Seminars in perinatology
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Since Roman times, physicians have been instructed to perform postmortem cesarean deliveries to aid in funeral rites, baptism, and in the very slim chance that a live fetus might still be within the deceased mother's womb. This procedure was disliked by physicians being called to a dying mother's bedside. As births moved to hospitals, and modern obstetrics evolved, the causes of maternal death changed from sepsis, hemorrhage, and dehydration to a greater incidence of sudden cardiac arrest from medication errors or embolism. ⋯ If a mother has a resuscitatable cause of death, then her life may be saved as well by a prompt and timely cesarean delivery during CPR. Sadly, too often, we are paralyzed by the horror of the maternal cardiac arrest, and instinctively, we try CPR for too long before turning to the perimortem delivery. The quick procedure though may actually improve the situation for the mother, and certainly will save the child.
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Seminars in perinatology · Feb 2012
The role of the maternal-fetal medicine subspecialist in review and prevention of maternal deaths.
The maternal-fetal medicine subspecialist plays a critical role in the evaluation and management of women with obstetrical and medical comorbidities. These women have a higher risk for obstetrical morbidity, "near miss," and maternal mortality. Maternal death surveillance is essential to understand the factors that contribute to maternal mortality. Maternal-fetal medicine subspecialists' involvement and leadership in peer review of maternal deaths can provide guidance in developing and supporting management protocols to the obstetrical community and health care facilities.
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Obesity has been linked as a risk factor for wound complications and is becoming a more common occurrence. We reviewed the risk factors, preventive strategies, and recommended management of wound complications in obese women undergoing cesarean delivery. The limited available data support the use of prophylactic antibiotic before cesarean delivery, closure of subcutaneous space >2 cm, and maintaining normothermia intraoperatively to help reduce the incidence of postoperative wound complications. ⋯ Antibiotics should be administered in the presence of cellulitis or systemic toxicity. Use of vacuum-assisted wound closure devices may be useful in wound management. There is a need for randomized controlled trials which evaluate the prevention and management of wound complications in obese women undergoing cesarean delivery.
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Obesity is associated with serious morbidity during pregnancy, and obese women also are at a high risk of developing complications during labor, leading to an increased risk for instrumental and Cesarean deliveries. The engagement of the obstetrical anesthetist in the management of this group of high-risk patients should be performed antenatally so that an appropriate management strategy can be planned in advance to prevent an adverse outcome. ⋯ Apart from providing analgesia and alleviating physiological derangements during labor, the presence of a functioning epidural catheter can also be used to induce anesthesia quickly in the event of an emergency cesarean section, thus avoiding a general anesthesia, which has exceedingly high risks in the obese parturient. Successful management of the obese patient necessitates a comprehensive strategy that encompasses a multidisciplinary and holistic approach from all care-providers.
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The number of bariatric surgeries performed in the United States has increased exponentially. Given that most patients are female and of reproductive age, it is important for clinicians who manage women's health issues to be aware of the surgery, its long-term goals, and the potential effect on future pregnancies. ⋯ Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring.