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The objective of the study is to demonstrate whether cooling the uterine smooth muscle during cesarean section (following delivery of the fetus) will promote better uterine contraction and involution resulting in lower blood loss, use of fewer uterotonic medications, and fewer hysterectomies following cesarean section. The investigators suspect that it may.
Study Design:
Patients will be randomly assigned to either the study group or the control group. Patients may receive regional (epidural or spinal/epidural) or general anesthesia.Initially, the investigators plan to enroll 200 subjects, 100 to the study group and 100 to the control group.
Following delivery of the fetus, patients in the study group also will have Pitocin® administered to them according to the usual protocol.Immediately following delivery of the fetus the uterus will be externalized in the usual fashion and the body of the uterus cephalad to the hysterotomy incision will be wrapped in sterile surgical towels saturated in sterile, iced normal saline. These towels will come from a sterile cooling pot set to 30 degrees Fahrenheit. The skin of the abdomen will be draped to prevent contact with the cold towels. Additional uterotonic medications may be given at the discretion of the attending obstetrician.
Iced saline-soaked towels will be kept in place for a minimum of 5 minutes and replaced at the discretion of the attending obstetrician until the hysterotomy is closed and the uterus is replaced into the patient's abdomen. The surface temperature of the uterus will be measured using an infrared thermometer prior to replacing the uterus into the abdomen.
Two surgical suction canisters will be available. Immediately after delivery of the fetus and prior to delivery of the placenta, the amniotic fluid and blood on the surgical field will be aspirated into the first canister. The second suction canister will be used to aspirate blood and fluid until the conclusion of the operation.
At the conclusion of the surgery blood loss will be calculated by measuring the content of blood in the second canister minus the amount of irrigation fluid used, and by weighing the surgical sponges. Average blood loss during cesarean sections has previously been reported as 500 to 1000 cc.
The duration of cooling the uterus will be recorded.
Use and amount of uterotonic medications also will be recorded.
During the surgery the patient's vital signs will be monitored in the usual fashion. Particular attention will be paid to a change in her temperature. Warmed blankets and forced air warming blankets will be used to maintain normothermia, if required.
At the conclusion of the study the amount of blood loss between the control and study groups, and the amount of uterotonic drugs will be calculated and compared. The number of patients in each group who require additional surgeries, e.g. hysterectomy or D&C, will be monitored. Pre-op and post-op hemograms will be compared if obtained at the discretion of the attending obstetrician. Blood product administration will be recorded.
Determination of an ideal temperature of cooling towels is not an objective of the study. We're asking a qualitative question, not a quantitative question at this time.
Study Rationale: The uterus is a smooth muscle whose contraction is modulated most directly by intrinsic or extrinsic oxytocin. During pregnancy the spiral arteries within the uterus and beneath the placenta enlarge to provide adequate perfusion to the placenta. After separation of the placenta the uterine smooth muscle cells contract in a pincer-like action to pinch the spiral arteries closed. When uterine contraction is inadequate (approximately 4-6% of normal pregnancies) the spiral arteries continue to bleed. If not addressed the bleeding can be excessive, even leading to maternal death. Approximately 5-8 out of 1,000 cesarean sections require hysterectomy to control bleeding.
Release of calcium ions from sarcoplasmic reticulum stores is the immediate initiator of contraction, and calcium's diffusion from the muscle filaments and re-uptake by the sarcoplasmic reticulum results in relaxation of contraction. In some smooth muscles cold enhances contraction; perhaps by slowing the re-uptake of calcium. When the usual pharmacologic agents fail to induce adequate contraction of the uterine smooth muscle, the investigators suspect that application of cold may.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control | No Intervention | Normal cesarean technique. | |
| Uterine Cooling | Experimental | Immediately following delivery of the fetus the uterus will be externalized in the usual fashion and the body of the uterus cephalad to the hysterotomy incision will be wrapped in sterile surgical towels saturated in sterile, iced normal saline. These towels will come from a sterile cooling pot set to 30 degrees Fahrenheit. Iced saline-soaked towels will be kept in place for a minimum of 5 minutes and replaced at the discretion of the attending obstetrician until the hysterotomy is closed and the uterus is replaced into the patient's abdomen. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Uterine Cooling | Procedure | Immediately following delivery of the fetus the uterus will be externalized in the usual fashion and the body of the uterus cephalad to the hysterotomy incision will be wrapped in sterile surgical towels saturated in sterile, iced normal saline. These towels will come from a sterile cooling pot set to 30 degrees Fahrenheit. Iced saline-soaked towels will be kept in place for a minimum of 5 minutes and replaced at the discretion of the attending obstetrician until the hysterotomy is closed and the uterus is replaced into the patient's abdomen. |
| Measure | Description | Time Frame |
|---|---|---|
| Blood Loss | At the conclusion of the surgery, blood loss will be calculated by measuring the content of blood in the suction canister, and by weighing the surgical sponges. The amount of blood loss in the PACU will be measured by weighing pads. | During surgery and in the PACU (approximately 3 total hours) |
| Measure | Description | Time Frame |
|---|---|---|
| Change in Pre- vs Post-operative Hematocrit | 48 hours post operative period | |
| Use of Uterotonic Medications | During surgery and in the PACU (approximately 3 total hours) | |
| Measure | Description | Time Frame |
|---|---|---|
| Patient Temperature | Pre-op, Intra-op, Post-Op | |
| Total Time Uterus Wrapped | During hysterotomy repair | |
| Uterine Temperature After Wrap Removed |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Janice L Mitchell, MD | Baylor University Medical Center Resident | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Baylor University Medical Center | Dallas | Texas | 75246 | United States |
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| ID | Title | Description |
|---|---|---|
| FG000 | Control | Normal cesarean technique. |
| FG001 | Uterine Cooling | Immediately following delivery of the fetus the uterus will be externalized in the usual fashion and the body of the uterus cephalad to the hysterotomy incision will be wrapped in sterile surgical towels saturated in sterile, iced normal saline. These towels will come from a sterile cooling pot set to 30 degrees Fahrenheit. Iced saline-soaked towels will be kept in place for a minimum of 5 minutes and replaced at the discretion of the attending obstetrician until the hysterotomy is closed and the uterus is replaced into the patient's abdomen. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Control | Normal cesarean technique. |
| BG001 | Uterine Cooling | Immediately following delivery of the fetus the uterus will be externalized in the usual fashion and the body of the uterus will be wrapped in sterile surgical towels saturated in sterile, iced normal saline. These towels will come from a sterile cooling pot set to 30 degrees Fahrenheit. Iced saline-soaked towels will be kept in place for a minimum of 5 minutes and replaced at the discretion of the attending obstetrician until the hysterotomy is closed and the uterus is replaced into the patient's abdomen. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Blood Loss | At the conclusion of the surgery, blood loss will be calculated by measuring the content of blood in the suction canister, and by weighing the surgical sponges. The amount of blood loss in the PACU will be measured by weighing pads. | Posted | Mean | Standard Deviation | cc | During surgery and in the PACU (approximately 3 total hours) |
|
Approximately 4 days
All patients received routine post-operative and postpartum care. Their vitals were monitored for evidence of hypothermia or infection, and they received both routine post-operative day 1 labs, including a CBC, as well as follow labs as indicated. They were monitored for evidence of delayed postpartum hemorrhage.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Control | Normal cesarean technique. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Janice Mitchell, PI | Baylor University Medical Center | 713-705-6240 | janicemitchellmd@gmail.com |
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| ID | Term |
|---|---|
| D006473 | Postpartum Hemorrhage |
| D014593 | Uterine Inertia |
| D006470 | Hemorrhage |
| ID | Term |
|---|---|
| D007744 | Obstetric Labor Complications |
| D011248 | Pregnancy Complications |
| D005261 | Female Urogenital Diseases and Pregnancy Complications |
| D000091642 | Urogenital Diseases |
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|
|
| Use of Extra Oxytocin |
| Intraoperatively |
| Use of Methergine | Intraoperatively |
| Use of Hemabate | Intraoperatively |
| Use of Cytotec | Intraoperatively |
| Bakri Bulb Placement | Intraoperatively |
| Use of Additional Measures to Control Blood Loss, Including Pharmacological and Surgical Interventions | Intraoperatively |
| Requirement of Blood Products | During surgery and in the PACU (approximately 3 total hours) |
| Total Blood Loss Greater Than 1000 cc | Intra-op, Post-Op |
| Requirement of Cesarean Hysterectomy | During surgery and in the PACU (approximately 3 total hours) |
| Immediately following hysterotomy repair |
| BG002 | Total | Total of all reporting groups |
| years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race (NIH/OMB) | Count of Participants | Participants |
|
| Height (ft) | Mean | Standard Deviation | feet |
|
| Weight (lbs) | Mean | Standard Deviation | pounds |
|
| Gravidity | Mean | Full Range | pregnancies |
|
| Parity | Mean | Full Range | births |
|
| Gestational Age (wks) | Mean | Standard Deviation | weeks |
|
| Fetal Presentation | Number | participants |
|
| Multiple Gestations | Number | participants |
|
| Fetal Weight (g) | Mean | Standard Deviation | grams |
|
| Previous Cesareans | Mean | Full Range | cesareans |
|
| Trial of Labor | Number | participants |
|
| Pre-op Epidural | Number | participants |
|
|
|
| Secondary | Change in Pre- vs Post-operative Hematocrit | Posted | Mean | Standard Deviation | percent | 48 hours post operative period |
|
|
|
| Secondary | Use of Uterotonic Medications | Posted | Number | participants | During surgery and in the PACU (approximately 3 total hours) |
|
|
|
| Secondary | Use of Extra Oxytocin | Posted | Number | participants | Intraoperatively |
|
|
|
| Other Pre-specified | Patient Temperature | Posted | Mean | Standard Deviation | degrees Fahrenheit | Pre-op, Intra-op, Post-Op |
|
|
|
| Other Pre-specified | Total Time Uterus Wrapped | Posted | Mean | Standard Deviation | minutes | During hysterotomy repair |
|
|
|
| Other Pre-specified | Uterine Temperature After Wrap Removed | Posted | Mean | Standard Deviation | degrees Fahrenheit | Immediately following hysterotomy repair |
|
|
|
| Secondary | Use of Methergine | Posted | Number | participants | Intraoperatively |
|
|
|
| Secondary | Use of Hemabate | Posted | Number | participants | Intraoperatively |
|
|
|
| Secondary | Use of Cytotec | Posted | Number | participants | Intraoperatively |
|
|
|
| Secondary | Bakri Bulb Placement | Posted | Number | participants | Intraoperatively |
|
|
|
| Secondary | Use of Additional Measures to Control Blood Loss, Including Pharmacological and Surgical Interventions | Posted | Number | participants | Intraoperatively |
|
|
|
| Secondary | Requirement of Blood Products | Posted | Number | participants | During surgery and in the PACU (approximately 3 total hours) |
|
|
|
| Secondary | Total Blood Loss Greater Than 1000 cc | Posted | Number | participants | Intra-op, Post-Op |
|
|
|
| Secondary | Requirement of Cesarean Hysterectomy | Posted | Number | participants | During surgery and in the PACU (approximately 3 total hours) |
|
|
|
| 0 |
| 100 |
| 0 |
| 100 |
| EG001 | Uterine Cooling | Immediately following delivery of the fetus the uterus will be externalized in the usual fashion and the body of the uterus cephalad to the hysterotomy incision will be wrapped in sterile surgical towels saturated in sterile, iced normal saline. These towels will come from a sterile cooling pot set to 30 degrees Fahrenheit. Iced saline-soaked towels will be kept in place for a minimum of 5 minutes and replaced at the discretion of the attending obstetrician until the hysterotomy is closed and the uterus is replaced into the patient's abdomen. | 0 | 100 | 0 | 100 |
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| D011644 | Puerperal Disorders |
| D014592 | Uterine Hemorrhage |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D004420 | Dystocia |
| Post-operative |
|