BACKGROUND & AIMS: :This Special Section Guest Editorial provides an overview of the topical area and an introduction to the articles featured in the special section.

背景与目标： : 本特殊部分来宾社论概述了主题领域，并介绍了特殊部分中的文章。

BACKGROUND & AIMS: PURPOSE:Uterine prolapse complicating pregnancy is extremely rare. This report presents the surgical correction of uterine prolapse during cesarean section. CASE:We report a case of a 33-year-old woman with twin gestation who admitted to obstetric clinic with labor pain and total uterine prolapse at 33 weeks of gestation. An emergent cesarean section was performed for the indication of acute fetal distress. At the same operation, following cesarean delivery, abdominal hysteropexy using rectus fascia strips was performed successfully. On control performed 6 months later, patient was examined and it was detected uterine prolapse had regressed and babies were uneventful. CONCLUSION:This surgical method offers effective treatment of uterine prolapse.

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BACKGROUND & AIMS: :We report a case of severe acute pulmonary oedema following induction of general anaesthesia for emergency caesarean section. After several hours of aggressive resuscitation, both mother and child had a favourable outcome. Postoperative investigation of acute renal failure demonstrated a supra-adrenal mass. Further investigation confirmed bilateral phaeochromocytoma as the cause of her condition. A literature review confirmed this to be a rare but important clinical entity, owing to its high mortality. Antenatal diagnosis greatly improves survival. Magnesium sulphate appears to be a useful and safe agent to employ in cases of undiagnosed hypertensive obstetric emergencies.

背景与目标： : 我们报告了一例在进行紧急剖腹产的全身麻醉后引起的严重急性肺水肿。经过几个小时的积极复苏，母亲和孩子都有了良好的结果。急性肾衰竭的术后检查显示肾上腺上肿块。进一步的调查证实了双侧嗜铬细胞瘤是她病情的原因。文献综述证实，由于其高死亡率，这是一种罕见但重要的临床实体。产前诊断大大提高了生存率。硫酸镁似乎是在未诊断的高血压产科紧急情况下使用的有用且安全的试剂。

BACKGROUND & AIMS: :Lateral table tilt or a pelvic wedge are commonly used to reduce inferior vena cava compression during obstetric anaesthesia in the supine position. Direct measurement of pelvic angle allows individual assessment of the effectiveness of these manoeuvres in achieving a tilted position. We observed routine practice during caesarean section after random allocation to one or other of these methods. The anaesthetist managing the case was asked to position the women after induction of spinal anaesthesia using either left table tilt or a wedge under the right hip. We then measured pelvic angle in all women, and the table angle in women who had table tilt. The mean (SD [range]) pelvic angle was 20.2° (8.1° [9°-37°]) in 18 women with table tilt and 21.0° (7.5° [10°-36°]) in 17 women with a wedge. The mean (SD [range]) table angle was 12.4° (3.1° [8°-21°]) in the women with table tilt. There was a significant difference between table angle and pelvic angle in the women with table tilt (p = 0.0003), but no significant difference in pelvic angle between the table tilt and wedge groups. Measurement of table angle does not represent pelvic position adequately in the majority of women. However, this study showed that lateral table tilt and a pelvic wedge were equally effective in producing tilt of the pelvis.

背景与目标： : 侧卧台倾斜或骨盆楔形通常用于减轻仰卧位产科麻醉期间的下腔静脉压迫。直接测量骨盆角度可以单独评估这些动作在实现倾斜位置方面的有效性。在随机分配给这些方法中的一种或另一种后，我们观察了剖腹产期间的常规做法。要求处理该病例的麻醉师在使用左表倾斜或右臀部下方的楔形物诱导脊柱麻醉后对妇女进行定位。然后，我们测量了所有女性的骨盆角度，以及有桌子倾斜的女性的桌子角度。18位倾斜的女性平均 (SD [范围]) 骨盆角度为20.2 ° (8.1 ° [9 °-37 °])，17位楔形女性为21.0 ° (7.5 ° [10 °-36 °])。在倾斜桌子的妇女中，平均 (SD [范围]) 桌子角度为12.4 ° (3.1 ° [8 °-21 °])。台倾斜妇女的台角和骨盆角度有显著性差异 (p   =   0.0003)，但台倾斜组和楔形组的骨盆角度无显著性差异。在大多数女性中，测量桌子角度并不能充分代表骨盆位置。然而，这项研究表明，侧面倾斜和骨盆楔形在产生骨盆倾斜方面同样有效。

BACKGROUND & AIMS: BACKGROUND:A block to touch to T5 is widely used to indicate an adequate level of block for caesarean section with spinal anaesthesia. However, two studies using a "block to light touch" to T5 as their end-point, had a high requirement for intraoperative analgesia and their results cast doubt on the adequacy of a block to touch to T5. On enquiry, these two papers did not assess complete block to touch, but asked mothers when the touch sensation "was the same as" a control stimulus. The difference between these two assessment methods is unknown. The current study presents prospectively collected sensory block data which included both block to touch and the level when touch was the same as a control stimulus. METHODS:The levels of block were assessed using a Neurotip®. The mother was asked four questions to assess the block: first touch level, first sharp level, touch same as control and sharp same as control. RESULTS:The first touch level was a median of two dermatomes lower than the touch same as a control level [IQR 0-3, range 0-6]. Block level assessment methods using first sharp and touch same as control were equivalent. CONCLUSION:When describing a sensory block, not only is it necessary to indicate the exact stimulus used, but it is important to define the actual question asked of the patient. Clinically, block assessment using the first sharp level and touch same as control are equivalent.

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BACKGROUND & AIMS: :The event rates up to 1 year after insertion of a Copper-T IUD were compared in 76 women who had 1 or more cesarean sections, and were given their IUD immediately after medical termination of pregnancy, and in 76 women matched for age and parity but normal vaginal deliveries. The cesarean group had abortion performed under general anesthesia; the vaginal group had iv diazepam and paracervical block. All subjects were less than 11 weeks gestation. They were followed up at 7 days, 6 weeks, and 3 monthly intervals for 1 year. No perforations or pregnancies occurred. Incomplete abortion caused expulsion in 2.6% of women in both groups, and removal in 6.5 and 5.3%, in the cesarean and control groups respectively, and was responsible for most discontinuations. It was concluded that IUD insertion is safe after medical termination of pregnancy in women with a history of cesarean section, depending on the skill of the surgeon.

背景与目标： : 比较了76名剖宫产1次或更多次，并在医学终止妊娠后立即给予宫内节育器的妇女和76名年龄和胎次匹配但阴道分娩正常的妇女插入铜-T宫内节育器后1年的事件发生率。剖宫产组在全麻下进行人工流产术; 阴道组静脉注射安定和宫颈旁阻滞。所有受试者妊娠均少于11周。对他们进行了7天，6周和3个月的随访，为期1年。没有发生穿孔或怀孕。不完全流产导致两组2.6% 的妇女被驱逐，剖宫产组和对照组分别在6.5和5.3% 中被驱逐，这是大多数中止的原因。结论是，根据外科医生的技能，有剖宫产史的妇女在医学终止妊娠后插入宫内节育器是安全的。

BACKGROUND & AIMS: OBJECTIVE:The objective of the study was to determine whether a model for predicting vaginal birth after cesarean (VBAC) can also predict the probabilty of morbidity associated with a trial of labor (TOL). STUDY DESIGN:Using a previously published prediction model, we categorized women with 1 prior cesarean by chance of VBAC. Prevalence of maternal and neonatal morbidity was stratfied by probability of VBAC success and delivery approach. RESULTS:Morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOL (P < .001) but not elective repeat cesarean section (ERCS) (P > .05). When the predicted chance of VBAC was less than 70%, women undergoing a TOL were more likely to have maternal morbidity (relative risk [RR], 2.2; 95% confidence interval [CI], 1.5-3.1) than those who underwent an ERCS; when the predicted chance of VBAC was at least 70%, total maternal morbidity was not different between the 2 groups (RR, 0.8; 95% CI, 0.5-1.2). The results were similar for neonatal morbidity. CONCLUSION:A prediction model for VBAC provides information regarding the chance of TOL-related morbidity and suggests that maternal morbidity is not greater for those women who undergo TOL than those who undergo ERCS if the chance of VBAC is at least 70%.

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BACKGROUND & AIMS: BACKGROUND:In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates. OBJECTIVES:To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates. SEARCH STRATEGY:Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016. SELECTION CRITERIA:Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates. DATA COLLECTION:Data on study design, interventions used, CS rates, and perinatal outcomes were extracted. RESULTS:Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias. CONCLUSION:We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates. TWEETABLE ABSTRACT:Use of the Robson classification in clinical audit cycles to reduce caesarean rates.

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BACKGROUND & AIMS: :We examined deliveries of twins to identify factors most strongly associated with an increased risk of transfusion. We reviewed the obstetric records of 511 twin deliveries at the Japanese Red Cross Katsushika Maternity Hospital from 2003 through 2007. After 18 (3.5%) of these deliveries, transfusions were required. Transfusion was significantly more likely after elective cesarean delivery at a gestational aged of 37 weeks or more (odds ratio, 4.85; 95% confidence interval, 1.87-12.61). Emergency cesarean delivery (at > or =37 weeks' gestation) was not associated with an increased risk of transfusion. The delivery mode of twins should be carefully considered because of the increased risk of transfusion after elective cesarean delivery at a gestational age of 37 weeks or more.

背景与目标： : 我们检查了双胞胎的分娩，以确定与输血风险增加最密切相关的因素。我们在2007年2003年审查了日本红十字会葛藤妇产医院511例双胞胎分娩的产科记录。在这些递送中的18 (3.5%) 之后，需要输血。在妊娠37周或以上的择期剖宫产后，输血的可能性明显更高 (优势比，4.85; 95% 置信区间，1.87-12.61)。紧急剖宫产 (妊娠> 或 = 37周) 与输血风险增加无关。应仔细考虑双胞胎的分娩方式，因为在胎龄为37周或以上的选择性剖宫产后输血的风险增加。

BACKGROUND & AIMS: :Tuberculosis is a worldwide prevalent disease. The emergence of multidrug-resistant strains spurred the search for new drugs. There are several tuberculosis treatment guidelines, international and local in a programmatic approach. An Argentinean specialists panel draw practical guidelines based in clinical criteria and the local and international bibliography through consensus meetings, including issues as: antituberculosis drugs available in Argentina, initial and re-treatement modalities, special situations treatment, adverse reactions to antituberculosis drugs, current indications of surgical treatment and new drugs under study for the treatment of the disease.

背景与目标： : 结核病是一种世界性的流行疾病。多重耐药菌株的出现刺激了对新药的寻找。有几个结核病治疗指南，国际和本地的方案方法。阿根廷专家小组通过协商一致的会议，根据临床标准以及当地和国际参考书目制定实用指南，包括以下问题: 阿根廷现有的抗结核药物、初始和再治疗方式、特殊情况治疗、抗结核药物的不良反应、目前外科治疗的适应症和正在研究的治疗该疾病的新药。

BACKGROUND & AIMS: BACKGROUND:Women with a migration background are reportedly at a higher risk of emergency caesarean section. There is evidence that this is due in part to suboptimal antenatal care use and quality of care. Despite the fact that migrant women and descendants of migrants are often at risk of socioeconomic disadvantage, there is, in comparison, scarce and incomplete evidence on the role of socioeconomic position as an independent risk factor for emergency caesarean delivery. We therefore investigate whether and how migration background and two markers of socioeconomic position affect the risk of an emergency caesarean section and whether they interact with each other. METHODS:In 2013-2016, we recruited women during the perinatal period in Bielefeld, Germany, collecting data on health and socioeconomic and migration background, as well as routine perinatal data. We studied associations between migration background (1st generation migrant, 2nd/3rd generation woman, no migration background), socioeconomic status (educational attainment and net monthly household income), and the outcome emergency caesarean section. RESULTS:Of the 881 participants, 21% (n = 185) had an emergency caesarean section. Analyses showed no association between having an emergency caesarean section and migration status or education. Women in the lowest (< 800€/month) and second lowest (between 800 and 1750€/month) income categories were more likely (aOR: 1.96, CI: 1.01-3.81; and aOR: 2.36, CI: 1.27-4.40, respectively) to undergo an emergency caesarean section than women in the higher income groups. CONCLUSIONS:Migration status and education did not explain heterogeneity in mode of birth. Having a low household income, however, increased the chances of emergency caesarean section and thereby contributed towards producing health disadvantages. Awareness of these findings and measures to correct these inequalities could help to improve the quality of obstetric care.

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BACKGROUND & AIMS: OBJECTIVE:Caesarean section surgical site infection (SSI) is a surgical wound site infection occurring within 30 days of surgery with a reported incidence of 3-15%. This quality improvement (QI) project aimed to reduce caesarean section SSI by 50% in a tertiary maternity center. METHODS:Using multidisciplinary team approach, the project was designed with evidence-based interventions. The Royal College of Physicians of Ireland/Royal College of Surgeons in Ireland "Preventing Surgical Site Infections Key Recommendations for Practice" guideline was used as standard perioperative care. A care bundle was designed targeting preoperative personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique, all measured using a patient survey. The rate of SSI was followed for 14 months. The Model for Improvement methodology was used to implement change. RESULTS:Surgical site infection rate decreased from 6.7% (n = 684 caesarean sections, n = 46 SSI) to 3.45% (n = 3,206 caesarean sections, n = 110 SSI), p = .0006. Reduction occurred in both elective (4.4%-2.7%) and emergency (9.1%-4.1%) caesarean section groups. There was excellent adherence to all three elements of the care bundle. The 50% reduction in caesarean section SSI was sustained over the 14-month period, significantly reducing maternal morbidity. CONCLUSIONS:The success of this QI project is attributable to frontline ownership and empowerment of patients and staff.

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BACKGROUND & AIMS: OBJECTIVE:To compare the risk of uterine rupture between a cohort of women with previous low-transverse cesarean section (CS) and a cohort with intact uterus. METHODS:All women with a singleton pregnancy and previous low-transverse CS requiring induction of labor from January 1, 1992 to December 30, 2001 (n = 310) were compared with a cohort of women with intact uterus undergoing induction of labor during the same study period (n = 5420). Protocols of induction using prostaglandin E2 gel and oxytocin infusion were consistent within groups, but differed between the previous CS and the intact uterus group. RESULTS:Uterine rupture occurred in 0.3% in the previous CS group vs. 0.03% in the intact uterus group (p = 0.37). Logistic regression analysis showed no significant difference in rate of uterine rupture between the previous CS vs. intact uterus group (p = 0.16) after controlling for maternal age, parity, gestational age at delivery, Bishop score on admission, use of prostaglandin and oxytocin, and birth weight. Our study had adequate power to detect a 0.38% difference in rate of uterine rupture between the two groups (alpha = 0.05, beta = 0.80). CONCLUSION:Induction of labor is not associated with significantly higher rates of uterine rupture among women with previous low-transverse CS compared with women with intact uterus provided a consistent protocol with strict intervention criteria is adopted.

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BACKGROUND & AIMS: :The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute nontraumatic headaches in the emergency department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis, while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists' perspective, written on behalf of the Refractory, Inpatient, Emergency Care section of the American Headache Society (AHS). The commentary have been reviewed and approved by Board of Directors of the AHS.

背景与目标： : 美国急诊医师学会 (ACEP) 在2019年7月上发布了有关急诊科急性非创伤性头痛的诊断和管理的指南，主要侧重于蛛网膜下腔出血的诊断以及影像学和腰椎穿刺在诊断中的作用。ACEP临床政策文件旨在帮助急诊医生处理出现急性头痛的患者，并提高诊断的准确性，同时促进安全的患者护理实践。临床政策文件还强调了未来研究最佳实践的必要性，以区分原发性和继发性头痛以及当前急性头痛治疗方案的有效性和安全性。以下关于这些指南的评论旨在从头痛专家的角度支持和扩展这些指南，这些指南是代表美国头痛协会 (AHS) 的难治性，住院，急诊护理部门编写的。评注已经由AHS董事会审查和批准。

BACKGROUND & AIMS: OBJECTIVE:To determine the prevalence and correlates of cesarean deliveries (CS) in Beirut. METHODS:A cross-sectional study conducted on 18,837 consecutive infants born at nine hospitals from the National Collaborative Perinatal Neonatal Network (NCPNN). Stepwise Logistic Regression was performed to determine CS correlates. RESULTS:The rate of CS was 26.4% and correlated with socio-demographic, obstetrical and provider-related variables. Regression analysis identified age, paternal occupation, mode of payment, parity, birth weight, gestational age, multiple pregnancies, adequate prenatal care, complications during pregnancy, body mass index at delivery, hospital teaching status, day of the week and year of delivery to be significant correlates of CS. CONCLUSION:This study shows an increased CS rate in a middle-income country, and identifies the correlates of women delivering by the abdominal route. These correlates may be used for effective reduction policies in the future.

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