Substance use disorder (SUD) is a disease characterized by behavior patterns of substance use leading to dysfunction in cognition, mood, and quality of life. The prevalence of perinatal substance use disorders in the United States continues to rise and have adverse effects on the maternal-infant dyad. Mirroring the rise in SUD is an increasing prevalence of severe maternal morbidity (SMM). However, this relationship needs further examination.

Third-trimester lower uterine segment thickness (LUST) is associated with uterine rupture during trial of labor after cesarean (TOLAC) but threshold values vary according to the approach used (lower values with vaginal ultrasound, higher values with abdominal ultrasound).

The research and implementation process for a new screening test should involve two steps. First, one has to demonstrate that the test can predict a certain outcome or appropriately stratify the patients based on risk for the outcome. The second step requires evidence of clinical utility. The Food and Drug Administration has approved screening tests for risk stratification or progression of preeclampsia despite the absence of data on clinical utility. Introduction into clinical practice and eventual integration into the standard of care might follow quickly, making a clinical utility trial challenging to accomplish. This manuscript provides an overview of the research and regulatory pathways used for screening and diagnostic tests in medicine in general and obstetrics in particular. For illustration purposes, we review the relevant data gathered so far regarding tests that are promoted for prediction, risk stratification, and progression of preeclampsia. We then discuss the importance of proving clinical utility before introducing tests into clinical practice and the potential unintended consequences of adoption prior to proving clinical utility.

Preeclamptic women, in addition to traditional anti-hypertensive medications, often receive magnesium supplementation and are at increased risk of post-spinal hypotension Post-spinal hypotension increases the risk of fetomaternal morbidity. Calcium is a physiological antagonist of magnesium in vascular smooth muscle. Therefore, the study hypothesized that calcium is better suited for preserving systemic vascular resistance and preventing post-spinal hypotension during cesarean delivery.

Various interventions have been applied to reduce perineal trauma and obstetric anal sphincter injuries (OASIS). The efficacy of warm compresses during the second stage of labor for reducing the occurrence of perineal tears is controversial.

This expert review provides recommendations for the cesarean technique after placental delivery to skin closure. Following placental delivery during cesarean, sponge curettage may be omitted as it has not been shown to decrease the risk of retained products of conception. Uterine irrigation and mechanical cervical dilation cannot be recommended. Either intra-abdominal or extra-abdominal repair of the hysterotomy is acceptable with some possible benefits with decreased postoperative pain and nausea/vomiting with intra-abdominal repair. There is insufficient evidence to recommend one uterine closure technique over the other with regards to suture type, continuous versus interrupted, locking or non-locking, one versus two-layer closure. Double layer uterine closure has been shown to be more beneficial with regards to residual myometrial thickness and full thickness bites (including endometrium) should be considered. Glove change by the surgical team is recommended after placental delivery and prior to closure of the abdominal wall. The following techniques are not recommended: intra-abdominal irrigation, use of adhesion-prevention barriers, peritoneal closure, and rectus muscle re-approximation. Based on non-cesarean evidence, fascial closure bites should be at least 5 × 5 mm with monofilament suture for vertical incisions. As an adjunct to postoperative pain control, surgeons may consider wound infiltration with local anesthesia either supra- or sub-fascial. Prior to closure, subcutaneous irrigation may be performed with saline, and routine use of subcutaneous drains is not recommended. Though closure of the subcutaneous layer can be considered in all patients, it should occur when the depth is ≥ 2cm. A monofilament absorbable suture, such as poliglecaprone, should be used to close the CD skin incision. There is no level 1 evidence evaluating the potential benefit of additional skin adhesive or sterile strips after suture skin closure. If a dressing is preferred over the skin incision the following may be considered: a DACC-impregnated dressing if available, otherwise a standard gauze dressing is appropriate. Prophylactic negative pressure would therapy can be considered in patients with obesity. Vaginal seeding at CD is not recommended.

The following review focuses on routine postoperative care after cesarean delivery (CD), including specific Enhanced Recovery After Cesarean (ERAS) recommendations as well as important postpartum counseling points. Following CD, there is insufficient evidence to support administration of prophylactic multi-dose antibiotics to all patients. Additional antibiotic doses are indicated for the following scenarios: patients with obesity, CD lasting ≥ 4 hours since prophylactic dose, blood loss >1,500 mL, or those with an intra-amniotic infection. An oxytocin infusion for prevention of postpartum hemorrhage should be continued post-CD. While initial measures to prevent postoperative pain occur in the intraoperative period, with the consideration of 1g intravenous (IV) acetaminophen and IV or intramuscular (IM) non-steroidal anti-inflammatory medications (e.g., 30mg IV ketorolac), the focus postoperatively continues with this multimodal approach with scheduled acetaminophen per os (PO, 650mg every 6 hours) and non-steroidal agents (ketorolac 30mg IV every 6 hours for 4 doses followed by ibuprofen 600mg PO every 6 hours) being recommended. Short-acting opioids should be reserved for breakthrough pain. Low-risk patients should receive mechanical thromboprophylaxis until ambulation with chemoprophylaxis being reserved for patients with additional risk factors. When an indwelling bladder catheter was placed intraoperatively for scheduled CD, it should be removed immediately postoperatively. Chewing gum to aid in return of bowel function and early oral intake of solid food can occur immediately after CD and within 2 hours, respectively. For prevention of postoperative nausea and vomiting, administration of 5HT antagonists in recommended with the addition of either a dopamine antagonist or a corticosteroid as needed based on non-cesarean data. Early ambulation after CD starting 4 hours postoperatively is encouraged and should be incentivized by pedometer. For patients that receive a dressing over the CD skin incision, there is limited evidence regarding when best to remove it. Adjunct non-pharmacologic interventions for postoperative recovery discussed in this review are acupressure, acupuncture, aromatherapy, coffee, ginger, massage, reiki and TENS. In the low-risk patient, hospital discharge may occur as early as 24-28 hours if close (i.e., 1-2 days) outpatient neonatal follow up is available due to the potential for neonatal jaundice; otherwise, patients should be discharged at 48-72 hours postoperatively. Upon discharge, the multimodal pain control recommendations of acetaminophen and ibuprofen should be continued. If short-acting opioids are necessary, the prescribing practices should be individualized based upon the inpatient opioid requirements. Other portions of postoperative/postpartum counseling during the inpatient stay include the optimal interpregnancy interval of 18 to 23 months, encouraging exclusive breastfeeding for at least 6 months, quick resumption of physical activity and vaginal intercourse guidance as tolerated. Patients should also be counseled pre-CD on the option of immediate postpartum IUD insertion, intraoperative salpingectomy or placement of long acting reversible contraception in the postpartum period. Implementation of such evidence-based postoperative care protocols decrease length of stay, surgical site infection rates, and improve patient satisfaction and breastfeeding rates.

Lidocaine patches are a common topical analgesic therapy but have not been thoroughly investigated in the surgical or obstetric literature. We sought to investigate the impact of adding topical lidocaine patches to routine post-cesarean pain management on patients' post-cesarean pain scores and opioid use.

Congenital diaphragmatic hernia (CDH) is characterized by a diaphragmatic defect, leading to herniation of abdominal organs into the chest, lung compression, and impaired lung development, often resulting in pulmonary hypertension and lung hypoplasia. Prenatal imaging techniques like ultrasound and MRI provide anatomical predictors of outcomes, but their limitations necessitate novel biomarkers for better prognostic accuracy.

Intravenous fluid (IVF) administration is a ubiquitous medical intervention. Although there are clear benefits to IVF in certain obstetric scenarios, IVF are often given in unindicated circumstances; the ongoing IVF shortage highlights an opportunity to reduce unindicated IVF in obstetrics. This document provides evidence-based recommendations to reduce IVF use within general obstetric practice. The three sections address IVF use within 1) antepartum care, 2) intrapartum care, and 3) postpartum care, including postpartum hemorrhage risk reduction. Using the GRADE framework, we provide a summary of the available evidence surrounding use of IVF in obstetrics and recommend strategies to reduce IVF. We recommend transitioning intravenous (IV) antibiotics to IV push or oral when possible, discontinuing IVF bolus prior to neuraxial anesthesia or for the treatment of preterm labor, and avoiding unnecessary continuous IVF infusions. There may be further opportunities for fluid conservation with IV medications that could be given intramuscularly (IM). These suggestions for IVF use reduction should be evaluated based on local need and capabilities as well as the characteristics and risk factors of the population. Patients with sepsis, postpartum hemorrhage, burns, diabetic ketoacidosis, and hemodynamic instability should not have a reduction in IVF administration as these diagnoses have evidence-based resuscitation guidelines that include IVF. The recommendations presented may be applicable beyond the immediate IVF shortage and should be considered as an area for future research.

Induction of labor (IOL) is currently used for one in 10 pregnancies globally. Methods used for induction have shown major changes over time. Medical interventions trace their origins back to ancient civilizations, with evidence suggesting that they began over 5000 years ago in ancient Egypt. During this era, the Egyptians employed natural remedies such as castor oil and date fruits for the IOL. These early practices highlight the rich history and long-standing tradition of using natural substances in medical treatments, laying the foundation for the development of modern obstetric practices. After that, Hippocrates practiced mammary stimulation and mechanical cervical dilatation about 2500 years ago in Greece. Since then, there has been a marked change, especially over the last century, with the development of safer and more effective methods. Mechanical methods were the main method until the early 20th century, which were then substituted by pharmacological methods with more experiments in the mid to late 20th century. Nowadays, effectiveness, safety, cost, and client satisfaction are the main determinants of the methods used. This review summarizes how labor induction practices have evolved from the Egyptian era to the present-day randomized controlled trials and meta-analysis evidence, paying attention to their effectiveness, safety, and future directions.

Physical activity in pregnancy decreases the risk of adverse maternal and neonatal outcomes. This study evaluates the association between first trimester physical activity, assessed by Kaiser Physical Activity Survey (KPAS) scores, and adverse perinatal outcomes.