	Contemporary OB/GYN contriburors at ACOG    

Articles

The following board members - both past and current - authors and collaborators will be appearing in Austin at the ACOG Annual Clinical and Scientific Meeting in April. Here is a rundown on where you can find them, the programs they will be participating in, plus links to their recent articles in Contemporary OB/GYN.

Contemporary OB/GYN contributors at ACOG

Enhanced recovery pathways (ERP) are rapidly gaining acceptance and use in gynecologic surgery. Studies have shown that patients on an ERP have fewer complications, a shorter length of hospital stay and attain a higher level of satisfaction with their surgical experience.

 ERPs utilize patient-centered multidisciplinary teams to optimize patient outcomes through evidence-based best practices in perioperative care.

 The essentials of ERPs include:  1) reducing surgical stress; 2) maintaining normal physiological function perioperatively; and 3) expediting postoperative recovery.

 While originally based in colorectal surgery, these protocols have been expanded to other surgical specialties, including gynecology. In 2016, the ERAS® Society published guidelines for gynecologic/oncology surgery. Several of these guidelines are well-established standards of care, such as skin preparation, antimicrobial prophylaxis, and thromboembolism prevention. Others, however, represent a significant departure from long-standing practices like the avoidance of prolonged fasting, mechanical bowel preparation, and opioid pain medications. The benefits for patients and health care systems at large argue for prompt implementation of ERP protocols. This article reviews both established and more recent guidelines which have been less readily adopted and describes how to incorporate these guidelines into surgical practice.

 Ideally, preparation for surgical recovery begins at the time surgical management is recommended. Educating patients and caregivers on what to expect before and after surgery leads to decreased fear and anxiety.

 Encouraging patients to actively participate in their recovery facilitates improved compliance and outcomes. Counseling is performed by primary surgeons, perioperative nurses, and anesthesiologists, emphasizing day-to-day goals and expectations during the entire perioperative period. Take-home materials such as enhanced recovery brochures provide resources for patients to reference before and after surgery.    

Because opioid abuse has become a public health crisis, it is imperative to adequately and responsibly treat pain secondary to surgery. ERPs focus on non-narcotic multimodal
approaches to pain control during the entire perioperative period, with a goal of reducing opioid consumption. Patients should receive counseling on these pain management strategies and education on opioid risks and ways to minimize opioid use after surgery.

 Prior to surgery, nutritional status and medical conditions such as diabetes and anemia should be optimized. Optimization allows the body to prepare for the stress of surgery and reduces surgical morbidity.

 An emphasis should be placed on cessation of tobacco and excessive alcohol use for at least 4 weeks prior to surgery to promote wound healing and reduce postoperative complications.

 Given that long-term hormone replacement therapy and oral combined hormonal contraceptives are risk factors for postoperative thromboembolism, consideration should be given to discontinuation of them prior to surgery. Alternative forms of contraception or transdermal hormone therapies can be substituted in their place. Employ thromboprophylaxis for patients utilizing these therapies at the time of surgery.

 A large body of evidence clearly shows that mechanical bowel prep, especially in gynecology, does not improve surgical outcomes.

 Avoid routine use of mechanical bowel preparation for patients undergoing benign gynecologic procedures.

Preoperative fasting and carbohydrate loading.

 Preoperative intake of solid food up to 6 hours and clear liquids up to 2 hours prior to surgery is safe.

 Carbohydrate loading with a clear fluid containing complex carbohydrates is known to attenuate insulin resistance, minimize protein and muscle loss, and improve patient comfort.

 At the preoperative visit, patients are instructed to drink 3 12-oz. bottles of Clearfast before their scheduled surgical time, with the last bottle to be consumed 2 hours before anesthesia, as noted in the available 

. If Clearfast is not available, Gatorade can be used as a substitute.

Preanesthetic medications/nausea prophylaxis.

 Patients commonly experience high levels of anxiety in anticipation of surgery and may be given anxiolytics preoperatively. However, anxiolytics can cause varying levels of sedation, impairing early oral intake and mobilization.

 Avoid use of long-acting anxiolytics prior to surgery with administration of short-acting agents only as necessary. Instead, consider other strategies to reduce anxiety, including an emphasis on preoperative counseling and education.

While ERAS Society guidelines recommend multimodal opioid-sparing analgesics in the postoperative period, the theory of pain pathway sensitization, or “protective analgesia,” argues for preoperative initiation.

 While there is some controversy regarding the role of oral vs intravenous (IV) analgesics, oral analgesics are certainly safe to use preoperatively. Consider beginning multimodal non-opioid analgesics preoperatively including a long-acting oral nonsteroidal anti-inflammatory drug (NSAID) (celecoxib 400 mg), acetaminophen (1000 mg), and possibly gabapentin (300-600 mg). Then continue the use of multimodal non-opioid analgesics as a mainstay of pain control post-operatively.

Postoperative nausea and vomiting (PONV) can impede the recovery process. A focus on multimodal PONV prophylaxis and prevention throughout the perioperative period should be utilized. Restricted use of inhalational  anesthetics combined with 3 or more  IV antiemetic medications with different mechanisms of action provide additive effects. The most commonly administered antiemetics are: ondansetron
(4 mg), dexamethasone (4-8 mg),  droperidol (0.625 mg) and metoclopramide (10-20 mg). For patients with a history of PONV, consider giving an oral dose of the NK1 receptor antagonist, aparepitant (40 mg) preoperatively.

 Minimally invasive approaches to surgery have myriad advantages over laparotomy. Advantages include reduction in intraoperative blood loss, decreased pain and narcotic use, earlier mobilization and return of bowel function, shorter hospital stay and fewer postoperative complications. Minimally invasive approaches to gynecologic surgery, by way of vaginal, traditional laparoscopic or robotic-assisted rooutes, are strongly recommended.

 Anesthetic protocols that allow for rapid recovery are strongly encouraged. Use of short-acting agents, such as propofol, promote rapid awakening. In addition, use of regional anesthesia in open abdominal and vaginal cases helps reduce postoperative pain, nausea and vomiting. Unfortunately, its use can also delay mobilization and Foley catheter removal, and should therefore be considered on a case-by-case basis.

While nasogastric (NG) and orogastric tubes aid in gastric decompression during traditional or robotic-assisted laparoscopy, tubes should be removed prior to patient awakening. In addition, routine placement of NG tubes until return of bowel function is no longer recommended, as systematic reviews have shown improved outcomes in those without traditional NG tube decompression after surgery.

 Hypothermia during the perioperative period can contribute to increased blood loss, a delay in wound healing, increased risk of surgical site infections, and cardiac morbidity.

 Use modalities to prevent  intraoperative hypothermia including temperature monitoring, active surface body warming systems, and pre-warmed IV fluids.

Avoiding mechanical bowel preparation and prolonged preoperative fasting with employment of carbohydrate loading and hydration allows maintenance of a euvolemic state and mitigates the need for excessive fluid resuscitation intraoperatively. ERPs emphasize the concept of euvolemia, or a zero-fluid balance. Excessive IV fluid administration delays patient recovery and increases risk of surgical complications.

With early advancement in oral intake, patients require less IV hydration. It can be discontinued once patients are tolerating clear liquids, which in most cases can be safely resumed immediately after surgery.

 For patients who are not discharged same-day, advancement to regular diet can be instituted upon arrival to the floor.

The use of multimodal opioid-sparing analgesia to adequately treat postoperative pain is a core element of ERPs. Acetaminophen and NSAIDs are the cornerstone of postoperative pain management, and can effectively reduce opioid consumption without compromising pain control or recovery.

 Preoperative administration of these medications, along with dexamethasone, should be given consideration. When used, oral opioid administration is preferred, especially for patients tolerating oral intake.

Guidelines recommend that routine peritoneal drainage be avoided in gynecologic/oncologic surgery. Urinary catheters should be utilized for a short duration, ideally less than 24 hours after surgery.

 Encouraging patients to mobilize within 24 hours after surgery is strongly recommended to decrease pulmonary complications and length of hospital stay, as well as aid in prevention of thromboembolic events.

Initiating and maintaining an ERP at your hospital

Steps to consider when implementing an ERP are outlined in Table 1. Securing support for the program from hospital administration, surgical and nursing department heads is critical. Gaining buy-in from a multidisciplinary team of surgeons, anesthesiologists and nursing staff is also essential. Then education and re-education on the pathways for hospital as well as outpatient clinic staff will greatly aid in success. Providing standardized educational materials and establishing easy-to-follow perioperative order sets will make transition to an ERP easier. Finally, true success will be determined by continuous auditing of program compliance and patient outcomes.

As value in healthcare becomes an increasing priority for healthcaresystems, enhanced recovery pathways will play a vital role in improving the quality of care provided to patients. With value measured as a ratio of outcome to cost, ERPs improve outcomes (i.e. quicker recovery, increased patient satisfaction) while reducing costs (i.e. reduced morbidity and length of stay). The use of ERPs is a reason patients should choose your practice for surgical care. With support from hospital leadership, employee education and continuous monitoring of compliance and outcomes, ERPs can be successfully implemented for the care of gynecologic surgery patients in any participating hospital. 

Disclosures The authors report no potential conflicts of interest with regard to this article.

1. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials.  

2. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients.  

3. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: a review.  

4. Lawrence D. Egbert, M.D., George E. Battit, M.D., Claude E. Welch, M.D., and Marshall K. Bartlett, M.D. Reduction of postoperative pain by encouragement and instruction of patients - a study of doctor-patient rapport. 

5. L.T. Sorenson. Wound healing and infection in surgery: the pathophysiologic impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. 

6. Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis.  

7. Oppedal K, MÃ¸ller AM, Pedersen B, TÃ¸nnesen H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev. 2012 Jul 11;(7):CD008343.

8. Tonnesen H, Kehlet H. Preoperative alcoholism and postoperative morbidity. Br J Surg. 1999;86:869–874.

9. Tonnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ. 1999;318:1311–1316

10. Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal Surgery: a systematic review. J Minim Invasive Gynecol. 2015 Jul-Aug;22(5):737-52.

11. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. 

12. Smith MD1, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. 

13. Walker KJ, Smith AF. Premedication for anxiety in adult day surgery.  

14. Moiniche S, Henrik K, Dahl J. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: The role of timing of analgesia. 

15. Choosing Route of Hysterectomy for Benign Disease. Committee Opinion No. 701. American College of Obstetricians and Gynecologists. 

16. Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K. A meta-analysis of the short- and long-term results of randomized controlled trials that compared laparoscopy-assisted and conventional open surgery for colorectal cancer.  

17. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. 

18. Hart S, Bordes B, Hart J, Corsino D, Harmon D. Unintended perioperative hypothermia. 

19. Schol PB, Terink IM, LancÃ© MD, Scheepers HC Liberal or restrictive fluid management during elective surgery: a systematic review and meta-analysis. 

20. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. 

21. Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. 

22. Charoenkwan K, Matovinovic E. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. 

23. Wong M, Morris S, Wang K, Simpson K. Managing Postoperative pain after minimally invasive gynecologic surgery in the era of the opioid epidemic. 

24. Nelson G, Altman A, Meyer LA, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – Part II. 

ERPs may take a year or two to get gong but the benefits to patients and the healthcare system can be significant.

Enhanced recovery in gynecologic surgery

A 50-year-old woman presented to Dr. A on 10/20/2011 at a nonparty hospital clinic with a complaint of pelvic pressure from fibroid growth. She testified that her grandmother, mother, and sister all died from uterine cancer and that she was advised by her mother’s physician to undergo a hysterectomy to decrease her risk of the disease. Following a lengthy discussion on the different ways in which he could perform the surgery, it was agreed that Dr. A would do a vaginal hysterectomy with conversion to abdominal hysterectomy as needed.

The woman was admitted on 12/29/2011 with a preoperative diagnosis of symptomatic fibroid uterus. A consent form was signed authorizing Dr. A to perform a diagnostic laparoscopy, cystoscopy, possible laparoscopy-assisted vaginal hysterectomy with removal of tube and ovaries, possible total vaginal hysterectomy, and possible laparotomy.

Dr. A, assisted by resident Dr. B, performed a cystoscopy, diagnostic laparoscopy, total vaginal hysterectomy, right salpingectomy, and uterosacral ligament colpopexy. During cystoscopy, brisk blue jets of urine were seen from each of the ureteral orifices. Following removal of the cystoscope and insertion of the laparoscope, Dr. A noted that the uterus was markedly enlarged and distorted due to the fibroid. He reported no significant adhesions from a prior cesarean delivery via vertical incision that were deemed to impact a vaginal hysterectomy.    

Before completing the procedure, Dr. C, a nonparty urologist was consulted and he stented the right ureter. According to his separate Operative Report, with the stent in place, IV methylene blue was given and seen coming out of the left ureteral orifice and out of the stent on the right side. Subsequently, the vaginal cuff was closed and vaginal packing was placed. Under Complications, a right ureteral injury was listed. The patient was transferred to the Recovery Room in stable condition with an indwelling Foley catheter and later to the floor in stable condition.

On 12/30/11 at 10:30 a.m., Dr. B reported that the patient was not yet out of bed but was feeling well. She complained of wetness, more when moving, laughing or coughing. Upon examination, it was noted that the catheter was in place and draining clear urine. No vaginal bleeding was seen when the packing was removed, but mild-moderate clear, odorless fluid was leaking from the vagina. The patient was ordered to be out of bed and advanced to a regular diet.

On 12/31/11, the patient was feeling well and her catheter was removed. She complained of vaginal leaking of mild-to-moderate clear fluid. The next day she complained of more intense leaking of clear/pinkish fluid from her vagina. The vaginal packing was removed and was described as moist and slightly blood-tinged. The patient also complained that she was leaking urine. The resident discussed the case with Urology and Dr. A, who commented that urinary incontinence was to be expected to some degree. The patient was discharged with instructions to follow up with Dr. A in 2 weeks and with Dr. C in 1 week.

The patient presented to the ED on 1/5/12, complaining of bed-wetting and right flank pain x2 days and moderate intermittent urinary incontinence x1 day. It was noted that the patient had spoken with a urologist, who instructed her to come into the office, but she did not want to wait as she was experiencing leg pain. A Foley catheter was placed and she was admitted to the gynecology service for possible ureteral injury. A computed tomography (CT) scan of the abdomen and pelvis with contrast showed bilateral distal ureteral leaks with associated fluid collections, a right ureteral leak in communication with the vagina, and possible pyelonephritis of the right kidney. The patient was advised that she was to be readmitted for operative repair.

On 1/7/2012, Dr. C performed a cystoscopy, speculum examination, and bilateral retrograde pyelogram and placed a left ureteral stent. The postoperative diagnoses were listed as urinary incontinence and ureterovaginal fistula. The Operating Room record noted that Dr. A was present during this procedure.

Dr. A examined the patient postoperatively, noting that she was feeling well and there had been no leaking since the surgery. Laparoscopic repair of the right ureteral injury was recommended, possibly on 1/9 or 1/10, but the procedure was subsequently put on hold.
Dr. A testified that repair was cancelled because the patient did so well immediately after the 1/7 surgery that spontaneous healing of the right ureter was anticipated. On 1/10/2012, the patient was discharged with a leg bag, prescription for ciprofloxacin, and instructions to call Dr. C for a follow-up appointment in 1 week.

The woman again presented to defendant hospital on 2/6/2012, arriving via ambulance. She reported that following the removal of 2 stents from her bladder 2 days earlier, she had been experiencing urinary leakage. Urinalysis showed large blood, positive nitrites, and large leukocyte esterase. A urine culture grew 

. Ciprofloxacin was given for a urinary tract infection. She was admitted under the care of Dr. C with diagnoses of persistent postoperative fistula, genital tract fistula, depressive disorder, and urethral stricture.

Two days later, Dr. C performed a cystoscopy and placed a right ureteral stent. According to the Operative Report, Dr. C encountered difficulty in passing the wire into the right ureteral orifice but a 6-Fr 24-cm right ureteral stent was inserted. Following the procedure, the patient’s Foley was discontinued and a drainage bag was placed. She was discharged home with prescriptions for acetaminophen/oxycodone and ciprofloxacin and advised to follow up with Dr. C.

At a postoperative visit with Dr. A. on 2/23/2012 , the plaintiff’s cuff was well healed and no leakage was noted. Dr. A also noted that the patient was to follow up with Urology regarding the stent.

On 4/12/2012, the plaintiff presented to the ED with complaints of constant right flank pain x2 days that was 10/10 on the pain scale. She reported that her right stent was removed 3 days earlier and she was now experiencing increasing involuntary leakage of urine. The patient was admitted under the care of Dr. C with a diagnosis of urinary incontinence for pre-op labs and CT abdomen/pelvis with IV contrast.

On 4/13/2012, a CT of the abdomen and pelvis revealed new moderate right hydronephrosis and hydroureter, “despite the presence of ureteral stent, which might be occluded.” The most distal segment of the right ureter, measuring 1.5 cm, could not be visualized, possibly due to a stricture.

There was also evidence of right pyelonephritis; the left kidney and ureter were unremarkable. No urine extravasation was seen. Later that day, the patient was discharged home with instructions to follow up with Dr. C.

On 5/9/2012, the plaintiff presented to defendant hospital with complaints of right-sided kidney pain x3 weeks, measuring 10/10 on the pain scale. It was noted that she was taking oxycodone 3x/day for the pain. The patient was readmitted under the care of Dr. C with a diagnosis of urinary calculus and a secondary diagnosis of stricture/kinking of the ureter. Dr. C performed a right ureteral reimplantation for a right ureteral stricture. Dr. C’s operative report indicated that once the right ureter was identified, “there appeared to be a very dense inflammatory process in the distal right ureter.” The ureter was freed very carefully. Nevertheless, “despite very minimal manipulation, the ureter looked ischemic in this area and easily tore.” The patient was discharged on 5/14/2012 with a catheter and leg bag, and instructions to follow up with Dr. C in 2 weeks.

On 5/17/2012, the patient presented to Dr. A’s office for an emergency visit. She complained of leaking from the abdominal incision and pain from the urinary catheter. Dr. A noted that the patient was tearful and stated that she was going to her social worker later that day for admission secondary to depression. The woman also demanded that the urinary catheter be taken out or she would pull it out herself. Although Dr. A advised the patient that Dr. C should remove the catheter and warned the patient of the risks of premature removal, he ultimately removed it “for safety reasons” after the patient began pulling it out herself. Dr. A examined the patient’s incision line and documented “seroma at superior edge, fascia intact.” Dr. A removed the staples, evacuated the seroma, and cleaned and packed the wound with a single 4x4.

On 5/18/2012, the plaintiff presented to the nonparty hospital ED with complaints of bleeding from the abdomen, status post-surgery, and abdominal pain rated 7/10 on the pain scale.  She reported that she had surgery 2 weeks prior for uterine fibroids and had her staples removed 5/17/2012 by Dr. A. and on arrival home she began bleeding from the abdominal site. On exam, the surgical wound was noted to be open in the midline of her abdomen and serosanguinous discharge was noted from the wound under the umbilicus.

The patient was placed on 1:1 observation for “suicidality.” She reported a history of domestic violence and bipolar disease. The Attending noted that the patient was aggressive and verbally threatening. She stated that “Dr. A is only concerned because I told him that I’m suing him.” The Attending noted that the on-call psychiatrist felt that the patient was not a danger to herself or others. She was evaluated by a psychiatrist, who recommended that she be discharged, and to follow up with her private psychiatrist the following day.

Plaintiff alleged that the defendants failed to properly perform a laparoscopic hysterectomy, right salpingectomy and uterosacral ligament colpopexy; improperly lacerated, tore and/or entered a blood vessel; caused and/or allowed plaintiff to bleed internally; caused and/or allowed a perforation, laceration and/or other injury to the right ureter; caused and/or allowed a uterovaginal fistula; and caused plaintiff to undergo additional surgical procedures. The plaintiff claimed the following permanent injuries: uterovaginal fistula; urinary incontinence; right ureteral stricture; right hydronephrosis; right hydroureter; perforation, laceration, injury and/or trauma to the right ureter; infection; unnecessary and prolonged hospitalizations.

Dr. A explained at his deposition that the injury in this case was likely due to an anatomical variation. He testified that with all the safety profiles he employs during the course of surgery to protect the ureter and identify the uterosacral ligament, the fact that he put in a stitch that caused direct trauma to the ureters suggests that they were much closer to the uterosacral ligament than is typical, or that the woman had extremely weak tissue since the stitch was able to cut through 2.5 cm of the tissue. He testified that “It’s unlikely that the stitch ripped through 2.5 cm” and that as a result, it’s likely that she had a “combination of weak tissue and an abnormal position of ureter to the operative field.”

Our ob/gyn expert agreed that colpopexy was a routine and necessary part of any vaginal hysterectomy, and that when the uterus is removed, the uterosacral ligaments have to be reattached some place and cannot just be left “flopping around.” He also agreed with Dr. A’s opinion that the injury to the ureter occurred during the colpopexy and not the hysterectomy. However, he did not agree that the injury reflected some anatomic anomaly, as such an injury can occur even in the face of normal anatomy. He added that because the patient already had a vertical abdominal incision, he would have performed an abdominal rather than vaginal hysterectomy.

Plaintiff’s expert gynecologist testified that Dr. A failed to provide the plaintiff with informed consent because he failed to offer her the alternatives to surgery including hormonal therapy, uterine-artery embolization, “watch and wait” because she was perimenopausal, and also failed to do a preoperative drug screen and genetic testing to further evaluate her cancer risk, notwithstanding the family history. He also testified that the alternative treatments should have been undertaken ahead of surgery and that failure to do so constituted a departure from standards of care.  The last departure flowed from the fact that their expert testified that it was ill-conceived to attempt to remove a 20-week/500-g uterus vaginally and that Dr. A should have performed a hysterectomy laparoscopically rather than remove the pieces vaginally.

Cross-examination, supported by our expert, made clear that there was no reason to discuss alternative treatments with the plaintiff as they were not viable under the circumstances because none of them addressed the uterine cancer issue. While the woman’s fibroids may well have been reduced with any of the treatments and have disappeared when she became menopausal, all of those options left her with her uterus in place and, thus, she remained at risk for uterine cancer. We further argued that the concept of genetic testing made no sense because regardless of the test outcome, hysterectomy would  be mandated because of the family history in that not all genetic subtypes of uterine cancer have yet to be identified.

Insofar as the propriety of the vaginal hysterectomy is concerned, on cross it was established that the American College of Obstetricians Gynecologists recommends vaginal hysterectomy as the procedure of choice. It was further established that the ureteral injury didn’t occur during hysterectomy but rather during colpopexy and thus plaintiff’s expert testimony that the uterus couldn’t be successfully removed vaginally was factually inaccurate and irrelevant.  

Ultimately, the case settled during jury deliberations for less than half of plaintiff’s pretrial settlement demand.

A family history of uterine cancer prompted the patient to seek a hysterectomy.

Did vaginal hysterectomy result in iatrogenic injuries?

As a proud wound closure materials geek, I view 3 patents as the most significant modern inventions in the field: US patent 3,297,033

  for polyglycolic acid suture (1967), US patent 8,721,681 B2

  for barbed suture (2014) and US patent 5,530,037

  for sterilizing cyanoacrylate (1996). The last of the triad essentially enabled Krazy® Glue (Elmer’s Products, Westerville, OH) to become Dermabond® (Ethicon, Inc., Somerville, NJ) and changed the way millions of wounds have been and will be reapproximated.

 Topical Skin Adhesive is sterile 2-octyl cyanoacrylate contained in a 0.8-g ampoule encased in a proprietary dispenser for single use. While each manufacturer of a 2-octyl cyanoacrylate topical skin adhesive claims their version is the best due to special additives and processes that alter the viscosity, as a user, the biggest differences seem to be in the dispensers. With its unique felt tip and pressure-producing wings, the LiquiBand Exceed

 dispenser was by far the best topical skin adhesive dispenser I have ever used. It consistently produced an even distribution of adhesive over wounds without clogging, enabling me to use all 0.8 g of glue.    

Advanced Medical Solutions, Ltd., neither invented cyanoacrylate nor figured out how to sterilize it so I can’t give them too many cleverness points. However, their felt-tipped, winged dispenser is a big improvement over the competition so kudos to them.

2-octyl cyanoacrylate is essentially a commodity product that will usually be subject to bundled pricing and thus highly variable in its cost. From my perspective, the real value discriminator between products is the dispensers. With some dispensers, the tips clog before all of the adhesive is delivered, often necessitating opening a second applicator and doubling the cost. With the LiquiBand Exceed

 dispenser I was able to use all of the adhesive in the ampoule every time. THAT…is good value.

This is simple. If you use topical skin adhesives for wound closure, you should try LiquiBand Exceed

 to see for yourself and your institution whether this is a good alternative to what you are currently using.

The views of the author are personal opinions and do not necessarily represent the views of 

Schmitt EE, inventor; American Cyanamid Company, assignee. Surgical Sutures. US patent 3,297,033. January 10, 1967.

Ruff, GL, inventor; Ethicon, Inc. assignee. Barbed suture in combination with surgical needle. US patent 8,721,681 B2. May 13, 2014.

McDonnell PF, inventor; Loctite, Ltd, assignee. Sterilized cyanoacrylate adhesive composition, and a method of making such a composition. US patent 5,530,037. June 25, 1996.

Dr. James Greenberg gives his review of the LiquiBand Exceed Topical Skin Adhesive.

Tools Test Drive: LiquiBand Exceed Topical Skin Adhesive

As obstetricians we commit ourselves to a job that consists mostly of bringing life to the world. These celebrations offer such joy in our work. Less often we are shepherds of loss. We help a couple through miscarriage or stillbirth and support families with the loss of a newborn, for example. These moments are most devastating for patients and their families, but they are also full of grief for us. We are never prepared for, nor do we completely recover from, the loss of a mother. Mothers are young. Mothers are the foundations of a family. Most of the time, the loss of a mother is sudden and unexpected. It leaves an empty space unlike any other. Most obstetricians can recite the names of every mother we helped take care of, but lost.

’s maternal mortality series and to share our experiences. When we were asked to write, we accepted without a second thought; it is easy to write about people we think about on most days. We hope that reflecting on these lives and how we have been changed by them can help our colleagues reflect on their own experiences. We also aim to help motivate a movement to improve efforts to prevent maternal mortality. Our reflection on these cases cannot dwell purely on the profound sadness of it all or how we might have wanted it to go differently. From each case we need to grow and change and get better for the next woman that comes through our door.

During a low point in training, during a time of loss, one of our mentors offered important words of encouragement in this context: “You will be changed by this event. You will either be better from it, or worse from it. But you are the one who chooses which it will be.” In trying to make things better, and in a spirit of fellowship for our colleagues reading this, we are sharing our stories. 


We paused in the hallway halfway between triage and the operating room (OR), so she could kiss her kids. “We will take good care of her,” I remember saying to the two scared, sleepy looking faces. They were in pajamas and attached to their dad. One was about a year younger than my daughter and one was about a year older. 

“She lost a lot of blood,” her husband said again. I nodded, said “I know” and tried to sound reassuring. “We have blood on the way, but the most important thing right now is that we get her into the operating room.” And off we went. It was 5:45 am.

By the time the case started, I had two chiefs operating with me. Thank goodness for change of shift. We worked quickly to get in, acutely aware of how quickly blood was coming out from below. The woman was scheduled to be seen for the first time the next day by maternal-fetal medicine (MFM), but I knew at minimum she had a bleeding previa and two prior cesareans. Anesthesia was transfusing, the cell saver was being assembled, oncology was on their way, my back-up was coming. I was supported. This was the way it was supposed to work. 

Yet despite my amazing team, a very prepared hospital, and my years of training, 90 minutes later I was giving chest compressions. And despite a trauma surgeon, two gynecologic oncologists, and a critical care boarded MFM all by my side, a few minutes after 8 am, I was telling that scared man, now father of three, that he was a single parent. 

Six hours later, after debriefing with the many residents, nurses, and specialists who shared in this tragedy with me, I was back home. My family was the same, my house was the same, but nothing would ever be quite the same. I took a healthy young woman into the OR to deliver her baby and she died on my OR table in my care. 

As I learned more about my patient in the days that followed her death, from the neonatal intensive care unit doctors who took care of her 32-weeker, from hospital staff who knew her as a friend, and from her family who spoke at her funeral, I was bothered most by the fact that we did not have the chance to know one another. I hated that our entire patient-doctor relationship was defined by that night. I wanted her to know the kind of doctor I was. I wanted the opportunity to answer her questions and concerns. I wanted to reassure her that even in the brief moments we had together, I understood how much she loved her children, and I would have done anything to have her case end differently. I wanted then and now to be able to reach out to her family, to see her kids, to tell them in person how sorry I was.  And yet because of the Health Insurance Portability and Accountability Act, the medical legal system, and perhaps most importantly because of a brief moment of eye contact between her husband and me at the funeral, I have stayed away. I am a caregiver but I continue to care in this instance in silence. 

Now almost a decade out from this tragedy, I continue to think about this woman, her daughter, and her family almost every day. In the early years, what used to surprise me most was that I barely knew this woman or her family and yet I thought about them not only at work when I was counseling, operating, and teaching, but at home when I was tucking my kids in, laughing with my husband, or admiring a sunrise. As the years have passed, I have become more comfortable with how frequently my thoughts drift to her and her family. Her story has become part of my story even though our endings were so different. 

For my part, I have been exceptionally lucky. This tragedy could have led to self-doubt and a disdain for the uncertainty and powerlessness of obstetrical care. Perhaps because of the amazing team who got me through that night, I continue to believe that I kept my promise and that we took good care of this mom. I continue to love obstetrics, especially the most challenging deliveries, which push us all to be better. I will forever feel vulnerable because of that night, but I feel honored to be with families at these most dangerous and intimate moments.


She came to our practice after finding out the worst and best information a woman can hear. A neurologist told her the bad news that she had suspected: Her symptoms indeed were signs that the disease that took her mother would also slowly but soon take her life, too. At the same time, she found out she was pregnant. The neurologist and our MFM team were uncertain if she would live through her pregnancy. She was certain she would try. She wanted to be a mother, she wanted her husband to be a father, and she wanted to give life to her child.

With her first visit to our practice she set into motion a transformation of our service. We spent weeks coordinating her care and planning her admission. We assembled all of the specialists and all of the nursing units for regularly scheduled morning meetings planning for her pregnancy. At a certain point she and her husband wanted to join the meetings. Despite our trepidation at this request, based on a paternalistic fear that we would have trouble discussing openly some of the scarier parts of her care, we accepted this challenge. And together we planned for the joy of birth but also for all of the frightening moments she might encounter to get there.  

We took care of the woman for four months in the hospital-she was in the ICU all of those days-progressively losing her strength to move, talk, and breathe. With each week we added another specialty to our meetings, to support her feeding or to plan her tracheostomy and ventilator management. But at the same time, we tried to commit to all of the normal aspects of childbirth, too. Our lactation team visited her in the third trimester to discuss her plans for breastfeeding.  The labor and maternity nurses threw her a baby shower in the intensive care unit. One of my highest honors as an obstetrician was to be invited; it remains, and will probably always be, the only baby shower I have attended. She was committed to becoming well again and having as normal an experience as possible. She believed there would be a cure for her disease in her lifetime.

Her plan was for a vaginal birth and despite her weakness we believed it was medically possible. At term, when we found out that her baby was in breech presentation, she requested an external cephalic version. We tried, but failed, and she ended up with a cesarean that included skin-to-skin, breastfeeding, and rooming-in, even in the ICU.  She left the hospital with her husband and her baby, to go live and die at home.

She was able to see her child’s first birthday. As a result, she avoided becoming a “maternal mortality” “pregnancy-related death” statistic. Admittedly, when we talk about efforts to reduce maternal mortality we are not talking about preventing cases like this.  But despite all we were able to do for her, those who took care of this family experienced profound loss because she did not live long enough. For me and my colleagues, years later even, this still has all of the sadness of a maternal loss.

All the way through the end, she felt blessed and had no regrets. I think she knew how much she touched and influenced each of her caregivers.  Her courage and strength were something that built strength in our hospital’s service and made us so much better at taking care of complicated patients. Our introspection on her care and her life was important for our thinking about how to build a patient-centered destination hospital for the highest-risk pregnancies. Realizing how often complex patients at our hospital could be helped by this level of coordination, this work became a regularly occurring meeting that continues monthly to this day. What she started for us continues to amaze me. New specialties join our meetings all the time, though this is hardly challenging in a tertiary care center. It is when a family member, a church leader, an attorney, a conservator, or a patient joins us for these meetings that I am convinced we would not be meeting our patients’ true needs if our patient had not blessed us with her experience.

I think about her regularly. Certainly, each meeting of the Proactive Care group generates memories of our first meetings working together. But I also think about her every time I work harder to support a vaginal birth or the breastfeeding goals of a woman who faces smaller but still important challenges related to her medical problems or social issues. Most of all, I think of her strength and courage and her commitment to getting better in the face of her inevitable death. This makes me stronger, too.

Two physicians recount their experiences of losing a patient.

Memorials to two mothers


Cesarean section is the most commonly performed surgical procedure in the United States, with nearly 1.3 million cases performed each year. After rising for several decades, the cesarean rate has plateaued at approximately 32% of all deliveries.

 Some portions of the procedure have been thoroughly investigated in the literature, while others have not. The purpose of this article is to review the steps in a cesarean delivery and examine the best available evidence for performing the procedure.

Surgical site infections (SSIs) add significantly to a patient’s cost of care. Cesarean sections are associated with a 10-fold increased risk of infection as compared to vaginal delivery.

 Abdominal preparations with a bactericidal solution have been shown to decrease the risk of a SSI. The preparations come in a variety of types, but the most commonly studied are povidone-iodine (PI), PI-alcohol, and chlorhexidine gluconate (CHG)-alcohol.    

 found insufficient evidence to recommend one skin preparation over another, but at that time data in obstetrics were lacking. Huang et al

 performed a more recent meta-analysis comparing CHG versus PI preparations, both with and without alcohol, and found no difference in SSI rates. This was supported in a subgroup analysis comparing CHG-alcohol versus PI-alcohol (RR 0.59, CI 0.33-1.06). Individual studies, however, varied in both concentration of the preparation and presence of other agents, such as isopropyl alcohol. They also noted a lack of quality studies.        

 randomized patients undergoing cesarean deliveries to PI-alcohol or CHG-alcohol. There were significantly lower SSI rates in the CHG group (RR = 0.55; CI 0.34-0.90). Unlike prior studies, this study included unscheduled cesarean deliveries (42%), improving the generalizability of the results. In general, CHG-alcohol solutions have been shown to decrease SSI rates in a variety of surgeries; based on these studies and the results of Tuuli’s trial, CHG-alcohol skin preps are a reasonable first choice for obstetrical patients. Of note, alcohol-containing skin preps require 3 minutes of drying time to avoid the flammability that may occur prior to evaporation, whereas preparations without alcohol can be used immediately without a “dry time.” The methods of application are different and the manufacturers’ instructions should be followed for proper application.

Vaginal preparation before cesarean delivery

Vaginal preparation with bactericidal solutions has been studied as a mechanism to reduce infectious morbidity after cesarean delivery. Vaginal cleansing with PI has been shown to significantly reduce incidence of endometritis by over 50%.

 This was even more pronounced for women in labor or with ruptured membranes at the time of cesarean. These findings were supported in a 2017 meta-analysis of studies using either a PI- or CHG-based vaginal prep, which found a reduction in endometritis and postoperative fever with vaginal preparation (RR 0.52, CI 0.28-0.97), even more so in women laboring or with ruptured membranes (RR 0.23, CI 0.10-0.52).

Whether this translates to benefit in non-laboring or unruptured patients is less clear. Furthermore, many of the studies included in this meta-analysis excluded patients with chorioamnionitis or included patients who received antibiotics after cord clamping, a practice known to increase SSI risk. Lastly, it is unknown how vaginal preparation may impact the vaginal microbiome and infant health. More data from a modern setting-incorporating current skin preparation solutions and antibiotic administration practices-are needed to fully evaluate the potential impact of vaginal cleansing.

Cesarean delivery is the single most important risk factor for maternal postpartum infection. While antibiotic prophylaxis is recommended, the timing, dose, agents, and use of post-delivery antibiotics have all been recently investigated. Originally, prophylaxis was given after umbilical cord clamping because of the potential concern for masking neonatal sepsis or infection. Several large studies evaluating antibiotic prophylaxis administered after cord clamping versus at the time of skin incision, however, found a reduced incidence of infectious morbidity when antibiotics were given within the 60 minutes preceding the skin incision. In 2011, The American College of Obstetricians and Gynecologists (ACOG) (Practice Bulletin #120) recommended pre-incision antibiotic administration as routine practice.

Extended spectrum antibiotics that have coverage against gram-positive, gram-negative, and some anaerobes are appropriate for prophylaxis given the multiple organisms that have been implicated in SSIs. Cefazolin, a first-generation cephalosporin, is most commonly chosen. A combination of clindamycin and an aminoglycoside can be used for women with significant penicillin allergies.

 was a multicenter study that randomized 2013 women undergoing cesarean delivery during labor or after membrane rupture to an additional 500 mg azithromycin or placebo to their standard antibiotic prophylaxis. A 50% reduction in postoperative SSI was demonstrated with the addition of azithromycin (Figure 1). Furthermore, a cost-effectiveness model using an azithromycin-cephalosporin combination for cesarean prophylaxis found it to be cost-effective, leading to improved maternal outcomes beyond a reduction in SSI, including fewer cases of sepsis, venous thromboembolism, and future uterine ruptures.

 Adding azithromycin to the standard antibiotic prophylaxis in women undergoing cesarean who are laboring or with ruptured membranes may be warranted.

Obesity is a known risk factor for SSI. Given the different pharmacokinetics in obese women, a higher dose of antibiotics may be indicated in women with body mass index greater than 30 kg/m2 or absolute weight of more than 100 kg.

Most cesarean sections are performed using the Pfannenstiel skin incision, which has been associated with better wound healing and decreased postoperative pain compared to vertical skin incisions. The Joel-Cohen incision has been described as an alternative.

 It is a straight incision, versus the slightly curved Pfannenstiel, and is located 3 cm below the anterior superior iliac spines. The subcutaneous tissue layer is only opened sharply 2 to 3 cm in the midline down to the fascia. The incision is then stretched transversely using blunt dissection. Entry into the peritoneum occurs bluntly in a cranial to caudal fashion.

The Joel-Cohen technique was found to decrease all of the following when compared to the Pfannenstiel incision: time to delivery, overall operating room time, blood loss, and postoperative pain medication requirements.

 There were no differences regarding wound infection, blood transfusions or muscle strength 3 months after delivery. There are a number of Joel-Cohen-related techniques described in the literature, all of which share the common theme of limited dissection of the existing tissue in favor of bluntly developing surgical planes.

Creating a bladder flap is a vestige of prior times, when it could be used to isolate the hysterotomy from the peritoneal cavity to decrease risk of infection. In clinical trials with modern antibiotic use, however, routine creation of a bladder flap has not demonstrated any benefit, although it does increase operative time.

 In certain specific situations (e.g., repeat cesarean with significant adhesive disease, suspected placenta accreta), use of a bladder flap may facilitate access to the lower uterine segment. It is unnecessary, though, as a routine measure.

Typically, hysterotomy is created in a transverse fashion through the lower uterine segment, given the increased risk of uterine rupture associated with classical cesareans. After uterine entry, the hysterotomy may be extended bluntly or sharply, most often with bandage scissors. Blunt dissection has been found to result in a quicker extension, less risk of inadvertent neonatal injury, and lower blood loss.

 Whether to extend the hysterotomy with transverse manual traction versus cephalo-caudad manual traction has also been evaluated.

 Transverse extensions resulted in a higher rate of unintended extensions laterally (and potentially into the uterine artery) and greater blood loss. Altogether, these data support blunt extension of the uterine incision in a cephalo-caudad direction.

After fetal delivery, the placenta should typically be allowed to deliver spontaneously. A Cochrane review in 2008 found higher rates of endometritis, blood loss, and greater drops in hematocrit with manual extraction.

 Spontaneous placental delivery allows uterine contraction to limit blood loss from the dilated uterine sinuses supplying the placenta.

Hysterotomies may be closed in a variety of fashions, but most often in single or multiple layers. Single-layered closure has consistently shown beneficial results for short-term outcomes such as decreased blood loss, operative time, and postoperative pain.

 However, single-layer closure may present a risk factor for uterine rupture during a future trial of labor after cesarean delivery.

 did not find increased rates of uterine rupture between a single or double-layered closure. Instead, they found that a locking, single-layered closure increased risk of uterine rupture when compared to an unlocked, single-layered closure. Given these data, it may be the locked nature of the suture, possibly strangulating the tissue, which increases risk of future uterine rupture. In a setting where vaginal birth after cesarean (VBAC) is uncommon, a single-layer closure is likely adequate, but the authors recommend a double-layer closure in a patient considering VBAC in the future.

Given a lack of data regarding the choice of suture material, it is reasonable to select a suture type based on the surgeon’s preference.

Adhesion formation can complicate future cesarean deliveries, resulting in prolonged surgical time, increased blood loss, or visceral injury. The role of peritoneal closure in prevention of adhesion formation, though, remains unclear. While observational studies suggest that closure of the parietal peritoneum may play a role in adhesion prevention,

 prospective studies randomizing patients to closure versus non-closure of the parietal peritoneum do not seem to show a benefit when adhesions are evaluated at the time of subsequent cesarean delivery.

 Further study is needed before recommending routine closure of the peritoneum.

Adhesion barriers, such as sodium hyaluronic acid/carboxymethylcellulose, may also prevent adhesion formation. However, randomized trials in obstetrics have not demonstrated benefit when used at time of cesarean delivery.

 Given the expense of these adhesion barrier products and without evidence of proven benefit, we advocate against their routine use.

Based upon a meta-analysis performed in 2004, subcutaneous tissue should be closed if the thickness is greater than 2 cm.

 That analysis demonstrated a 34% decreased risk of wound disruption when subcutaneous tissue greater than 2 cm was closed. The subcutaneous tissue may be closed with either a continuous suture or interrupted sutures, based on the surgeon’s preference. There appears to be no additional benefit to wound healing for routine placement of a subcutaneous drain.

Skin closure technique was evaluated in a 2013 randomized controlled trial comparing subcuticular suture and skin staples, which found a decreased incidence of wound complications associated with use of suture.

 Use of subcuticular skin closure was further supported by a 2015 meta-analysis revealing an overall RR of 0.49 (CI 0.28-0.87) for wound complications in the suture group.

Suture material has also been a recent area of study. Buresch et al

 randomized women to undergo closure of skin with poliglecaprone 25 (Monocryl™) versus polyglactin 910 (Vicryl™) and found lower rates of wound complications associated with the former. This study, however, did not include emergent cesarean deliveries and the specific antiseptic skin preparation was not identified, which may limit generalizability of the results. This is a topic of ongoing research.

Obesity is a known risk factor for wound infections. Negative-pressure wound therapy after cesarean may be associated with reduced risk of surgical site infections, but larger trials are needed to clarify their benefit in this population.

Based on recent trials and meta-analyses, a number of recommendations can be made regarding routine performance of cesarean delivery (Table 1). As in any area of medicine, clinical scenarios may dictate a particular approach and cause a practitioner to deviate from the “standard” approach (for example, creating a bladder flap when faced with dense lower-uterine segment adhesions). An increased research focus, however, allows us to continue refining our surgical technique for this common obstetrical intervention. 

 The authors report no potential conflicts of interest with regard to this article.

1. Martin JA, Hamilton BE, Osterman MJ. Births in the United States, 2015. 

2. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. 

3. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. 

4. Huang H, Li G, Wang H, He M. Optimal skin antiseptic agents for prevention of surgical site infection in cesarean section: a meta-analysis with trial sequential analysis. 

5. Tuuli MG, Liu J, Stout MJ, et al. A randomized trial comparing skin antiseptic agents at cesarean delivery. 

6. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. 

7. Caissutti C, Saccone G, Zulio F, et al. Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis. 

8. ACOG Practice Bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. 

9. Tita AT, Szychowski JM, Boggess K, et al and C/SOAP Trial Consortium. Adjunctive azithromycin prophylaxis for cesarean delivery. 

10. Skeith AE, Niu B, Valent AM, Tuuli MG, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis: a cost-effectiveness analysis. 

11. Wallin G, Fall O. Modified Joel-Cohen technique for caesarean delivery. 

12. Mathai M, Hofmeyr GH, Mathai NE. Abdominal surgical incisions for caesarean section. 

13. Tuuli MG, Odibo AO, Gogertey P, Roehl K, Stamilio D, Macones GA. Utility of the bladder flap at cesarean delivery: a randomized controlled trial. 

14. Magann EF, Chauhan SP, Bufkin L, Field K, Roberst WE, Martin JN Jr. Intra-operative Haemorrhage by blunt versus sharp expansion of the uterine incision at cesarean delivery: a randomized clinical trial. 

15. Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. 

16. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. 

17. Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of cesarean section. 

18. Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL. Single- versus double-layer uterine incision closure and uterine rupture. 

19. Roberge S, Chaillet N, Boutin A, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. 

20. Lyell DJ, Caughey AB, Hu E, Daniels K. Peritoneal closure at primary cesarean delivery and adhesions. 

21. Kapustian V, Anteby EY, Gdalevich M, Shenhav S, Lavie O, Gemer O. Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study. 

The purpose of this article is to review the steps in a cesarean delivery and examine the best available evidence for performing the procedure.

Vol. 63 No. 04

Contemporary OB/GYN contributors at ACOG

Enhanced recovery in gynecologic surgery

Did vaginal hysterectomy result in iatrogenic injuries?

Tools Test Drive: LiquiBand Exceed Topical Skin Adhesive

Memorials to two mothers

Cesarean sections - based on the evidence