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   Table of Contents - Current issue
Coverpage
July-December 2022
Volume 12 | Issue 2
Page Nos. 79-172

Online since Friday, September 2, 2022

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EDITORIALS  

Hysterotomy repair during cesarean delivery – In or out, does it really matter? p. 79
Adithya Bhat, Preet M Singh
DOI:10.4103/JOACC.JOACC_46_22  
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Patient safety in obstetric anesthesia p. 82
Vimi Rewari, Sana Y Hussain
DOI:10.4103/JOACC.JOACC_47_22  
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CONSENSUS STATEMENT Top

The association of obstetric anesthesiologists, India – An expert committee consensus statement and recommendations for the management of maternal cardiac arrest Highly accessed article p. 85
Sunil T Pandya, Kajal Jain, Anju Grewal, Ketan S Parikh, Karuna Sharma, Anjeleena K Gupta, Shilpa Kasodekar, Aruna Parameswari, Daisy Gogoi, Lalit K Raiger, Gonibeed Lakshminarayana Rao Ravindra, Sunanda Gupta, Anjan Trikha
DOI:10.4103/JOACC.JOACC_44_22  
Maternal cardiac arrest (MCA) requires a multidisciplinary team well versed in the cascade of steps involved during resuscitation. Historically, maternal outcomes were poor, primarily because cardiac arrest management in pregnant women was neither optimum nor standardized. However, current evidence has shown better maternal survival given the young age and reversible causes of death. There are specific interventions such as manual left uterine displacement (MLUD) for relief of aortocaval compression that, if not performed, may undermine the success of resuscitation. The team should simultaneously explore the etiology of MCA, which could be a combination of pregnancy-related causes and comorbid conditions. Resuscitative Hysterotomy or Resuscitative Uterine Interventions (RUI) should be considered if there is no return of spontaneous circulation following 4–5 min of cardiopulmonary resuscitation. Teamwork is critical to success in the high-stakes environment of MCA. This consensus statement was prepared by the experts after reviewing evidence-based literature on maternal resuscitation during MCA.
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REVIEW ARTICLES Top

Medication errors in a parturient: A huge cost to two lives p. 94
Manpreet Kaur, Bharat Yalla, Anjan Trikha
DOI:10.4103/JOACC.JOACC_17_22  
Medication errors in a parturient can be devastating as two lives are involved. Owing to the absence of critical incident reporting in parurients in multiple countries of the world, these errors are underreported. We herein discuss the common medication errors in a parturient, the published literature, and the management protocols practiced.
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Role of high flow nasal cannula (HFNC) for pre-oxygenation among pregnant patients: Current evidence and review of literature p. 99
Ajay Singh, Ankita Dhir, Kajal Jain, Anjan Trikha
DOI:10.4103/JOACC.JOACC_18_22  
With an increasing understanding of respiratory physiology and pathology, many new oxygen delivery devices have been introduced lately. Among them, high flow nasal cannula (HFNC) seems a promising modality that can deliver heated and humidified flows higher than the peak inspiratory flow at high FiO2 (fractional inspired oxygen), hence decreasing the work of breathing without causing discomfort to the patient. Applications of HFNC have escalated for use in multiple areas besides perioperative period over the last decade. The use of HFNC in obstetric population is particularly intriguing as this population is at risk of adverse airway related events. Hence, this narrative review focuses upon the role of HFNC for pre-oxyenation of pregnant patients in peripartum and in intensive care units. We have reviewed the current state of knowledge and the future prospects of HFNC use in obstetric setting.
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Rotational thromboelastometry reference range during pregnancy, labor and postpartum period: A systematic review with meta-analysis p. 105
Alexander M Ronenson, Efim M Shifman, Aleksandr V Kulikov, Yu S Raspopin, Klaus Görlinger, Alexander M Ioscovich, Galina P Tikhova
DOI:10.4103/JOACC.JOACC_21_22  
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have become increasingly popular for urgent assessment of the hemostasis system. Accordingly, TEG and ROTEM algorithms and their corresponding cut-off values are not interchangeable. ROTEM provides fast results (including validated early clot firmness parameters [A5 and A10]), that are easy to use, and the graphical display of the results is easy to interpret. ROTEM manufacturer, Tem Innovations GmbH (Munich, Germany), mentions in the user manual that the manufacturer has not set any strict reference values for INTEM, EXTEM, FIBTEM, APTEM, and NATEM in any patient population (including pregnant women) and that these values are highly variable in healthy subjects. To date, no systematic review assessing ROTEM parameters in pregnant, parturient, and postpartum women is available. With the increasing usage of ROTEM, we conducted this systematic review and meta-analysis to determine the reference values of ROTEM parameters in pregnant, parturient, and postpartum women compared with non-pregnant population.
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ORIGINAL ARTICLES Top

Randomized trial of bolus ephedrine or mephentermine for maintenance of arterial pressure and fetal outcome during spinal anesthesia for the cesarean section p. 116
Thomas S Linette, T Gurumurthy
DOI:10.4103/JOACC.JOACC_34_21  
Background and Aims: Spinal anesthesia remains the preferred choice for cesarean deliveries, but hypotension is one of the common complications which may have detrimental effects on both the mother and fetus. In this study, we compared the efficacy and adverse effects of bolus doses of ephedrine hydrochloride and mephentermine sulfate administered intravenously to treat spinal-induced hypotension and the fetal outcomes through Apgar scores and umbilical cord blood gas analysis in the lower segment cesarean section. Material and Methods: In this prospective, randomized, double-blind study, 60 patients undergoing the lower segment cesarean section (LSCS) under spinal anesthesia were randomized into two groups of 30 each using computer-generated random numbers which were kept in an opaque envelope. Patients were pre-loaded with Ringer's lactate solution 10 ml/kg before the spinal anesthesia. Hypotension was defined as the fall in systolic blood pressure of less than or equal to 20% of the baseline or systolic blood pressure of less than 90 mmHg. Whenever hypotension occurred, patients in group E (ephedrine) received a bolus dose of ephedrine 6 mg intravenous and patients in group M (mephentermine) received a bolus dose of mephentermine 6 mg intravenous. Intra-operative recording included maternal hemodynamic parameters and the number of bolus doses of study drugs required to treat maternal hypotension and the adverse effects of study drugs. The Apgar score and umbilical cord blood gas values were recorded. Data were analyzed by analysis of variance test, Student's t-test, and Chi-square test. A P value of < 0.05 was considered as significant. Results: There was a statistically significant (p < 0.05) increase in systolic and mean arterial blood pressure at the second min and fourth min after administration of ephedrine in group E compared to mephentermine in group M. The systolic blood pressure at the second min in the ephedrine group was 114.3 ± 12.06, whereas in the mephentermine group, it was 106.10 ± 8.41 and was statistically significant (p < 0.05). At the fourth min, the systolic blood pressure in the ephedrine group was 115.03 ± 8.87, whereas in the mephentermine group, it was 108.46 ± 8.10 and was statistically significant (p < 0.05). There was a transient increase in heart rate immediately after administration of spinal anesthesia. The mean number of bolus doses of vasopressor consumption was 2.4 (14.4 mg) in the ephedrine group and 2 (12 mg) in the mephentermine group. The umbilical cord blood gas analysis and Apgar scores were similar in both the groups. Three patients (10%) developed bradycardia in the mephentermine group compared to the ephedrine group (0%). The incidence of nausea (13.3% vs 3.3%) and vomiting (10% vs 1%) was higher in the ephedrine group compared to the mephentermne group, and it was not statistically significant (p > 0.05). No significant differences were observed in the umbilical arterial blood pH and Apgar scores. Conclusion: In conclusion, after hypotension, ephedrine and mephentermine administration as bolus doses are equally efficacious in preventing spinal-induced hypotension in patients undergoing the cesarean section and are associated with similar neonatal outcomes.
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Comparison of phenylephrine and norepinephrine for prevention of hypotension in patients undergoing cesarean section under spinal anesthesia – A randomized prospective study p. 122
Wakhloo Renu, Bhagat Heena, Gandotra Megha, Suri Era
DOI:10.4103/JOACC.JOACC_44_21  
Background: Hypotension is a common side effect of spinal anesthesia for cesarean section with incidence of upto 71%. Various vasopressors are available for counteracting spinal hypotension each with different pharmacological profile. Norepinephrine is currently one of the feasible options for prophylaxis of spinal induced hypotension in patients undergoing cesarean section. Aims: To compare efficacy of phenylephrine and norepinephrine for reducing incidence of hypotension in patients undergoing cesarean section under spinal anesthesia and their effect on neonatal outcome. The primary outcome compared was incidence of hypotension (defined as fall in systolic blood pressure of >20% from the baseline value or a value <90 mmHg). The secondary outcomes noted were incidence of bradycardia, nausea, vomiting in the mother, and neonatal outcome. Methodology: A total of 80 singleton full term pregnant patients of American Society of Anesthesiology (ASA) grade II scheduled for elective cesarean section were randomly assigned to 2 groups of 40 patients each. Group P received phenylephrine 50 mcg and Group N received norepinephrine 10 mcg as intravenous bolus over 1 min immediately after the patient had been made supine after giving spinal anesthesia. The vital parameters, adverse effects, and neonatal outcome were assessed and analyzed statistically. Results: Intraoperatively, norepinephrine group had a significantly higher mean heart rate than phenylephrine group. Neonatal outcome was similar in both the groups with respect to appearance, pulse, grimace, activity, and respiration (Apgar) scores and umbilical arterial pH. Conclusions: In cesarean section under spinal anesthesia, norepinephrine efficacy in rescuing maternal hypotension is similar to that of phenylephrine without obvious maternal or neonatal adverse outcomes and with a lower incidence of bradycardia.
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A comparison between intrathecal nalbuphine versus fentanyl as an adjuvant with 0.5% hyperbaric bupivacaine for postoperative analgesia in parturients undergoing lower segment cesarean section p. 127
Neena Jain, Surendra K Sethi, Amrit L Saini, Veena Patodi, Kavita Jain, Beena Thada
DOI:10.4103/JOACC.JOACC_67_21  
Background: Nalbuphine when used as an adjuvant to hyperbaric bupivacaine has improved the quality of perioperative analgesia. Fentanyl is a lipophilic opioid with a rapid onset and does not cause respiratory depression and improves duration of sensory anesthesia without producing significant side effects. The aim of this study was to compare intrathecal nalbuphine and fentanyl as adjuvants to hyperbaric bupivacaine for postoperative analgesia in lower segment cesarean section. Methods: A total of 100 American Society of Anesthesiologists (ASA) Physical Status (PS) I and II parturients were enrolled for lower segment cesarean section. Parturients were randomly allocated into 2 groups - Group F (n = 50) received bupivacaine 0.5% (heavy) 1.6 ml (8 mg) + fentanyl 20 μg (0.4 ml) and Group N (n = 50) received bupivacaine 0.5% (heavy) 1.6 ml (8 mg) + nalbuphine 0.4 mg (0.4 ml) under subarachnoid block (total volume = 2 ml). Time of onset and duration of sensory and motor block, Visual Analog Scale (VAS) score, duration of analgesia, sedation, rescue analgesic consumption, APGAR score, hemodynamic changes and adverse effects were noted. Results: Onset of sensory and motor block were significantly faster in Group F while duration of sensory block was significantly longer in Group N (P < 0.05). Duration of analgesia was also significantly longer in Group N (214.34 ± 9.31 min) compared to Group F (195.00 ± 9.18 min) (P < 0.001). No significant hemodynamic changes and adverse effects were noted in both groups (P > 0.05). Conclusion: Both of these drugs can be effectively used as an adjuvant to hyperbaric 0.5% bupivacaine in subarachnoid block for parturients undergoing lower segment cesarean section.
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Effect of abdominal girth, vertebral column length, and hip/shoulder width ratio on the spread of spinal anesthesia in term parturients undergoing elective cesarean section: A prospective observational non-randomized study p. 133
Anil K Bhiwal, Heena A Bhatt, Lalita Jeengar, Karuna Sharma, Aditi S Baghel, Sunanda Gupta
DOI:10.4103/JOACC.JOACC_68_21  
Background: Spinal anesthesia is the preferred technique for cesarean section, and a suitable level of spinal anesthesia is essential, which may be variable in every parturient. The aim of this study was to evaluate the correlation of abdominal circumference (AC), vertebral column length (VCL), hip shoulder width ratio (HSR), and vertebral column length (VCL)/Abdominal Circumference (AC)2 with the spread of spinal anesthesia in term parturient undergoing elective cesarean section. Methods: Two hundred term parturients undergoing elective cesarean section were enrolled in this prospective observational study. Spinal anesthesia was performed with 10 mg (2 ml) of 0.5% hyperbaric bupivacaine in L2-L3 or L3-L4 interspace using a 25 G Quincke needle. The cephalad spread (loss of pinprick discrimination) was assessed up to 30 minutes after intrathecal injection. Linear regression analysis was used to analyze the relationship between age, weight, height, body mass index (BMI), AC, VCL (C7-Sacral hiatus and C7-iliac crest), HSR, VCL/AC2, and the spread of spinal anesthesia. Results: The maximum sensory level showed a significant correlation with AC (P < 0.001), VCL [C7-SH and C7-IC] (P < 0.039 and P < 0.025) and VCL/AC2 (P < 0.001). Individually, hip width and shoulder width showed a significant correlation with cephalad spread of spinal anesthesia (P < 0.05); however, HSR had no significant correlation with the spread of anesthesia (P > 0.05). Conclusion: AC, VCL, and VCL/AC2 have a significant correlation with cephalad spread of spinal anesthesia when a fixed dose of hyperbaric bupivacaine is used in term parturients undergoing elective cesarean section, while HSR did not show any significant correlation.
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Spinal anaesthesia in kyphoscoliotic parturients undergoing caesarean delivery – A retrospective study from a tertiary care centre in India p. 140
Ranju Singh, Rashi Sardana, Pooja Singh
DOI:10.4103/JOACC.JOACC_78_21  
Introduction: Kyphoscoliosis with pregnancy is a rare but serious disorder which often requires caesarean delivery. Both general and regional anaesthesia have been used in these cases but data regarding outcomes with spinal anaesthesia (SA) are limited. Methods: We conducted a retrospective study to identify patients with kyphoscoliosis undergoing caesarean delivery at a tertiary care hospital in India. Those parturients who received SA were compared with those receiving general anaesthesia (GA group) with respect to cardiorespiratory parameters, maternal outcomes and neonatal outcomes. Results: The GA group had significantly worse cardiorespiratory parameters including pulmonary function tests, right atrial pressures and cardiac ejection fraction as compared to SA group. All the GA group patients required mechanical ventilation while no patients in the SA group needed mechanical ventilation. Intraoperative hypotension was more common in the SA group. Neonatal outcomes were worse in the GA group with lower Apgar scores at 1 and 5 min and more nursery admissions than the SA group. No maternal or neonatal deaths occurred in either group. Conclusion: Kyphoscoliotic parturients scheduled for CD can be successfully managed with SA with good maternal and neonatal outcomes. GA may be reserved for severe kyphoscoliotic parturients with cardiorespiratory complications. The safety of SA in severe kyphoscoliosis requires further studies.
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Retrospective analysis of the outcome of the anaesthetic procedures in COVID-19 parturient undergoing cesarean delivery in a tertiary care hospital in Delhi, India p. 144
Bharti Wadhwa, Prachi Gaba, Kapil Chaudhary, Kirti N Saxena, Kavita R Sharma, Mousumi Saha, Saurabh Gaur, Pallavi Doda
DOI:10.4103/JOACC.JOACC_93_21  
Context: The effect of coronavirus disease 2019 (COVID-19) on a parturient undergoing cesarean delivery (CD) is not fully understood. Aims: To evaluate anesthetic management of a COVID parturient undergoing CD. Settings and Design: Tertiary care hospital, retrospective analysis. Methodology: Hospital case record files of COVID-19 parturients who underwent CD were reviewed with respect to clinical presentation, anesthetic technique, peri-operative course, and maternal-fetal outcome. Data Analysis: Continuous variables are reported as mean ± SD or median (range) and categorical variables as numbers (percentages). Results: Hundred COVID-19 parturients underwent CD: Ninety-eight parturients had asymptomatic to mild clinical presentation, whereas two had a severe presentation. Raised liver enzymes, raised D-dimer, and thrombocytopenia were observed in 65, 34, and 11 parturients, respectively. Combined spinal-epidural anesthesia (CSEA), subarachnoid block (SAB), and general anesthesia were administered in 72, 26, and 2 parturients, respectively. Meantime to administration of SAB and CSEA were 23.5 ± 3.2 min and 28.4 ± 2.8 min, respectively. Adequate block height for CD was achieved in all parturients. Post-spinal hypotension that responded promptly to fluids and vasopressors was reported in six parturients. Postoperatively, two parturients required intensive care unit (ICU) care with one maternal mortality. None of the neonates tested positive for COVID-19. Three neonates had a low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) at 5 min with one neonatal mortality. Conclusions: Neuraxial anesthesia seems to be a safe and preferred anesthetic technique for CD in a COVID-19 parturient. The incidence of post-spinal hypotension is low and responds promptly to treatment. The course of neuraxial anesthesia and the neonatal outcome is unaffected by the COVID-19 status of the patient.
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Labor epidural analgesia: Comparison of intermittent boluses of ropivacaine with three different concentrations of fentanyl – A randomized controlled trial p. 150
Sajan Rahman, Nitu Puthenveettil, Riya Ann Jacob, Greeshma C Ravindran, Sunil Rajan, Lakshmi Kumar
DOI:10.4103/JOACC.JOACC_100_21  
Background and Aims: Labor epidural analgesia can be provided with local anesthetics alone or in combination with opioids. The aim of this study was to compare the duration of analgesia, onset time, and obstetric and fetal outcomes with three different concentrations of fentanyl. Methods: This double-blinded trial was conducted on 75 parturients who delivered with epidural analgesia. They were randomly assigned to three groups by the closed envelope technique. Groups A, B, and C received a bolus dose of 20 ml 0.1% ropivacaine with 1 μgml-1, 1.5 μgml-1, and 2 μgml-1 fentanyl, respectively, as an initial epidural dose. The duration, time to onset of analgesia, top-up doses required, hemodynamics, fetal-maternal outcomes, and complications were compared. Results: The mean duration of analgesia with the first epidural dose was 57.4 ± 14.207, 121.52 ± 33.951, and 165.08 ± 34.271 min in the A, B, and C groups, respectively, with a P of <.001. There was a higher duration of analgesia in the B group than in the A group (p-value <.001), in the C group than in the B group (p. 016), and in the C group than in the A group (p-value <.001). The onset of analgesia was faster in the C group than in the A and B groups (7.960 ± 1.695, 6.800 ± 1.607, and 5.960 ± 1.645 min in groups A, B, and C, respectively, with a P of. 001). The number of epidural boluses required was 3.480 ± 0.509, 2.640 ± 0.489, and 2.120 ± 0.331 in the A, B, and C groups, respectively. Conclusion: Labor epidural analgesia with a higher concentration of fentanyl produces a prolonged and faster onset of analgesia with fewer requirements for top-up boluses.
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CASE REPORTS Top

Psychogenic non-epileptic seizures: Why anaesthesiologist should know? p. 155
Pavan Kumar Dammalapati
DOI:10.4103/JOACC.JOACC_80_21  
A 19-year-old primigravida underwent caesarean section under spinal anaesthesia. She presented with seizures on 7th post-operative day. All the common etiological factors for seizures were ruled out. We found out that the seizures were due to a psychiatric condition called 'psychogenic non-epileptic seizure (PNES)'. There were previous case reports of PNES that were documented on known patients of seizures, followed by general anaesthesia. Here is a case of PNES without any previous history of functional or organic seizures followed by spinal anaesthesia.
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Inadvertent intravenous injection of carboprost in a COVID-19-positive patient: A case report p. 158
Nazia Nazir, Deepti Chopra
DOI:10.4103/JOACC.JOACC_82_21  
We present a case report of an inadvertent administration of intravenous carboprost in a COVID-19-positive parturient who was taken up for an emergency caesarean section for meconi um-stained liquor. Unintentionally, the patient was administered intravenous carboprost instead of ondansetron. The patient developed breathlessness, uneasiness and hypertension. Despite the mishap, the patient fully recovered and was discharged after 15 days. Although the medical error in the present case was non-harmful, the treating doctor discussed the case with the patient. Conclusion: A case with inadvertent intravenous administration of carboprost in a COVID-19-positive parturient is reported with a good outcome.
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Anaesthetic management of a parturient with juvenile parkinson's disease in emergency – A case report p. 161
Aravind Ramalingam, Divya Devanathan, Rani Ponnusamy
DOI:10.4103/JOACC.JOACC_96_21  
The association of Parkinson's disease and pregnancy is very rare. We present a case of juvenile Parkinson's disease patient who underwent emergency caesarean section. The anaesthetic considerations and management are discussed.
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Neuraxial anaesthesia in a parturient with space occupying lesion in brain for caesarean section: Demystifying the myth – A case report with review p. 164
Abinaya Ramachandran, Sivakumar Segaran, Nikithamani , RV Ranjan
DOI:10.4103/JOACC.JOACC_94_21  
Pregnancy makes a patient undergo diverse physiological changes and predisposes them to many pathological disorders such as pre-eclampsia, eclampsia, cortical vein thrombosis, and pituitary apoplexy. Any intervention during pregnancy presents a unique challenge as it affects two individuals. Once diagnosed with a clinical condition, they are prone to further medical, obstetric and anaesthetic complications. Herein, we report the anaesthetic management of a 32-year-old female previously diagnosed with pituitary adenoma and now presenting with twin pregnancy for emergency caesarean section along with emphasis on the anaesthetic concerns pertinent to brain tumours in pregnancy.
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Combined spinal-epidural for emergency cesarean section in a multiparous parturient with achondroplasia p. 167
Siyu Lye, Phui Sze Au Yong
DOI:10.4103/JOACC.JOACC_109_21  
Parturients with achondroplasia post unique challenges to the anesthetist. Term achondroplastic parturients may have cephalopelvic disproportion resulting in lower section cesarean section (LSCS). Premature ossification of bones results in characteristic craniofacial abnormalities and is associated with atlantoaxial instability and macroglossia leading to a difficult airway. With pregnancy, airway edema and reduced functional reserve capacity further complicate intubation. Central neuraxial blockade (CNB) is challenging due to potential kyphoscoliosis, spinal stenosis, the unpredictable spread of local anesthetics in central neural space, and uncertainty of dose due to disproportionate spinal column to overall height. We present the challenges in a multiparous achondroplastic parturient coming in for emergency cesarean section done under combined spinal-epidural anesthesia technique.
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LETTER TO EDITOR Top

Real-time assessment of esophageal occlusion by ultrasound-guided paralaryngeal pressure application in emergency LSCS—Time to change practices? p. 170
Pallavi Ahluwalia, Bhavna Gupta
DOI:10.4103/JOACC.JOACC_114_21  
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ERRATUM Top

Erratum: Enhanced recovery after cesarean protocol versus traditional protocol in elective cesarean section: A prospective observational study p. 172

DOI:10.4103/2249-4472.355359  
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