الفهرس 
CESAREAN SECTIONOnly 14 pages are availabe for public view
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Abstract
Cesarean delivery is defined as the birth of a fetus through incisions in the abdominal wall (Laparotomy) and the uterine wall (Hysterotomy). Its rate varies from one country to another; however there has been a rising rate of cesarean section over the last 25 years in most of the countries.
There are more than 1.2 million cesarean sections performed each year in the United States alone during which surgeons are in contact with patient’s blood and body fluids and working with needles and sharp instruments.
The most common exposure to patient’s blood is from needlestick injury (NSI). NSIs are wounds caused by needles that accidentally puncture the skin. NSIs depend on several factors, such as surgical specialty (greater risk in gynecologic, cardiothoracic, trauma, general and vascular surgical procedures), role of the individual (surgeon and first assistant at greater risk), duration of the operation, number of needles used, and surgeon experience.
The Occupation Safety and Health Administration estimates that 800,000 NSIs occur annually among health care workers in the United Stated conferring increased risk of infection from more than 20 agents.
The most significant infectious agents are hepatitis B, hepatitis C and human immunodeficiency virus with approximate transmission rates of 30%, 3% and 0.3% respectively after percutaneous exposure from an infected source patient.
NSIs have transmitted many other diseases involving viruses, bacteria, fungi, and other microorganisms to health care workers, laboratory researchers, and veterinarian staff. The diseases include: Blastomycosis, Brucellosis Cryptococcosis, Diphtheria, Cutaneous gonorrhea, Herpes, Malaria, Mycobacteriosis, Mycoplasma caviae, Rocky Mountain spotted fever, Sporotrichosis, Staphylococcus aureus, Streptococcus pyogenes, Syphilis, Toxoplasmosis and Tuberculosis. Many of these diseases were transmitted in rare, isolated events. They still demonstrate, however, that NSIs can have serious consequences.
Although the risk of infections by blood-borne agents from single NSIs is low, but the cumulative occupational risk for surgeons should be estimated considering also the prevalence of infected patients in the area, the incidence of intraoperative contamination, and the total number of operations performed during the career. The Centers for Disease Control has recommended that all blood should be considered potentially infected and “universal precautions” should be always observed in the operating room to decrease the risk of contamination.
Percutaneous skin injury not only affects surgical staff but also present a risk to patients from potential exposure to injured staff’s blood.
Strategies to reduce the rate of NSIs include using instruments rather than fingers to retract tissue and grasp needles, double gloving, using surgical staplers for skin closure, and substituting blunt tip surgical needles for sharp tip needles.
Surgical needles consist of three structural parts: the swage or eye, the body and point types depending upon their surgical use. Three types of eye are in common surgical use: swaged, controlled release and open. Body may be round, triangular or ovoid. Needles are most commonly classified according to the cross section of their point. Needle points may be either tapered, cutting, reverse cutting or blunt. Blunt suture needle is one of the methods to reduce the incidence of sharp injuries in obstetric and gynecologic surgery.
The present study aims to compare blunt suture needle and sharp suture needle in repair layers of cesarean section regarding rate of glove perforation and to survey physician satisfaction with blunt needles during the procedure.
This prospective randomized controlled study was conducted at Ain Shams University maternity hospital from April 2010 to August 2010, approved by hospital committee on human investigation. One hundred Patients requiring elective cesarean deliveries were eligible for the study. Patients were assigned randomly to groups using a computerized random sequence generator. Group A: included 50 patients that were randomly assigned to repair all anatomical layers of cesarean section by blunt needles (study group).Group B: included 50 patients that were randomly assigned to repair all anatomical layers of cesarean section by Sharp needles (control group).
Every woman was subjected to: A- Verbal consent. B- Patient demographics collected including age, height, weight, parity and hepatitis status from the history.
C- General and Local examination D- Information about the surgery collected including total surgery time, experience level of surgeon, type of anesthesia and neonatal weight.
E- Repair layers of cesarean section using either blunt suture needle or sharp suture needle. F- Assessment of: 1- NSIs and glove perforations detected by surgical teams in the operation. 2-Rate of glove perforations as assessed by testing glove perforation. 3- Survey physician satisfaction with blunt needles during the procedure. 4- Incidence of hepatitis diseases among women of the study and risk of exposure among surgical team to hepatitis.
The surgical technique used by obstetricians was lower-segment transverse incision, including pfannenstiel incision and double layer closure of the uterus. Obstetricians performed tubal ligation in one case in group of sharp needle.
Regarding demographic data, obstetrics and clinical variables in our study, there was no significant difference between sharp and blunt needle groups. Also regarding experience of surgeons and assistants, type of anesthesia and adhesions in our study, there was no significant difference between the two groups.
There was significant difference between sharp and blunt suture needles regarding NSIs detected by surgical team. NSIs recorded among surgical team in 6 operations (12%) with the use of sharp suture needles. In the use of blunt suture needles no NSIs detected among surgical team.
The present study results illustrated a significant difference between sharp and blunt suture needles regarding rate of glove perforation (P < 0.05). In the group of sharp needle rate of glove perforation was 30.9% and in blunt needle group was 17.3%. As shown, there is decrease in the rate of glove perforation with the use of blunt suture needles than that with sharp suture needles and this reduction of the incidence of glove perforation among all surgical team (P < 0.05). So blunt needle may be an important adjunctive measure in reducing the risk of transmission of viral infections in surgery.
In the present study, there was no statistical significant difference between blunt and sharp suture needles regarding the total operative time. But regarding duration of repair layers of caesarean section blunt needle group showed significantly longer time of closure compared to sharp needle group.
The present study found that 5% of patients in the study groups have hepatitis disease with no past history or family history of hepatic diseases or previous blood transfusion and it’s discovered accidentally by the screening test. The study also found that total risk of exposure of surgical team was 9.3% and the surgeons and first assistant are at highest risk followed by nurses.
This study demonstrates that Surgeons are at highest risk for glove perforations in the operation room followed by first assistants and nurses. The further away from the wound a person was, the less risk for contamination there was.
The results illustrated that surgery with glove perforation had significantly longer operating times than that without glove perforation. This means that, the longer the time of cesarean section, the more rate of glove perforation.
The present study found that the adhesion significantly affected the rate of glove perforation; cases with no adhesion which mainly in primary cesarean section, perforation occurred only in 50% of operation and increase in cases with adhesion to 82% of operation.
The present study found that the experience of surgeon or assistants not significantly affected the rate of glove perforation. Although the surgeries performed by resident surgeon was the more liable to glove perforation. As residents tend to perforate their own hand; they may also tend to perforate any other hand in the operative field. Thus, use of blunt needle for suturing, instruments for assistance and instruction may distance these hand from perforation.
The second out come of this study was to assess surgeons’ acceptance of blunt needles as a possible protective mechanism against NSIs. Although 70% of physicians reported that blunt needles may require more pressure to penetrate tissues and 44% reported that blunt needles increase time of operation but 86% of surgeons accepted to use blunt needle again.
Safety devices must be acceptable to the HCWs who use them. In this study, blunt needles were acceptable to surgeons as replacement for some or all conventional curved needles in a variety of procedures. Although specific uses and limitations of blunt needles require further delineation, the findings of this study support the use of blunt needles as an effective component of a PI-prevention program in obstetrics and gynecologic surgery and possibly for other surgical specialties.
We recommend that obstetricians and gynecologists should try blunt tip suture needles in repair all layers of cesarean delivery as it decreases percent of needlestick injury and so decreases parentral infection either from patient to doctor or the reverse.