/j.ajog.2022.05.012