Benjamin Tuschy

Mode of delivery and its influence on women's satisfaction with childbirth

OBJECTIVE Many factors affect womens satisfaction with the experience of childbirth. Some of these are known, but most have not been fully evaluated. The influence of the mode of delivery is unclear. This study investigated the extent to which satisfaction with childbirth depends on the mode of delivery, and evaluated factors determining postpartum satisfaction. STUDY DESIGN Women with singleton pregnancies at term were included prospectively. After childbirth, all women meeting the inclusion criteria received a standardised questionnaire - the German version of Salmons Item List (SIL-Ger) - for completion before discharge to evaluate the birth experience. The chi-squared test, Fishers exact test, and Kruskal-Wallis test were used for statistical analysis. Univariate and multivariate linear regression analyses were used to assess associations between demographic and pregnancy-associated variables and variables influencing the perception of childbirth in the total SIL-Ger score. Univariate and multivariate binary logistic regression models were used to evaluate effects of demographic and clinical parameters on SIL-Ger scores of <70 versus SIL-Ger scores of ≥ 70. All covariates with a P value ≤ 0.10 in the univariate analysis were included in multivariate logistic regression models. All tests were two-sided, and P values<0.05 were considered statistically significant. RESULTS The analysis included 335 questionnaires. No differences were observed between different modes of delivery (normal 84.5 ± 14.6, primary caesarean 87.0 ± 13.5, secondary caesarean 83.2 ± 13.8, emergency caesarean 79.3 ± 7.3, operative vaginal delivery 83.9 ± 13.6; P=0.503). Multivariate analysis identified two independent factors associated with higher SIL-Ger scores: good/very good satisfaction with childbirth (P<0.001) and good/very good involvement in decision-making afterwards (P=0.005). Severe pain perception during childbirth was associated with lower SIL-Ger scores (P=0.003). Absence of a person of trust during childbirth was linked with scores<70 (P=0.005), indicating a negative experience. Good/very good satisfaction with childbirth (P<0.001) reduced the probability of a score<70. CONCLUSION Mode of delivery does not directly influence womens satisfaction with childbirth. Involvement in decision-making, support during labour and effective analgesia appear to be the most important factors that improve womens birth experience.

Clinical aspects of intraoperative radiotherapy in early breast cancer: short-term complications after IORT in women treated with low energy x-rays

BackgroundTo assess postoperative complications, clinical outcome and histological findings in patients undergoing intraoperative radiotherapy with low energy x-rays for early breast cancer.MethodsWe retrospectively analysed data of 208 women who underwent intraoperative irradiation during breast conserving surgery (BCS) between 2002 and 2007. Demographic, clinical and surgical parameters as well as short-term complications within the first postoperative week and histological findings were evaluated. Toxicities were assessed using the CTC/EORTC Score.ResultsPostoperative complications were rare and the immediate toxicity low, without any grade 3/4 acute toxicity. The most frequent postoperative side effects were suggillation (24%) and palpable seroma (17.3%). In 78.6% of the axillary seroma and in 25% of the breast seroma a needle aspiration was inevitable. Erythema grade I-II of the breast was found in 27 women (13%); whereas in 7 patients (3.4%), mastitis was confirmed. In 57.7% of the cases, the pathological assessment revealed ductal invasive breast cancer and tumour size ranged between 0.1 and 4.5 cm (mean = 1.6 cm).ConclusionIORT using Intrabeam® during BCS is safe, although it is associated with postoperative adverse events such as seroma. These should be mentioned and explained to women in detail during the preoperative discussion. This explicitly clinical description is useful for daily clinical practice; especially for giving a detailed analysis of the postoperative side effects during preoperative counselling.

Sequential use of double‐balloon catheter and oral misoprostol versus oral misoprostol alone for induction of labour at term (CRBplus trial): a multicentre, open‐label randomised controlled trial

To evaluate the efficacy of inducing labour using a double‐balloon catheter and oral misoprostol sequentially, in comparison with oral misoprostol alone.

Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter, open‐label, randomized controlled trial

To determine whether the amniotic fluid index (AFI) or the single deepest vertical pocket (SDP) technique for estimating amniotic fluid volume is superior for predicting adverse pregnancy outcome.

Myasthenia Gravis in Pregnancy: A Case Report

Objective. To present a case of maternal myasthenia gravis in pregnancy and give a systematic review of the literature. Case. We report the case of a 38-year-old parturient with a life-threatening complication of immune-mediated myasthenia gravis shortly after an elective cesarean section on patients request under spinal anesthesia at 35 + 3 weeks of gestation. The newborn was transferred to the pediatric unit for surveillance and did not show any signs of muscular weakness in the course of time. The mother developed a respiratory insufficiency on the second day postpartum. The myasthenic crisis led to a progressive dyspnoea within minutes, which exacerbated in a secondary generalized seizure with cardiac-circulatory arrest. After successful cardiopulmonary resuscitation, the patient was transferred to intensive care. The interdisciplinary therapeutic approach included ventilatory assistance via endotracheal intubation, parenteral pyridostigmine, azathioprine, and steroids. By interdisciplinary measures, a stable state was regained. Conclusion. Myasthenia gravis especially when associated with pregnancy is a high-risk disease. As this disease predominantly occurs in women of reproductive age, it is important to be aware of this condition in obstetrics and its interdisciplinary diagnostic and therapeutic management.

Solo surgery – Early results of robot-assisted three-dimensional laparoscopic hysterectomy

Abstract Objective : Report of our initial experience in laparoscopic hysterectomy by a solo surgeon using a robotic camera system with three-dimensional visualisation. Material and methods : This novel device (Einstein Vision®, B. Braun, Aesculap AG, Tuttlingen, Germany) (EV) was used for laparoscopic supracervical hysterectomy (LASH) performed by one surgeon. Demographic data, clinical and surgical parameters were evaluated. Our first 22 cases, performed between June and November 2012, were compared with a cohort of 22 age-matched controls who underwent two-dimensional LASH performed by the same surgeon with a second surgeon assisting. Results : Compared to standard two-dimensional laparoscopic hysterectomy, there were no significant differences regarding duration of surgery, hospital stay, blood loss or incidence of complications. The number of trocars used was significantly higher in the control group (p <.0001). All hysterectomies in the treatment group were performed without assistance of a second physician. Conclusion : Robot-assisted solo surgery laparoscopic hysterectomy is a feasible and safe procedure. Duration of surgery, hospital stay, blood loss, and complication rates are comparable to a conventional laparoscopic hysterectomy.

Finding the most accurate method to measure head circumference for fetal weight estimation.

OBJECTIVE Accurate measurement of fetal head biometry is important for fetal weight estimation (FWE) and is therefore an important prognostic parameter for neonatal morbidity and mortality and a valuable tool for determining the further obstetric management. Measurement of the head circumference (HC) in particular is employed in many commonly used weight equations. The aim of the present study was to find the most accurate method to measure head circumference for fetal weight estimation. STUDY DESIGN This prospective study included 481 term pregnancies. Inclusion criteria were a singleton pregnancy and ultrasound examination with complete fetal biometric parameters within 3 days of delivery, and an absence of structural or chromosomal malformations. Different methods were used for ultrasound measurement of the HC (ellipse-traced, ellipse-calculated, and circle-calculated). As a reference method, HC was also determined using a measuring tape immediately after birth. FWE was carried out with Hadlock formulas, including either HC or biparietal diameter (BPD), and differences were compared using percentage error (PE), absolute percentage error (APE), limits of agreement (LOA), and cumulative distribution. RESULTS The ellipse-traced method showed the best results for FWE among all of the ultrasound methods assessed. It had the lowest median APE and the narrowest LOA. With regard to the cumulative distribution, it included the largest number of cases at a discrepancy level of ±10%. The accuracy of BPD was similar to that of the ellipse-traced method when it was used instead of HC for weight estimation. CONCLUSION Differences between the three techniques for calculating HC were small but significant. For clinical use, the ellipse-traced method should be recommended. However, when BPD is used instead of HC for FWE, the accuracy is similar to that of the ellipse-traced method. The BPD might therefore be a good alternative to head measurements in estimating fetal weight.

Elective Caesarean section on maternal request in Germany: factors affecting decision making concerning mode of delivery

PurposeTo investigate sociopsychological factors of women undergoing a caesarean section on maternal request (CSMR).MethodsTwenty-eight women who underwent CSMR and 29 women with vaginal delivery (VD) filled in standardized questionnaires concerning psychological burden (SCL-R 90), fear of childbirth (W-DEQ, STAI), personality structure (HEXACO-Pi-R) and social support (F-SozU) as well as one questionnaire assessing potential factors influencing their mode of delivery.ResultsWomen with CSMR were older (36.5 ± 5.4 vs. 30.6 ± 5.2 years; p < 0.001) and suffered more from fear of childbirth (W-DEQ 4.3 ± 0.8 vs. 3.7 ± 1.2; p = 0.041), concerns for their child (W-DEQ 2.0 ± 1.5 vs. 1.3 ± 0.7; p = 0.026) and appraised the birth less negative (W-DEQ 2.0 ± 0.7 vs. 2.7 ± 1.1; p = 0.008). The majority of parturients had chosen their preferred mode of delivery before pregnancy (CS 61% vs. VD 82%, p = 0.328). In the decision-making process for the mode of delivery, the advice of the partner (85 and 90%) played an important role. 82% of the women who delivered via CSMR did not regret the decision for this mode of delivery.ConclusionWomen who underwent CS had higher fear of childbirth and appraised the birth less negative. The majority did not regret the decision for the CS and would even choose this mode of delivery for their next pregnancy. Although the partner and the physician seem to be important in the decision process for of the mode of delivery, reasons for the choice for CSMR appear to be multifactorial.

Intraoperative radiotherapy of early breast cancer using low-kilovoltage x-rays-reasons for omission of planned intraoperative irradiation.

The purpose of this study is to investigate reasons for omission of a planned intraoperative radiotherapy (IORT) during breast‐conserving surgery (BCS). Between 2002 and 2009, in 297 women an IORT during BCS was planned. In 55 women this irradiation was finally not performed. We retrospectively analyzed pre‐, peri‐, and postoperative data of these 55 women. Main reasons for omission of an IORT were insufficient tumor–skin distance (n = 20, 35.1%), an oversized wound cavity (n = 14, 24.6%), and a combination of both (n = 8, 14%). Further reasons (n = 12, 21.1%) were temporal shortage, unplanned maintenance work of the Intrabeam® device, unsuitable anatomicosurgical conditions, and ineligible histologic findings. Apart from suitable anatomic conditions, a precise preoperative ultrasonography as well as a strict interdisciplinary preoperative management is important for successful application of IORT.

Gynaecological laparoscopic surgery for benign conditions: do women care about incisions?

OBJECTIVE To determine the relevance of the number and location of incisions in women undergoing gynaecologic laparoscopy due to benign conditions. STUDY DESIGN This study included 141 women, who underwent gynaecologic laparoscopic surgery with 4 incisions due to benign conditions between November 2010 and November 2011 at the University Medical Centre Mannheim, Germany. Women with malign histology were excluded. Demographic parameters, type and duration of surgery, perioperative complications and duration of hospital stay were analysed. Women were contacted using a standardized telephone survey with an interval of at least 22 weeks after surgery. Patients were interviewed regarding the number, postoperative pain and their preferences for omission of incisions. RESULTS Eighty-seven women (61.7%) responded to the standardized questionnaire. 38 (43.7%) remembered the number of incisions correctly. 45 of the women (51.7%) thought they had less, 4 (4.6%) thought, they had more incisions as they actually did have. If one of the incisions had to be discarded 28 (32.2%) patients did not have any preferences with regard to the localisation. Of the other 59 patients, 44 (74.6%) would prefer to eliminate the umbilical one. CONCLUSION The majority of the women remembered fewer incisions than actually used. Most of the patients interviewed would, if possible, eliminate the umbilical incision. Therefore from the patients perspective the skin scars after conventional laparoscopic surgery seem to be of limited importance and the alleged advantage of omission of additional incision using single site surgery remains debatable.