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Is There a Place for Family-centered Cesarean Delivery during Placenta Accreta Spectrum Treatment?

Existe um lugar para cesariana centrada na família durante o tratamento do espectro da placenta acreta?

ABSTRACT

Objective

Placenta accreta spectrum (PAS) is a cause of massive obstetric hemorrhage and maternal mortality. The application of family-centered delivery techniques (FCDTs) during surgery to treat this disease is infrequent. We evaluate the implementation of FCDTs during PAS surgeries.

Methods

This was a prospective, descriptive study that included PAS patients undergoing surgical management over a 12-month period. The patients were divided according to whether FCDTs were applied (group 1) or not (group 2), and the clinical outcomes were measured. In addition, hospital anesthesiologists were surveyed to evaluate their opinions regarding the implementation of FCDTs during the surgical management of PAS.

Results

Thirteen patients with PAS were included. The implementation of FCDTs during birth was possible in 53.8% of the patients. The presence of a companion during surgery and skin-to-skin contact did not hinder interdisciplinary management in any case.

Conclusion

Implementation of FCDTs during PAS care is possible in selected patients at centers with experience in managing this disease.

Keywords
placenta accreta; humanization; birthing centers; patient-centered care

Resumo

Objetivo

O espectro da placenta acreta (do inglês placenta accreta spectrum - PAS) é causa de hemorragia obstétrica maciça e mortalidade materna. A aplicação de técnicas de parto centrado na família (do inglês family-centered delivery techniques - FCDTs) durante a cirurgia para tratar esta doença é pouco frequente. Avaliamos a implementação das FCDTs durante as cirurgias do PAS.

Métodos

Estudo prospectivo e descritivo que incluiu pacientes com PAS submetidos a tratamento cirúrgico durante um período de 12 meses. Os pacientes foram divididos de acordo com a aplicação de FCDTs (grupo 1) ou não (grupo 2), e os resultados clínicos foram medidos. Além disso, anestesiologistas hospitalares foram entrevistados para avaliar suas opiniões sobre a implementação das FCDTs durante o manejo cirúrgico do PAS.

Resultados

Foram incluídos 13 pacientes com PAS. A implementação de FCDTs durante o parto foi possível em 53,8% das pacientes. A presença do acompanhante durante a cirurgia e o contato pele a pele não prejudicou o manejo interdisciplinar em nenhum caso.

Conclusão

A implementação de FCDTs durante o atendimento do PAS é possível em pacientes selecionados em centros com experiência no manejo dessa doença.

Palavras-chave
placenta acreta; humanização; centros de parto; cuidado centrado no paciente

Introduction

Placenta accreta spectrum (PAS) is a cause of maternal morbidity.11 Hasegawa J, Tanaka H, Katsuragi S, Sekizawa A, Ishiwata I, Ikeda TMaternal Death Exploratory Committee in Japan and the Japan Association of Obstetricians and Gynecologists. Maternal deaths in Japan due to abnormally invasive placenta. Int J Gynaecol Obstet. 2018;140(03):375–376. Doi: 10.1002/ijgo.12368
https://doi.org/10.1002/ijgo.12368...
Its management may require highly complex interventions, including prolonged surgeries with extensive dissection and massive transfusions.22 Stafford I, Belfort M. Placenta accreta, increta, and percreta: lifesaving strategies to stop the bleeding. Contemp Ob Gyn. 2008;53(05):48–53 Those conditions make general anesthesia the most widely used anesthetic method for PAS surgery, especially in low- and middle-income countries.33 Muñoz LA, Mendoza GJ, Gomez M, Reyes LE, Arevalo JJ. Anesthetic management of placenta accreta in a low-resource setting: a case series. Int J Obstet Anesth. 2015;24(04):329–334. Doi: 10.1016/j.ijoa.2015.05.005
https://doi.org/10.1016/j.ijoa.2015.05.0...
,44 Urfalıoglu A, Öksüz G, Bilal B, et al. Retrospective evaluation of anesthetic management in cesarean sections of pregnant women with placental anomaly. Anesthesiol Res Pract. 2020;2020:1358258. Doi: 10.1155/2020/1358258
https://doi.org/10.1155/2020/1358258...
Although the benefits of family-centered delivery techniques (FCDTs), such as having a companion during the surgical procedure or allowing skin-to-skin contact between neonates and the mother, have been demonstrated when part of a routine cesarean section,55 Dominguez-Bello MG, Costello EK, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A. 2010;107(26):11971–11975. Doi: 10.1073/pnas.1002601107
https://doi.org/10.1073/pnas.1002601107...

6 Hung KJ, Berg O. Early skin-to-skin after cesarean to improve breastfeeding. MCN Am J Matern Child Nurs. 2011;36(05):318-–324, quiz 325–326. Doi: 10.1097/NMC.0b013e3182266314
https://doi.org/10.1097/NMC.0b013e318226...

7 Guala A, Boscardini L, Visentin R, et al. Skin-to-skin contact in cesarean birth and duration of breastfeeding: a cohort study. Scientific World Journal. 2017;2017:1940756. Doi: 10.1155/2017/1940756
https://doi.org/10.1155/2017/1940756...
-88 Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11(11):CD003519. Doi: 10.1002/14651858.CD003519.pub4
https://doi.org/10.1002/14651858.CD00351...
their use in PAS surgery is infrequent.

In patients affected by PAS, being aware of the possibility of suffering from serious complications (even death) and being subjected to highly complex interventions have been found to be related to posttraumatic stress disorder99 Tol ID, Yousif M, Collins SL. Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP). Placenta. 2019;81:42–45. Doi: 10.1016/j.placenta.2019.04.004
https://doi.org/10.1016/j.placenta.2019....
and to the request for psychological support.1010 Welz J, Keyver-Paik MD, Gembruch U, Merz WM. Self-reported physical, mental, and reproductive sequelae after treatment of abnormally invasive placenta: a single-center observational study. Arch Gynecol Obstet. 2019;300(01):95–101. Doi: 10.1007/s00404-019-05175-z
https://doi.org/10.1007/s00404-019-05175...

We evaluate the implementation of FCDTs during PAS surgeries, as well as the opinions of a group of anesthesiologists about this activity.

Methods

A prospective descriptive study was conducted between August 2018 and March 2020. We included all patients undergoing PAS surgical management on a scheduled basis, after a prenatal diagnosis was established and interdisciplinary surgery planning at the Fundación Valle de Lili (FVL), Cali, Colombia. Cases with an intraoperative diagnosis of PAS were excluded.

Details of the anesthetic and surgical protocols are described elsewhere.1111 López-Erazo LJ, Sánchez B, Blanco LF, Nieto-Calvache AJ. Placenta accreta spectrum anaesthetic management with neuraxial technique can be facilitated by multidisciplinary groups. Indian J Anaesth. 2021;65(02):153–156. Doi: 10.4103/ija.IJA_1216_20
https://doi.org/10.4103/ija.IJA_1216_20...
,1212 Nieto-Calvache AJ, Vergara-Galliadi LM, Rodríguez F, et al. A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum. J Trauma Acute Care Surg. 2021;90(05):807–816. Doi: 10.1097/TA.0000000000003090
https://doi.org/10.1097/TA.0000000000003...
Details about the FCDTs applied (having a companion during the surgery and skin-to-skin contact between the newborn and the mother) are described in Chart 1.

Chart 1
Details of the presence of a companion in the operating room and skin-to-skin contact

In July 2019, a survey was conducted among all FVL anesthesiologists seeking their opinion about the application of FCDTs during the surgical management of PAS.

We divided the patients into those who had skin-to-skin contact with their neonates and/or the presence of a relative during the surgery (group 1) and those who did not (group 2). The clinical results were compared between the two groups, as were the mother-neonate interaction and the anesthesiologist's perception of the impact of FCDTs on the anesthetic procedure.

Continuous variables were expressed as central tendency measurements (median) and dispersion measurements (interquartile range [IQR]) based on normal distribution criteria. Categorical variables were expressed as absolute and relative frequencies.

The ethics committee of FVL approved the study protocol (protocol no. 1023), and informed consents were obtained from all the study participants.

Results

During the study period, 16 patients with suspected PAS were treated. Three of them had an intraoperative diagnosis and were excluded, and the remaining 13 patients were included in the analysis. In 7 patients (53.8%), FCDTs were applied (group 1), while the remaining 6 patients underwent the surgery unaccompanied, and skin-to-skin contact was not allowed (group 2). Table 1 presents the opinions of the 28 FVL anesthesiologists about the application of FCDTs during the care of PAS patients

Table 1
Opinions of anesthesiologists on FCDT during the care of patients with PAS (n = 28)

Table 2 shows the clinical outcomes of groups 1 and 2.

Table 2
Clinical characteristics of the patients, according to the strategy used for emotional support to the patient during birth

Table 3 shows the differences in the interaction between mother and neonate between groups 1 and 2.

Table 3
Results observed with the strategy used for emotional support of the patient during birth

Discussion

The presence of a companion during surgery and skin-to-skin contact did not hinder anesthetic management in any case (Table 3). Similar to observations in other high-risk obstetric populations,1313 Behruzi R, Hatem M, Goulet L, Fraser W, Leduc N, Misago C. Humanized birth in high risk pregnancy: barriers and facilitating factors. Med Health Care Philos. 2010;13(01):49–58. Doi: 10.1007/s11019-009-9220-0
https://doi.org/10.1007/s11019-009-9220-...
the implementation of FCDTs has difficult challenges to overcome, such as the burden of responsibility for the health of the mother and fetus, the added challenges posed by the presence of a companion, and the fear of legal conflicts about complications during surgery (Table 1).

Although almost all of the anesthesiologists surveyed (n = 26, 92.8%) stated that they were familiar with FCDTs and applied them during elective cesarean sections (Table 1), only 25% and 35.7% of them reported that they would allow the presence of a companion and skin-to-skin contact during PAS surgery, respectively (Table 1). Furthermore, during the period studied, only 7 of the 13 patients with PAS undergoing surgery benefited from skin-to-skin contact with their neonates. Among those patients, only 5 had a companion present during the surgical procedure.

In some PAS reference centers, the frequency of neuraxial anesthesia can be as high as 95%,1414 Markley JC, Farber MK, Perlman NC, Carusi DA. Neuraxial anesthesia during cesarean delivery for placenta previa with suspected morbidly adherent placenta: a retrospective analysis. Anesth Analg. 2018;127(04):930–938. Doi: 10.1213/ANE.0000000000003314
https://doi.org/10.1213/ANE.000000000000...
which allows the mother to be alert, as she anxiously awaits the resolution of a serious disease, and the birth of her child. Although greater maternal satisfaction with the experience of childbirth has been reported when a companion is allowed during the cesarean section,1515 Tessier España E, Camaño Gutiérrez I, García Burguillo A, et al. Cesárea humanizada. Prog Obstet Ginecol.. 2013;56(02):73–78 and although benefits are reported in terms of breastfeeding, neonatal temperature regulation, and neonatal cutaneous bacterial colonization when maternal-neonatal skin contact is made within the first hour of life,55 Dominguez-Bello MG, Costello EK, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A. 2010;107(26):11971–11975. Doi: 10.1073/pnas.1002601107
https://doi.org/10.1073/pnas.1002601107...
,88 Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11(11):CD003519. Doi: 10.1002/14651858.CD003519.pub4
https://doi.org/10.1002/14651858.CD00351...
these observations are often ignored during “complicated” cesarean sections.

The most common reason mentioned by the anesthesiologists surveyed for not allowing a companion in surgery was the high risk of complications in this type of surgery (n = 19, 67.8%). However, none of the 13 patients who were treated on a scheduled basis due to prenatal suspicion of PAS had sudden or uncontrollable massive bleeding.

The management of PAS in developing countries faces difficulties much higher in a priority list than the use of FCDT.1616 Nieto-Calvache AJ, López-Girón MC, Nieto-Calvache A, Messa-Bryon A, Benavides-Calvache JP, Burgos-Luna JM. A nationwide survey of centers with multidisciplinary teams for placenta accreta patient care in Colombia, observational study. J Matern Fetal Neonatal Med. 2022;35(12):2331–2337. Doi: 10.1080/14767058.2020.1786052
https://doi.org/10.1080/14767058.2020.17...
However, even in pregnancies with serious conditions, it is worth asking whether there is a place for FCDT, especially given that posttraumatic stress disorder is reported in 40% of patients with PAS,99 Tol ID, Yousif M, Collins SL. Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP). Placenta. 2019;81:42–45. Doi: 10.1016/j.placenta.2019.04.004
https://doi.org/10.1016/j.placenta.2019....
which highlights the importance to improve these women's birthing experience, and considering that the presence of a companion during surgery or skin-to-skin contact was not perceived by the anesthesiologist as hindering the normal performance of the activities necessary for PAS treatment among any patients in group 1.

Our study has limitations; we described a small number of cases from a single center, so that the external validity of our observations depends on the strategies used in other centers. Additionally, selection bias during candidates' selection for FCDTs cannot be ruled out. However, this study provides an initial observation of the viability of FCDTs during surgeries for selected cases of PAS. Finally, although we assume a benefit of applying FCDTs in terms of psychological impact during the surgical management of PAS, our study does not have the capacity to evaluate these types of implications. We only intend to draw attention to the issue, as multicenter studies are necessary to evaluate the receptivity of PAS teams to this type of intervention as well as the possible benefits for patients, their neonates, and their families.

Conclusion

Applying FCDTs during PAS care is possible in selected patients at centers with experience in managing this disease.

References

  • 1
    Hasegawa J, Tanaka H, Katsuragi S, Sekizawa A, Ishiwata I, Ikeda TMaternal Death Exploratory Committee in Japan and the Japan Association of Obstetricians and Gynecologists. Maternal deaths in Japan due to abnormally invasive placenta. Int J Gynaecol Obstet. 2018;140(03):375–376. Doi: 10.1002/ijgo.12368
    » https://doi.org/10.1002/ijgo.12368
  • 2
    Stafford I, Belfort M. Placenta accreta, increta, and percreta: lifesaving strategies to stop the bleeding. Contemp Ob Gyn. 2008;53(05):48–53
  • 3
    Muñoz LA, Mendoza GJ, Gomez M, Reyes LE, Arevalo JJ. Anesthetic management of placenta accreta in a low-resource setting: a case series. Int J Obstet Anesth. 2015;24(04):329–334. Doi: 10.1016/j.ijoa.2015.05.005
    » https://doi.org/10.1016/j.ijoa.2015.05.005
  • 4
    Urfalıoglu A, Öksüz G, Bilal B, et al. Retrospective evaluation of anesthetic management in cesarean sections of pregnant women with placental anomaly. Anesthesiol Res Pract. 2020;2020:1358258. Doi: 10.1155/2020/1358258
    » https://doi.org/10.1155/2020/1358258
  • 5
    Dominguez-Bello MG, Costello EK, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A. 2010;107(26):11971–11975. Doi: 10.1073/pnas.1002601107
    » https://doi.org/10.1073/pnas.1002601107
  • 6
    Hung KJ, Berg O. Early skin-to-skin after cesarean to improve breastfeeding. MCN Am J Matern Child Nurs. 2011;36(05):318-–324, quiz 325–326. Doi: 10.1097/NMC.0b013e3182266314
    » https://doi.org/10.1097/NMC.0b013e3182266314
  • 7
    Guala A, Boscardini L, Visentin R, et al. Skin-to-skin contact in cesarean birth and duration of breastfeeding: a cohort study. Scientific World Journal. 2017;2017:1940756. Doi: 10.1155/2017/1940756
    » https://doi.org/10.1155/2017/1940756
  • 8
    Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11(11):CD003519. Doi: 10.1002/14651858.CD003519.pub4
    » https://doi.org/10.1002/14651858.CD003519.pub4
  • 9
    Tol ID, Yousif M, Collins SL. Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP). Placenta. 2019;81:42–45. Doi: 10.1016/j.placenta.2019.04.004
    » https://doi.org/10.1016/j.placenta.2019.04.004
  • 10
    Welz J, Keyver-Paik MD, Gembruch U, Merz WM. Self-reported physical, mental, and reproductive sequelae after treatment of abnormally invasive placenta: a single-center observational study. Arch Gynecol Obstet. 2019;300(01):95–101. Doi: 10.1007/s00404-019-05175-z
    » https://doi.org/10.1007/s00404-019-05175-z
  • 11
    López-Erazo LJ, Sánchez B, Blanco LF, Nieto-Calvache AJ. Placenta accreta spectrum anaesthetic management with neuraxial technique can be facilitated by multidisciplinary groups. Indian J Anaesth. 2021;65(02):153–156. Doi: 10.4103/ija.IJA_1216_20
    » https://doi.org/10.4103/ija.IJA_1216_20
  • 12
    Nieto-Calvache AJ, Vergara-Galliadi LM, Rodríguez F, et al. A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum. J Trauma Acute Care Surg. 2021;90(05):807–816. Doi: 10.1097/TA.0000000000003090
    » https://doi.org/10.1097/TA.0000000000003090
  • 13
    Behruzi R, Hatem M, Goulet L, Fraser W, Leduc N, Misago C. Humanized birth in high risk pregnancy: barriers and facilitating factors. Med Health Care Philos. 2010;13(01):49–58. Doi: 10.1007/s11019-009-9220-0
    » https://doi.org/10.1007/s11019-009-9220-0
  • 14
    Markley JC, Farber MK, Perlman NC, Carusi DA. Neuraxial anesthesia during cesarean delivery for placenta previa with suspected morbidly adherent placenta: a retrospective analysis. Anesth Analg. 2018;127(04):930–938. Doi: 10.1213/ANE.0000000000003314
    » https://doi.org/10.1213/ANE.0000000000003314
  • 15
    Tessier España E, Camaño Gutiérrez I, García Burguillo A, et al. Cesárea humanizada. Prog Obstet Ginecol.. 2013;56(02):73–78
  • 16
    Nieto-Calvache AJ, López-Girón MC, Nieto-Calvache A, Messa-Bryon A, Benavides-Calvache JP, Burgos-Luna JM. A nationwide survey of centers with multidisciplinary teams for placenta accreta patient care in Colombia, observational study. J Matern Fetal Neonatal Med. 2022;35(12):2331–2337. Doi: 10.1080/14767058.2020.1786052
    » https://doi.org/10.1080/14767058.2020.1786052

Publication Dates

  • Publication in this collection
    23 Jan 2023
  • Date of issue
    2022

History

  • Received
    17 Jan 2022
  • Accepted
    28 Apr 2022
  • Published
    06 Sept 2022
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