Characteristics of women with cesarean section due to placenta previa at national hospital of obstetric and gynecology in 2020

Nội dung text: Characteristics of women with cesarean section due to placenta previa at national hospital of obstetric and gynecology in 2020

1. RESEARCH ARTICLE CHARACTERISTICS OF WOMEN WITH CESAREAN SECTION DUE TO PLACENTA PREVIA AT NATIONAL HOSPITAL OF OBSTETRIC AND GYNECOLOGY IN 2020 Nguyen Thi Thanh Huong1, Vu Dung2 1National Hospital for Obstetric and Gynecology, 2Thang Long University ABSTRACT Objective: Describe the clinical, participants had completed placenta previa subclinical, and resuscitation care after (85.2%) and 34.9% of them had Placenta placenta previa operations at the National Accreta. 63.1% of women had a cesarean Hospital For Obstetric And Gynecology. section and preserved the uterus and 36.9% Method: Descriptive study design was of them undergo surgery of hysterectomy. used to recruited 149 women who had a 43.6% of the women experienced servere cesarean section due to placenta previa at bleeding and half of them had to have a the department of resuscitation anesthesia blood transfusion, the average amount of in the National Hospital For Obstetric And transfusion was 3.11 ± 2.6 units of blood. Gynecology from January to September After surgery, 55% of pregnant women 2020. Results: The average age of pregnant recovered well. Conclusion: Most of the women was 32.5 ± 4.9 years old, mainly in women had better progress after surgery the 22 to 35 years old group (71.1%); 23.5% in terms of mental status, breathing, of them had comorbidities; 40.9% get circulation, pain sensation. Health care staff pregnant up to 3 times; 61.7% of them had should provide post-cesarean care for the ever a C-section. In the pregnancy, 42.8% woman with history of cesarean section due of the women had preterm birth and 4.1% to placenta previa, pregnancy with comorbid of them were pregnant with twins. While diseases, placenta accreta, emergency admitted to the hospital, 49% of women surgery and women with servere bleeding presented with vaginal bleeding and 34.9% pre-and post- surgery. of them were anemia; 57% of women had Keywords: after cesarean section, uterine contractions and most of them placeta previa, the National Hospital For presented with an open cervix. Almost of Obstetric And Gynecology. 1. INTRODUCTION. The placenta previa resulted a high rate mostasis and after surgery, bleeding may of preterm birth due to premature bleeding, still happen life-threatening for the wom- making it difficult to continue the pregnan- en. Complications that may occur during cy. One of the common indications in ce- and after surgery are hemorrhage, uterine sarean section is placenta previa. In the atony, hypovolemic shock and finally stop surgery, the risk of bleeding, difficult he- circulation, death [1]. Resuscitation care is intensive care, requiring the nurse to be professional, quickly and accurately assess Cor. author: Vu Dung the pregnant woman’s condition, carefully Email: vuzung246@gmail.com monitor and follow-up the patient, then, the Received: Feb 08, 2021 complications may be detected early. After Revised: Feb 15, 2021 surgery, notice and timely implementation Accepted: Mar 05, 2021 of medical intervention from the doctor as 76 Journal of Nursing Science - Vol. 04 - No. 01
2. RESEARCH ARTICLE well as the optimal nursing care interven- The minimum sample size calculated tion, thereby avoiding complications, espe- was 130 women. In fact, the study took all cially those that severely affect the life of 149 women who had cesarean section due the woman. In order to describe the char- to placenta previa during the study period. acteristics of the pregnant woman who had - Sample selection method: convenient a cesarean section due to the placenta and sample selection the results of monitoring and providing care of the woman during the tesuscitation care 2.3. Methods of data collection: Data period, the researcher conducted the study were collected from patient medical records with the objective to examine the clinical, and direct monitoring of each woman, infor- subclinical and post-operative regression of mation was documented in the research women who underwent a cesarean section records. at the National Hospital For Obstetric And 2.4. Measurements Gynecology - Classification of placenta previa was 2. RESEARCH METHOD according to the diagnostic lab results. 2.1. Research settings, time and participants - Uterine contraction was evaluated 2 levels of good and not good Research settings: the department of resuscitation anesthesia in the National - Pain level was assessed on VAS scale Hospital For Obstetric And Gynecology of 0 = painless; 1 to 3 = mild pain; 4 to 6 = Research time: from January to Sep- moderate pain and 7 to 10 = severe pain tember 2020. - Assess the status of pregnant women Participants: Women of all ages after in pregnant period was based on weight, cesarean delivery (emergency surgery, height, BMI calculation and WHO classifi- planned surgery). Except for pregnant cation: BMI 1 and within the 95% con- p x (1-p) fidence interval of CI and p <0.05. n= z2(1- α/2) d2 Journal of Nursing Science - Vol. 04 - No. 01 77
3. RESEARCH ARTICLE 3. RESULTS 13.4% of pregnant women got pregnant 3.1. Characteristics of women with for the first time. Regarding the history of cesarean section due to placenta previa cesarean section, 24.8% of women had one caesarean section, 32.9% had two Table 1. General characteristics, cesarean sections, and 4.0% of women had comorbidities and pregnant history of 3 or more cesarean sections. participants Table 2. Clinical and subclinical Characteristics n Percentage characteristics of women before surgery Age: Under 22 1 0,7 Characteristics n Percentage 22 to 35 106 71,1 Above 35 42 28,2 Gestational age: 32,5 ± 4,9 - Preterm 49 32,9 The average age Min:19 Max: 44 - Fullterm 100 67,1 Body status before Number of pregnancy: gestations: - Normal 114 76,5 - One gestation 143 95,9 - Thin 17 11,4 - Twins 6 4,1 - Overweight, obesity 18 12,1 Vaginal bleeding 73 49,0 Number of previous pregnancies Cervical: Not yet 20 13,4 - Close 134 89,9 1-2 times 68 45,7 - Open 15 10,1 ≥ 3 times 61 40,9 Uterine contractions: There were 35 23,5 - With contraction 85 57,0 comorbidities - No contractions 64 43,0 Number of cesarean Blood pressure: sections before - Normal 144 96,6 - Not yet 57 38,3 - Hypotension 2 1,3 - 1 time 37 24,8 - Hypertension 3 2,0 - 2 times 49 32,9 There are signs of - 3 times and above 6 4,0 2 1,3 shock The average age of the participants was Anemia: 32.5 ± 4.9 years, of which mainly the age - Reduced number 69 46,3 group from 22 to 35 years old, accounting of red blood cells for 71.1%, the age group over 35 accounting - Decreased Hb 52 34,9 for 28.2% and only 1 women in the group of concentration under 22 years old, this woman was only 19 Ultrasound years old. - Incomplete edge 19 12,8 Before this pregnancy, most of the placenta previa women were in a normal body status - Incomplete lower 3 2,0 (76.5%), 11.4% of them were underweight, placenta previa and 12.1% were overweight. 23.5% of - Complete placenta 127 85,2 women had comorbidities. 40.9% of women previa - Placenta accreta 52 34,9 had ever had two or more pregnancies. 78 Journal of Nursing Science - Vol. 04 - No. 01
4. RESEARCH ARTICLE In this pregnancy, 4.1% of the pregnancy was twins and 32.9% of the woman had the preterm birth. While admitted to hospital, 49.0% of women had vaginal bleeding; 57.0% had uterine contractions and 10.1% of women had an open cervix. Before surgery, most women had normal blood pressure (96.6%) and 2 women had fast pulse, low blood pressure. The results of blood tests showed that 43.6% of women had a decrease in the red blood cell index and 34.9% of them had a decrease in hemoglobin. Most women had the complete placenta previa (85.2%) and 34.9% had a placenta accreta. Table 3. Indication of cesarean section due to placenta previa and surgery method Indication and surgery method n Percentage Caesarean section and uterus preservation 94 63,1 Caesarean section and hysterectomy 54 36,2 Complete hysterectomy 1 0,7 Total 149 100,0 94 women underwent cesarean section and uterine preservation, accounting for 63.1% and 55 women undergoing cesarean section and hysterectomy, accounting for 36.9% of which 1 woman had a complete hysterectomy whose was with 17.2 week-pregnancy, 3rd child, old age, complete placenta previa and placenta accreta, no amniotic fluid; complete hysterectomy in controling blood loss. 3.2. Results of monitoring and proving care of pregnant women after surgery 100 Unconciuos Hypotension 80 High pulse rate 60 Pale skin 40 20 0 Minutes 0 5 15 30 45 60 90 120 150 180 Figure 1. mental status and circulation of pregnant women after surgery (n=149) Most women were conscious, stable blood pressure, normal pulse rate 3 hours after surgery. Journal of Nursing Science - Vol. 04 - No. 01 79
5. RESEARCH ARTICLE Table 4. Respiratory condition, uterine contraction and postpartum fluid at the time of follow-up Percentage of women at any time Min Min Min Min Min Min Min Min Min 0 15 30 45 60 90 120 150 180 Respiratory condition Ventilator 34.9 24.2 17.4 8.7 7.4 5.4 4 3.4 3.3 With endotracheal 57.7 0.7 0 0 0 0 0 0 0 tube Oxygen with 7.4 34.9 25.6 19.5 15.4 13.4 10.1 6 5.5 nasal catheter Spontaneous 0 0 57 71.8 77.2 81.2 85.9 90.6 91.2 breathing SpO2 (%) 96 98 98 98 99 99 100 100 100 Uterine contraction (n=94) - Good 98,9 98,9 98,9 96,8 96,8 97,8 97,8 98,9 - Not good 1,1 1,1 1,1 3,2 3,2 2,2 2,2 1,1 Postpartum fluid (n=94) - Normal 96,8 96,8 96,8 95,7 95,7 96,8 96,8 96,8 - Much with bloody 3,2 3,2 3,2 4,3 4,3 3,2 3,2 3,2 The results of women with mechanical ventilation decreased from 34.9% to 3.3% after 3 hours; the rate of women breathing through the endotracheal tube decreased from 57.7% to 0% after 30 minutes after surgery; the rate of women breathing on their own increased from 0% to 91.2% after 3 hours. Good respiratory support enabled capillary blood oxygen saturation with SpO2 always above 95% in all women. Most women were well progress, good uterine contration and normal postpartum fluid ranged from 95.7% to 98.9%. Table 5. Amount of blood loss and blood transfusion after surgery Index n Percentage Blood loss: - Less (<250ml) 7 4,7 - Medium (250- <500ml) 77 51,7 - Servere (500- <1000ml) 38 25,5 - Very servere (≥ 1000ml) 27 18,1 Women with blood transfusion - Yes 75 50,3 - No 74 49,7 Average units of transfused blood (n=75) 3,11 ± 2,6 (Min: 1 Max: 13) 18.1% of women experienced very servere blood loss; 25.5% of women had severe blood loss and 51.7% had moderate blood loss. With the above blood loss, 75 women experienced a blood transfusion and the average amount of transfusion was 3.11 ± 2.6 blood units. Especially, women had to transfuse up to 13 blood units (for two operations). 80 Journal of Nursing Science - Vol. 04 - No. 01
6. RESEARCH ARTICLE Table 6. Progress of pain sensation of women after surgery Grade of Hour 1 Hour 2 Hour 3 Hour 4 Hour 5 Hour 6 VAS n=149 n=149 n=136 n=49 n=22 n=12 20 19 10 8 5 4 0 (13,4%) (12,8%) (7,4%) (16,3%) (22,7%) (33,3%) 127 95 54 13 2 1 1-3 (85,2%) (63,8%) (39,7%) (26,5%) (9,1%) (8,3%) 1 32 68 27 14 6 4-6 (0,7%) (21,4%) (50,0%) (55,2%) (63,7%) (50,1%) 1 3 4 1 1 1 7-9 (0,7%) (2,0%) (2,9%) (2,0%) (4,5%) (8,3%) Pain level was assessed 1 hour after surgery and once an hour. The results indicated that in the first hour, the effect of anesthetic drugs caused less pain in pregnant women, and the later hours, pain level increased mainly on average. Table 7. Results of resuscitation care of women after surgery and related factors Results n Percentage Resuscitation time: - In 3 hours 82 55,0 - ≥ 3 hours 67 45,0 Complications - No 125 83,9 - Yes and mild 17 11,4 - Yes and heavy 7 4,7 Results of resuscitation - Good 82 55,0 - Not good 67 45,0 55% of women had resuscitation before 3 hours; 45% had resuscitation from over 3 hours, of which 11 women (7.4%) had resuscitation more than 6 hours. The average resuscitation time was 3 hours and 52 minutes. Women were consciousness as early as after 2 hours and 20 minutes and women had the longest resuscitation time of 18 hours. Most women had no complications (83.9%); 17 women had mild complications and 4.7% (7 women) had serious complications, in which 3 cases of re-surgery for hemostasis suture, 3 cases of uterine hemostasis balloon and 1 placenta accreta woman with very servere bleeding before surgery, surgery resulting injured bladder, a total of 2000ml of blood transfusion and blood products. After surgery, blood clotting disorder, the recovery time was 10.5 hours. 14 women with complications of varying degrees had resuscitation time of more than 6 hours. The results of general resuscitation included 82 women with well resuscitation (resuscitation time ≤ 3 hours and no complications) reaching 55%; 67 women had not good resuscitation (resuscitation time was over 3 hours with or without complications), accounting for 45% Journal of Nursing Science - Vol. 04 - No. 01 81
7. RESEARCH ARTICLE Table 8. Factors related to the resuscitation results Good Not good Factors OR, 95%CI p resuscitation resuscitation History of Not yet 44 13 4,8 cesarean <0,01 (2,28-10,12) section Had 38 54 No 70 44 3,05 Comorbidities <0,01 (1,38-6,74) Had 12 23 Planned 38 20 2,02 Surgical type <0,05 (0,97-4,25) Emergency 44 47 No placenta 70 27 accreta 8,6 Placenta previa <0,01 With placenta (3,72 – 20,63) 12 40 accreta <500ml 68 16 The amount of 15,4 <0,01 blood lost (6,43-37,51) ≥ 500ml 14 51 The results showed that the good resuscitation results were more common in women who had not had cesarean section before; no comorbidities; planned surgery; placenta previa without placenta accreta and low and average blood loss before and during surgery (less than 500ml). 4. DISCUSSION 4.1. General characteristics and that the participants were at high risk in the pregnant history of women who had a age group over 35. Especially in the study cesarean section due to placenta previa. there was a 19-year-old woman who was in very young age, which was not found in The study results showed that the literature. Therefore, the results showed average age of the participants was 32.5 ± that the placenta previa was always a 4.9 years, of which mainly the age group serious situation, the intervention should from 22 to 35 years old, accounting for considerate to preserve the uterus for very 71.1%. This study result was similar to that young women. of Pham Van Do (2018) while the pregnant woman’s age was about 20-45 years old The research results indicated that 11.4% [2]. Nguyen Trung Kien (2019) showed of women were thin; 12.1% of women were that the proportion of women over 35 years overweight and 23.5% had other medical old participating in the study accounted problems before getting pregnant. Most of for 30.9% [5], it was similar to the study of the other studies [3], [4], [5] did not mention 28.2%. The previous study results indicated these two characteristics of pregnant 82 Journal of Nursing Science - Vol. 04 - No. 01
8. RESEARCH ARTICLE women, however, the research conducted dangerous for the fetus and women. to find out more of these 2 information. The The rate of women with anemia before further studies should conduct to examine giving birth in the study was lower than that the effects of body status and comorbidities of the Le Thi Giang with anemia up to 60.5% to the postoperative recovery. [3]. From this result, it showed that anemia The research results indicated that the status of pregnant women was a problem of majority of study participants had ever been concern because it may affect the outcome pregnant, from the 3rd time up, accounting of the intervention and the resuscitation for the highest percentage of 40.9%; 2 status after the surgery. times (26.8%) and one pregnancy (18.8%). The research results were different from Results of placenta previa ultrasound of those recorded in the study of Le Thi Giang the particiants showed that the majority of (2015) with the highest percentage of women had the complete placenta previa participants who had ever been pregnant (85.2%). This result was consistent with once (67.4%) [3]. The group of participants research results of some authors Pham who had never had a cesarean section Van Do (59.1%) and Pham Thi Linh (98%) before accounted for the highest proportion [2], [6]. (38.3%), and ranked second was the group Regarding the handling of the placenta who had a cesarean section twice (32.9%). previa cases, the results showed that Particiapnts with 3 times of cesarean section 94 women underwent cesarean section 3 times or more accounted for a low rate and uterine preservation, accounting (4%). Regarding the group of particiapnts for 63.1% and 55 women with cesarean who had never had a cesarean section, section and hysterectomy, accounting the research results were higher than the for 36.9%. Among the women who had a research results of Nguyen Lien Phuong hysterectomy, one woman had to have a (8.3%) [7]. complete hysterectomy due to excessive 4.2. Clinical and subclinical bleeding, severe blood loss (this woman characteristics of women with cesarean had to transfuse 13 units of blood). She was section due to placenta previa tvery short gestational age of 17th week. According to the research results, the rate About blood loss, 43.6% of pregnant of women with vaginal bleeding accounts for women had very servere bleeding (over 49%. The research results were consistent 500ml). With such blood loss, 75 women had with research results of Le Thi Giang (55.2) to transfuse blood and the average amount [3]. The results were lower than that of of transfusion was 3.11 ± 2.6 units of blood. Nguyen Trung Kien (67.9%) [5]. Most of Especially, there were women who had to the participants at the National Hospital for transfuse up to 13 units of blood, which Obstetrics and Gynecology were appointed was the case of emergency surgery due to by doctors to stay in the hospital at full placenta previa with placenta accreta. In the term, to take care of the overall health of 3-unit blood transfusion surgery, 15 hours the woman and fetus according to medical after surgery, the patient had to re-operate orders to detect and report to the doctor for due to monitoring bleeding in the abdomen, early and timely intervention while there were continued extremly blood loss and signs of bleeding and labor to avoid vaginal continued infusion of 10 units. Our results bleeding, servere bleeding, which would be were similar to those published by Le Hoai Journal of Nursing Science - Vol. 04 - No. 01 83
9. RESEARCH ARTICLE Chuong showed that out of a total of 500 a relationship between previous cesarean cases of placenta previa, hysterectomy was section, placenta characteristics, level of 42 cases, accounting for 8.4%. According blood loss and resuscitation time after to Hoang Van Yen (2010), research on the cesarean section. The higher number of management of bleeding during and after previous cesarean sections made the longer cesarean section at the National Hospital for the resuscitation time after caesarean Obstetrics and Gynecology in 2008-2009, section. uterine artery constriction was selected in 86.9% of cases [8]. The following-up and detecting the heavy status after cesarean sections Regarding the results of regressive due to placenta previa is the task of care and related factors: In the study, we the resuscitation therapist to track vital analyzed and showed that women who signs, monitor bleeding in the wound, had had a caesarean section; women bleeding in abdomen, signs of uterine with comorbidities; women who have both contraction, monitoring postpartum fluid, a striker and a toothpaste and those who monitoring transmission. Therefore, in the have surgery in an emergency situation; recsuscitation care, nurses should plan fully women who lost a lot of blood before, and properly intervention for the risk women during surgery had worse recovery with previous cesarean sections, placenta results than women with advantages: no previa, placenta accreta blood lost before history of cesarean section, no associated and during surgery and comorbidities. disease, planned surgery and little blood loss. or medium. Our research results are 5. CONCLUSION AND RECOMMENDATION consistent with research results of some Conclusion: other authors [9], [10]. These authors indicated that there was an association Characteristics of research participants between cesarean section history, forward results indicated that the women were placenta characteristics, degree of blood average age 32.5 ± 4.9 years; 40.9% of loss, and time of resuscitation after pregnant women had pregnant ≥ 3 times; cesarean section. The more women who 61.7% of women had ever had a C-section; have had a caesarean section before, the while admitted to hospital, 49% of pregnant longer the time had consciousness and women had vaginal bleeding; 57% of recovered from a cesarean section due to women had uterine contractions and 89.9% the placenta. had an open cervix; 85.2% of women had complete placenta previa (85.2%) and The resuscitation results and related 34.9% of women had placenta accreta; factors indicated that the women with 36.9% of women had a hysterectomy and cesarean section, comorbidities, placenta 50.3% had a blood transfusion, the average previa with placenta accreta and emergency amount of transfusion was 3.11 ± 2.6 units surgery; blood lost before and during of blood. surgery had worse resuscitation results than the women without previous cesarean Most women had better progress after section, comorbidities, placenta previa with surgery in terms of mental health, breathing, placenta accreta and emergency surgery. circulation, pain sensation status. The results Results of the research were consistent of good resuscitation care accounted for with the results of some other authors [9], 55%. The rate of good resuscitation results [10]. This author pointed out that there was was higher among women who had not 84 Journal of Nursing Science - Vol. 04 - No. 01
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