**VEGETATION**

Edited by **Allan Sebata**

#### **Vegetation**

http://dx.doi.org/10.5772/intechopen.69411 Edited by Allan Sebata

#### **Contributors**

Fabiana Firetti, Manuel Pulido Fernández, J. Francisco Lavado Contador, Susanne Schnabel, Álvaro Gómez Gutiérrez, Javier Lozano-Parra, Miomir Jovanović, Bojan Vračarević, Miško Milanović, Albert Chirima, Peter Mundy, Andre F VanRooyen, Nicholas Ncube, Eusebio Cano Carmona, Carmen Bartolomé, Carmelo Maria Musarella, Piñar Fuentes J.C., Ricardo Quinto Canas, Pinto Gomes C.J., Ana Cano Ortiz, Cristiane Sarmento, Paramesha Mallegowda, Ganesan Rengaian, Siddappa Setty

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**12. Strain imaging in aortic regurgitation**

In contrast to aortic stenosis, aortic regurgitation (AR) generates LV volume overload with progressive LV dilatation, initially with preservation of LVEF and wall thickness (eccentric LV hypertrophy), but eventually with the development of LV systolic dysfunction expressed by a drop in LVEF (**Figure 2**). Several studies have described the value of strain imaging in the management of patients with aortic regurgitation. The results and conclusion statement of these studies are summarized in the following paragraphs:

**51**

**Figure 2.**

*global longitudinal strain at −14%.*

*Clinical Applications of Strain Imaging in Aortic Valve Disease*

• In patient with AR, LV strain analysis can detect early subclinical myocardial dysfunction before the development of impaired LVEF. Using tissue Doppler imaging, Marciniak et al. [42] demonstrated that patients with severe AR had significant impairment of LV longitudinal strain, in contrast to patients with

• Di Salvo et al. [44] evaluated 26 young patients (3-16 years) with asymptomatic AR and found LV average longitudinal strain to be significantly reduced in patients with progressive AR compared to those with stable AR (−17.8 ± 3.9% vs. −22.7 ± 2.7%, p = 0.001). On multivariate analysis, the only significant risk factor for progressive AR was average LV longitudinal strain (p = 0.04, cut-off value > −19.5%, sensitivity 77.8%, specificity 94.1%, area under the curve 0.889). These authors concluded that two-dimensional strain imaging

*Severe aortic regurgitation: this patient had severe aortic regurgitation with normal LV end-diastolic and end-systolic volumes (EDV, ESV) and preserved systolic function as estimated by a normal LV ejection fraction (EF) of 68%; however, there is already evidence of insipient LV dysfunction as demonstrated by a mild drop in*

moderate AR where there was no difference with controls.

• Smedsrud et al. [43] evaluated 47 AR patients and 31 controls with Longitudinal peak systolic strain rate and found they were significantly decreased in the patient's population (P < 0.001). Global longitudinal peak systolic strain rate was also significantly decreased in aortic stenosis and regurgitation compared to the control group (−1 ± 0.5, −0.9 ± 0.3, and −1.6 ± 0.3, P = 0.001). As far as the comparison between patients with aortic stenosis and aortic regurgitation, neither global strain rate nor strain rate for each wall was found to be different. They concluded that there was reduced global longitudinal strain in patients with chronic AR with preserved LV ejection fractions. Global longitudinal strain might therefore disclose incipient myocardial dysfunction with a consequent potential for improved timing of aortic

*DOI: http://dx.doi.org/10.5772/intechopen.93341*

valve surgery.


**Who Reads Food Labels? Selected Predictors of Consumer Interest in Front-of-Package and Back-of-Package Labels during and after the Purchase**

#### **Paweł Bryła**

Department of International Marketing and Retailing, Faculty of International and Political Studies, University of Lodz, Narutowicza 59a, 90-131 Lodz, Poland<EMAIL_ADDRESS>Tel.: +48-426655830

Received: 13 July 2020; Accepted: 25 August 2020; Published: 27 August 2020

**Abstract:** The paper aims to identify selected predictors of food label use to extend our knowledge about consumer behavior related to food purchases. Two types of information were examined: front-of-package (FOP) and back-of-package (BOP), and two contexts of reading labels were distinguished: during shopping and at home. Various types of potential predictors were tested, including demographic (e.g., age, gender, household size, place of living), socioeconomic (e.g., education, professional activity, income), behavioral (e.g., purchasing certain types of products), and psychographic (e.g., importance attached to various types of information) criteria. The survey was conducted with the use of the CAWI (Computer-Assisted Web Interviews) methodology in a sample of 1051 Polish consumers. Quota sampling was applied based on sex, age, education, place of living (urban vs. rural), and region. Descriptive statistics, *t*-tests, ANOVAs, Pearson correlation coefficients, and multiple and retrograde step regressions were applied. In retrograde step regression models, only one predictor (self-rated knowledge about nutrition healthiness) turned out to be significant for all four measures of label reading. The remaining predictors were specific to selected measures of reading labels. The importance of the information about the content of fat and that about the health effects of consuming a food product were significant predictors of three types of food label use. This study confirms the necessity to investigate reading labels in fine-grained models, adapted to different types of labels and different contexts of reading. Our results show that demographic or socioeconomic variables are not significant predictors of reading food labels for a large group of Polish consumers.

**Keywords:** food label use; front-of-package (FOP) labels; back-of-package (BOP) labels; nutrition claims; health claims; nutrition knowledge; consumer behavior

#### **1. Introduction**

In previous research, food label use was associated with consumer characteristics, product type, and purchasing context. The following variables were found to affect reading labels: gender [1–5], age [4,6], marital status [7], ethnicity [2], socioeconomic status [2,7], including education level [4,5,7–9], professional activity [9], income [5], place of living—rural or urban areas [2,5], Body Mass Index [2,4], being an athlete [10], food-related motivation [11], nutrition knowledge [4,12,13], self-reported health [4,10], having a special diet [4,9], being concerned with a healthy lifestyle [10], attitude towards the health value of the products [13], health orientation [14], taste [9,13], price [9], product specificity [12], buying the product for the first time [12], the amount of time spent shopping [9], and buying organic food [15]. There are various connections between these predictors, e.g., the gender effect is mainly due to differences in nutrition knowledge levels [12]. Health-related variables were the most important group of predictors of food label use, followed by motivating factors and sociodemographic variables. Placing importance on health, healthy eating, and nutritional value of food, perceived vulnerability for diet-related diseases, nutrition knowledge, numeracy, and gender were positively associated with the frequency of food label use [16]. Subjective norms and diet-health concern were significant predictors of intention to use food labels [17]. Self-efficacy and health literacy were predictors of food label use among young adults [18]. Consumers' level of nutrition knowledge influenced their ability to process food labels. Experts used the central route processing to scrutinize intrinsic cues and make judgments about food products, while novices used the peripheral route processing to make simple inferences about the extrinsic cues in labels [19]. Nutritional knowledge and attitude toward food label use positively predicted food label use through self-efficacy and trust. However, these mediation effects were moderated by gender such that the indirect relationship was stronger among men than women [20]. In their review [21], Soederberg Miller and Cassady found an overreliance on convenience samples relying on younger adults, limiting our understanding of how knowledge supports food label use in later life. This limitation is overcome in the current study, as it is based on a sample representative by age.

It is also important to distinguish between food label use at the point of purchase and at home. Education has a positive impact on the likelihood of using labels at home but not while shopping. The average amount of time spent on grocery shopping per visit affects label use while shopping but not at home. The same applies to the primary source of nutrition information being books, magazines, radio, TV, or newspapers. Moreover, being on a special diet influenced label reading in the shop but not at home. The importance of price while shopping affected reading labels at home only, and the importance of taste was a significant predictor of reading labels while shopping only [9]. These results support the need to study food label use separately while shopping and at home.

Findings consistently support a relationship between label reading and dietary practices [22,23]. Changes in diet quality due to label use were estimated for different types of label information. Consumer label use increased the average Healthy Eating Index. These improvements differed across label information types that were used. Among nutritional panels, serving sizes, nutrient content claims, a list of ingredients, and health claims, the use of health claims on food labels provided the highest level of improvement in diet quality [24]. Search for total fat, saturated fat, and cholesterol information on food labels was less likely among individuals who consumed more of the three nutrients, respectively. The search was also related to perceived benefits and costs of using the label, the perceived capability of using the label, knowledge of nutrition and fats, perceived efficacy of diets in reducing the risk of illnesses, perceived importance of nutrition in food shopping, perceived importance of a healthy diet, and awareness of a linkage between excessive consumption of the nutrients and health problems [25]. Nutrition knowledge had a strong effect on general label use, degree of use, and on use of nutrient content concerning fat, ingredients, and vitamins/minerals [26]. Subjects with chronic diseases were more aware of nutritional recommendations, checked more often for specific nutrients, and used nutrition information on food labels more often than did participants without such diseases. However, label use behavior was inconsistently associated with dietary guideline compliance [27]. The odds of healthy weight loss behaviors were two to four times higher when food labels were used frequently to seek information on calories and nutrients such as total fat, saturated fat, or cholesterol [28]. A recent review [29], by Anastasiou, Miller, and Dickinson, demonstrated that results were inconsistent in reporting a relationship between diet and food label use but indicated that reading the nutrition facts label was associated with healthier diets, measured by food frequency questionnaires and 24 h recalls. However, there is insufficient research on the association between dietary consumption and the use of ingredients lists, serving size information, and front-of-package (FOP) labels. Nutrition label use decreased the risk of poor dietary quality regardless of poverty status [30]. General food label use was the main determinant of diet quality and partly mediated the association between eating behavior traits and diet quality. The stronger mediating effect observed in men suggested they relied more on food labeling when attempting to restrain themselves, which translated into better diet quality [31].

It is also important to recognize that various food label types have different effects on consumer behavior. Compared with individual characteristics, nutrition label types had an increased impact on food product ranking ability [32]. Different food label formats differed in the understanding of consumers. The multiple traffic light (MTL) labels influenced the perceived healthiness of foods most often [33]. In an international, large-scale survey, viewing the MTL provided the most favorable ratings out of five FOP nutrition label formats (health star rating, MTL, Nutri-Score, reference intakes, and warning label) [34]. The perceived usefulness and public support of mandatory implementation were higher for the MTL than for the Nutri-Score label [35]. Nutri-Score, which is a summary, interpretive, polychromatic FOP label, emerged as the most effective in the Bulgarian context [36]. FOP nutrition labels were more likely to be viewed than Nutrition Facts labels [37]. Different degrees of health-orientation were reflected in the diverse use of labeled information. Highly health-oriented consumers were more likely to refer to the extensive information reported on the nutrition facts panel, whereas claims were of main interest for consumers with a low orientation to health [14]. Furthermore, 52.5% of consumers did not read the ingredients' list written on the food label [38]. Simplified FOP labels can induce healthier purchases compared with when only back-of-package (BOP) nutrition information is available [39]. Clearer BOP labeling is also needed [40]. Nutritional warnings cause a salience bias that makes excessive nutrient content and its negative health consequences more salient in consumers' minds, especially in the case of products with a particular health-related connotation [41]. Although FOP labels may help shoppers make healthier food choices, those advocating for effective labels must resist opposition from food corporations [42]. Future opportunities for FOP labeling include the potential for integrating nutritional profiles with non-nutrient factors affecting health such as food processing and environmental sustainability [43]. Although FOP labels help consumers to identify healthier products, their ability to nudge consumers toward healthier choices is more limited. Importantly, FOP labels may lead to halo effects, positively influencing not only virtue but also vice products, e.g., interpretive nutrient-specific labels improve health perceptions of both vice and virtue products, yet they influence only the purchase intention of virtues [44].

The paper aims to identify selected predictors of reading food labels with the distinction of the label type (FOP and BOP), and the context of food label use (during shopping and afterward, at home). Therefore, four measures of reading labels were considered in this study: FOP in the shop, BOP in the shop, FOP at home, and BOP at home. The main contribution of this paper lies in systematically analyzing predictors of reading labels from the perspective of two major label types (FOP and BOP) and two main reading contexts (in the shop and at home) based on a survey in a large, representative, nation-wide sample of consumers.

#### **2. Materials and Methods**

The survey was conducted with the use of the CAWI (Computer Assisted Web Interviews) methodology. The execution of the survey was commissioned to a specialized market research agency. The respondents were informed that the results would be used only for scientific purposes, respecting the anonymity principle. The sample size amounted to 1051 consumers. The target sample size was set at a comparable level with previous consumer studies conducted at the national level in Poland [45–47]. It was aimed to obtain a sample resembling the general population of Polish adults, regarding four criteria: age, sex, education level, and the size of the city of origin (in particular, the urban/rural divide). Quota sampling was applied based on five criteria: sex (men and women), age (the following age intervals: 15–24, 25–34, 35–44, 45–54, 55–64, 65 and more), education (primary, secondary and tertiary), place of living (urban and rural areas), and region (all 16 Polish regions). Thanks to this approach, the sample structure was similar to the general population of Polish consumers according to the above-mentioned criteria (Table A1).

The questionnaire was created by the author of this study. It was composed of elements adapted from previous research using validated tools [14,48–59]. It consisted of 38 questions. The full questionnaire is included in a book in Polish [60]. The operationalization of the key variables used in this study is provided in Table A2. Reading labels was investigated in 4 configurations: (1) FOP in the point of purchase (FOP shop), (2) BOP in the point of purchase (BOP shop), (3) FOP after purchase (FOP home), (4) BOP after purchase (BOP home). It was operationalized as a percentage share of food products the respondent buys. Some more difficult terms were explained in the questionnaire, in particular health claims, nutrition claims, and quality signs. The research examined general food labels. My dependent variables referred to FOP and BOP labels without specifying which information was put on which label. However, in some questions, I examined the importance attached to particular types of information placed on the labels, such as health claims, nutrition claims, list of ingredients, expiry date, country of origin, cooking recipes, brand, organic certificate, quality signs, recommendations of scientific institutes, price, as well as selected types of nutritional information (energy value, the content of fat, sugar, salt, protein, vitamins, dietary fiber, Omega-3 fatty acids) and health information (lowering cholesterol, reducing the risk of heart diseases, strengthening bones, impact on the digestive system, reducing tiredness and fatigue, maintaining proper vision, proper development of children, and proper functioning of the heart). Various types of potential predictors were tested, including demographic (e.g., age, gender, household size, place of living), socioeconomic (e.g., education, professional activity, income), behavioral (e.g., purchasing certain types of products), and psychographic (e.g., importance attached to various types of information) criteria. For most of the questions, 5-point Likert scales were used.

First, I tested the differences in reading food labels depending on selected demographic and socioeconomic criteria: sex, age, place of living, education, professional activity, income, household size, and the number of children. Second, I checked whether reading labels differed depending on some purchasing habits: buying dietary supplements, organic food, functional food, and fair trade products. Third, I examined label use according to selected criteria related to one's health and diet. Fourth, I examined the correlations of food label use with the evaluation of the quantity, understandability, and credibility of selected information on the food packaging.

Next, I tested the associations between food label use and the importance attached to selected types of information placed on the labels. Four questions were devoted to this issue. The first one concerned general food labels. Second, I focused on the importance of information at the first purchase of a given product. This question referred to a product that was new to the consumer and not necessarily to the entire market Third, I took into consideration typical types of nutritional information. Last, I examined the correlations with selected types of health-related information.

Furthermore, the associations between food label use and the importance attached to marketing communication instruments were identified. The following marketing communication options were put forward for the respondents' evaluation: TV commercials, producer website, retailer website, producer social media profile, retailer social media profile, consumer opinions in social media, mobile applications, recommendations of family or friends, recommendations of a dietician, outdoor advertising (e.g., billboards), advertising newsletters of retailers, articles in press and magazines, TV culinary programs, culinary blogs, product packaging, and shop assistant.

Regarding information used in the marketing communication for food products, the following options were considered: health effects of consuming a given product, care for the natural environment, supporting producers (e.g., farmers), low price, national origin of the product, the utility of the product in a certain diet, above-average quality of the product, and traditional method of production.

Based on statistical differences revealed in *t*-tests and ANOVAs as well as the most significant Pearson correlations, 32 independent variables were selected to be analyzed in multiple regressions. Separate regression models were constructed for each type of reading labels.

In the data analysis, descriptive statistics, *t*-tests, analyses of variance (ANOVAs), Pearson correlation coefficients, and multiple and retrograde step regressions were applied. T-tests were used to compare two quantitative results, ANOVAs were used to compare multiple quantitative results, Pearson correlation coefficients were used to examine the linear correlations between quantitative variables, the multiple regression models were used to examine the simultaneous influence of all

independent variables separately on the 4 types of reading labels, and the retrograde step regressions were used to narrow down the set of independent variables to those that remained significant at the *p* < **0.05** level. Independent variables that differentiated any measure of reading labels in a statistically significant way were included in separate multiple regression models for FOP shop, BOP shop, FOP home, and BOP home. To obtain more parsimonious models, only those predictors that reached statistical significance at the level of *p* < **0.05** were accepted in retrograde step regressions. The analyses were conducted in Statistica 12 (TIBCO Software Inc., Palo Alto, CA, USA). I report continuous *p*-values instead of thresholds, following the recent guidelines of statisticians [61]. Results that are statistically significant at *p* < **0.05** are boldfaced to increase their visibility.

#### **3. Results**

Women read food labels more often than men, but the sex differences reached statistical significance only for reading BOP labels at the point of purchase (BOP shop) and FOP labels after the purchase at home (FOP home) (Table 1).

**Table 1.** Reading food labels by sex.

A series of ANOVAs demonstrated that age (measured in 10-year intervals) did not differentiate any measure of reading labels (Table 2).

**Table 2.** Reading food labels by age.

Reading labels was not affected by the place of living (defined as rural areas, towns up to 50,000, cities of 50–500,000, and cities of more than 500,000) either (Table 3).

**Table 3.** Reading food labels by the place of living.

As far as the education level is concerned, only the FOP shop was influenced in a significant way (Table 4). Respondents who had tertiary education read food labels in shops more often than the other education groups.

**Table 4.** Reading food labels by education.

As far as the professional activity is concerned, it affected reading labels at the point of purchase—both FOP and BOP—but not after the purchase at home. White-collar workers read food labels most frequently in-store (both FOP and BOP) (Table 5).

Notes: 1—white-collar worker, 2—blue-collar worker, 3—unemployed, 4—student, 5—not working and taking care of one's family, 6—old age pensioner or disability pensioner; the category "other" was excluded from the ANOVA.

Reading food labels was associated with household income only for the FOP shop. It was highest among respondents living in households with middle income (3001–4000 PLN) and the highest income (over 6000 PLN per month) (Table 6).

**Table 6.** Reading food labels by income.

Notes: the average monthly disposable income of one's household; 1—below 2000 PLN, 2—2001–3000 PLN, 3—3001–4000 PLN, 4—4001–5000 PLN, 5—5001–6000 PLN, 6—over 6000 PLN.

Only FOP label reading (in the shop and at home) correlated positively and significantly with the size of one's household (Table 7).

**Table 7.** Pearson correlation coefficients of reading food labels with the size of one's household and the number of children.

Notes: household—the number of people in one's household, children—the number of children in one's household.

Reading food labels was associated with purchasing certain types of products, namely dietary supplements, organic food, functional food, and fair trade products (Table 8). Buying dietary supplements increased the frequency of reading labels on the front of the package in the shop and at home as well as on the back of the package at home only. Buying organic food affected all measures of reading labels in a highly significant way. Buying functional food influenced all kinds of reading labels except for the FOP shop. Buying fair trade products differentiated significantly reading only the BOP information.

**Table 8.** Reading food labels by purchasing certain products.

Note: the category "No" includes direct "No" answers and "I don't know" answers.

Reading food labels was correlated with self-rated healthiness of one's diet, one's knowledge about healthy nutrition, and self-rated health but not BMI (Body Mass Index) (Table 9).

**Table 9.** Pearson correlation coefficients of reading food labels with the self-rated healthiness of one's diet, self-rated knowledge about healthy nutrition, self-rated health, and BMI.

Note: BMI—Body Mass Index (kg/m2).

However, none of the investigated measures of reading labels depended on being on a special diet for health reasons (Table 10).

**Table 10.** Reading food labels by being on a special diet for health reasons.

Reading BOP labels was related to the evaluation of the quantity of selected information (health claims, nutrition claims, and quality signs) on food labels (Table 11). Those who considered that there was too little such information tended to read food labels more often. Moreover, all measures of reading labels were associated with the self-evaluated understandability of information put on the labels (namely health claims, nutrition claims, quality signs, functional food, and organic food). Finally, reading labels correlated with the perceived credibility of such information (health claims, nutrition claims, list of ingredients, expiry date, organic certificate, and quality signs). Those who trusted information placed on the labels more tended to read them more often both in the shop and at home.

**Table 11.** Pearson coefficients of reading food labels with the evaluation of the quantity, understandability, and credibility of selected information on food packaging.

Reading food labels depended on the importance attached to selected information put on them (Table 12). The subjective importance of almost all types of information correlated positively and significantly with reading FOP and BOP food labels both at the point of purchase and at home, except cooking recipes, the importance of which was correlated significantly only with the FOP home.

**Table 12.** Pearson correlation coefficients of reading food labels with the subjective importance of selected information on labels.

Notes: \* of scientific institutes; \*\* average evaluation of the importance of all types of information mentioned in this column of the table.

As far as the importance of information at the first purchase of a food product (excluding price) is concerned, it differentiated only BOP label reading, both in the shop and at home. The respondents indicating the list of ingredients read the highest share of BOP labels in both contexts (Table 13).

**Table 13.** Reading food labels by the most important information on the food label at the first purchase (excluding price).

Notes: COO—the country of origin, NI—nutritional information (e.g., about the content of fat or dietary fiber), HI—information on health effects (e.g., good for the bones, lowering cholesterol), LI—list of ingredients, ED—expiry date; the reading labels indicators were measured in percentages of food products the consumer bought; the responses "other" and "I don't know" were excluded from the ANOVAs.

All the investigated nutritional information types correlated significantly with all four measures of reading labels (Table 14).

**Table 14.** Pearson correlation coefficients of reading food labels with the subjective importance of selected nutritional information on labels.

All of the investigated health information types correlated significantly with all the measures of reading labels (Table 15).

**Table 15.** Pearson correlation coefficients of reading food labels with the subjective importance of selected health information on labels.

Furthermore, reading food labels was associated with the importance attached to all investigated promotion instruments for food products with health and nutrition claims, with some minor exceptions for particular food label use measures (Table 16).

**Table 16.** Pearson correlation coefficients of reading food labels with the evaluation of the importance of selected promotion instruments for food products with health and nutrition claims.

All kinds of reading labels were associated the most strongly with the importance attached to the health effects of consuming a given product (Table 17).

It is also worth noting that all the analyzed types of reading labels correlated significantly with the willingness to pay (WTP) a higher price for food products with health claims and nutrition claims compared to conventional products (Table 18). The strongest correlation was observed between the BOP shop and the WTP for nutrition claims.

**Table 18.** Pearson correlation coefficients of reading food labels with the willingness to pay more for food products with health and nutrition claims compared to conventional products.

The multiple regression models explained better reading BOP labels (BOP shop R<sup>2</sup> = 0.173, BOP home R2 = 0.143) than FOP labels (FOP shop R<sup>2</sup> = 0.091, FOP home R2 = 0.089) (Table 19). In the

full multiple regression model, reading FOP labels at the point of purchase was determined by only three predictors: self-rated knowledge about healthy nutrition, the importance of the expiry date information on the food packaging, and the importance of the information about the health effects of consuming a given product. Second, reading BOP information in the shop turned out to depend on five variables. It was positively associated with the importance attached to the list of ingredients, self-rated nutrition knowledge, indicating the list of ingredients as the most important information at the first purchase, and average assessment of the quantity of selected information on the food packaging: health claims, nutrition claims, and quality signs. It was negatively related to the consumer education level. The third regression model reported in this table refers to reading FOP labels at home. Six variables had a significant impact on this measure, four out of which were positively related: self-rated nutrition knowledge, the importance attached to culinary blogs, the importance of information about the health effects of consuming the product, and the importance of the information that the product reduces tiredness and fatigue. On the other hand, it was negatively associated with the information about the impact of the product on the digestive system and the importance attached to the recommendations of a dietician. The last regression model concerned the predictors of reading BOP information after the purchase. It was found to depend on five variables, all of which contributed positively: the importance of the information about the content of fat, the importance of the list of ingredients, the importance of the information about the health effects of consuming a product, the evaluation of the quantity of information on the label, and the importance of the list of ingredients when one buys a food product for the first time.

**Table 19.** Selected predictors of reading food labels—full multiple regression models.

**Table 19.** *Cont.*

According to the final retrograde step regression models (Table 20), the FOP shop increased with being a white-collar worker, having better (self-rated) knowledge about healthy nutrition, evaluating the credibility of information on labels higher, attaching importance to the expiry date, and health effects in the marketing communication for food products. Second, the BOP shop increased with one's knowledge about a healthy diet, better self-rated health, evaluating the quantity of information on labels as insufficient, attaching importance to the list of ingredients in general and during first-time purchases, and attaching importance to the content of fat. Third, reading FOP labels at home increased with the knowledge about a healthy diet, attaching importance to the content of fat and to the impact of the product on lowering cholesterol, attaching importance to culinary blogs, and to health effects in the marketing communications but decreased with the importance attached to the recommendations of a dietician. Finally, reading BOP labels at home depended on buying functional food, one's knowledge about a healthy diet, evaluation of the quantity of information on food labels, the importance attached to the list of ingredients, to the content of fat, and to health effects in the marketing communication.

**Table 20.** Selected predictors of reading food labels—retrograde step regression models.

Note: only predictors significant at *p* < **0.05** are included in these models.

#### **4. Discussion**

The main contribution of this paper is the identification of variables that influence food label use in four configurations: FOP in the shop, BOP in the shop, FOP at home, and BOP at home, based on a survey in a large, representative, nation-wide sample of consumers. In retrograde step regression models, only one predictor (self-rated knowledge about healthy diet) turned out to be significant for all four measures of label reading. Two more predictors (importance attached to the content of fat and health effects in marketing communication) were significant in three out of the four investigated forms of reading labels. The remaining independent variables were specific to one or two forms only. It confirms the necessity to study reading labels in fine-grained models, adapted to different types of labels and different contexts of reading. Moreover, this study demonstrated that sociodemographic

and behavioral characteristics have limited power of explaining reading labels in multivariate models (except being a white-collar worker for FOP shop and buying functional food for BOP home). Most of the relevant predictors were psychographic, as they concerned the importance attached to selected information types put on the labels or used in the marketing communication as well as the evaluation of the quantity and credibility of information placed on the labels. It is also worth noting that most of the predictors were related to the nutrition and health aspects of communication.

My results differed from some previous findings. In a sample of US adults, significant differences in food label use were observed across all demographic characteristics examined [62]. This difference may stem from: (1) international differences in food label use, (2) a different operationalization of food label use as well as (3) the inclusion of a wide set of psychographic criteria in my multivariate models, which turned out to be better predictors. In another study, determinants of food label use differed by sex. Age and diet quality perception were significant predictors of food label use for both men and women, but ethnicity was significant for males only. Similar to my findings, women checked food label components more often than men [63], but the current study distinguishes various forms and contexts of food label use. Significant differences between men and women were observed for reading BOP labels in the shop and FOP labels at home. Reading food labels has different predictors than the importance attached to some types of information placed on the labels. For instance, another study based on the same dataset demonstrated that the importance attached to salt content information depended on sex and age [64]. Following most previous studies, my results confirmed the impact of nutrition knowledge on food label use. However, interestingly, this relationship may be treated as bidirectional. Cavaliere et al. found that food label use increased the nutritional knowledge of consumers, which in turn favored a healthy diet [65]. It is also important to realize that the valuation of information on the labels is heterogeneous across consumer segments. For instance, Ballco and De Magistris [66] identified three consumer segments: "health-claims oriented", "nutritional- and health-claim oriented", and "indifferent". There is a complexity of targeting nutrition labels because a nonlinear effect of health attitude on the selection of products with increased nutrients content was revealed in previous research [67].

Information may not always be effective in improving food choices. One explanation is that nutrition information is complex and difficult to convey in a clear, actionable manner. In addition, knowledge, while necessary, may not be sufficient to motivate behavior change [68]. The online shopping environment offers new promising tools, such as dynamic food labels with real-time feedback [69], which are not available offline. Even though food label use was associated with improved dietary factors, it was not sufficient alone to modify behavior ultimately leading to improved health outcomes [62]. The perceived credibility of nutrition claims, agreeing that the availability of health-related information is not sufficient for the vast majority of consumers to change their food preferences, and believing that foods carry an excessive number of nutrition claims affected the importance of nutrition claims among food processors and distributors [70]. There is also evidence of mistrust in health claims, as indicated by the negative relationship between the consideration of such claims and the stated importance of "quality" and perceived need to "change dietary quality" the more discerning shoppers were the least likely to consider health claims [71].

There are a few limitations to this study. The first one is that it is based on self-reported data only. A known limitation of self-report instruments such as surveys and questionnaires is their susceptibility to socially desirable responding. Socially desirable responding is the tendency to give answers that make the respondent look good, or the tendency "to stretch the truth in an effort to make a good impression" [72]. In my survey, I minimized this bias by ensuring the survey anonymity and confidentiality of answers. At the beginning of the questionnaire, the respondents were informed that the survey was anonymous and the results would be used for scientific purposes only. Both self-reported and objective measures of food label use were positively associated with dietary quality. However, self-reported measures appeared to capture a greater motivational component of food label use than did more objective measures [73]. Second, the determination coefficients in

my regression models were relatively low, especially for reading FOP labels. This means that there may be other important predictors, which were not included in my study. Nevertheless, taking into consideration the wide range of potential predictors that were examined in my models, it may be also due to the difficulty of assessing the percentage of products the labels of which are read by the given respondent. I opted for the percentage measure rather than a Likert-type scale of frequency because of its higher objectivity. Responses such as "often" or "seldom" can be understood by different consumers differently, e.g., for some people reading 30% of labels may mean "often" and for others "seldom". That is why I preferred the percentage measures, bearing in mind also the weakness of this measure related to the different numerical skills of respondents. This shortcoming of my study may be overcome by applying a combination of observational methods (ethnography) and surveys in future research.

There are several implications of my results. First, nutrition knowledge improvement programs should be developed, as higher nutrition knowledge was found to translate into a higher interest in reading all kinds of food labels (FOP and BOP) in both contexts (during the purchase and after the purchase), and food label use leads to more favorable food choices for public health. Second, food processors and retailers should more often consider the possibility of emphasizing the health effects of a given product alongside or even instead of other attributes. Third, consumers are particularly sensitive to information about the content of fat. Therefore, the use of nutrition claims and graphical designs of the packaging pointing to the low-fat or zero-fat properties of a product is encouraged. Fourth, retailers should encourage their customers to read the labels at the point of purchase, which may be achieved by allocating special space and offering tools to obtain additional information about the products. Fifth, smartphone apps should be developed to facilitate consumer understanding of information placed on the labels and to facilitate comparisons across products in a given category. Sixth, it is important to pay attention not only to the type of information placed on the labels but also its quantity, and last but not least, credibility. The manufacturers should be selective and focus on the consumer-friendly design of labels. Public authorities should facilitate the use of official nutrition claims and health claims, at the same time keeping high standards of awarding such claims. Public information campaigns should be organized to explain the transparency of the procedures of obtaining health and nutrition claims and the credibility of other types of information on the labels. Finally, public authorities should increase their effort in monitoring the industry so that it adheres to high standards of labeling, including the accuracy, completeness, and visibility of information sought by consumers.

**Funding:** This research was funded by the National Science Centre, Opus grant numbers 2017/25/B/HS4/00031 and 2015/17/B/HS4/00253. The APC was funded by the National Science Centre, Opus grant number 2017/25/B/HS4/00031.

**Conflicts of Interest:** The author declares no conflict of interest. The funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

#### **Appendix A**

**Table A1.** A comparison of the sample with the general population (%).

**Table A1.** *Cont.*

Note: general population refers to the inhabitants of Poland aged 15 and more.

#### **Table A2.** *Cont.*

#### **Table A2.** *Cont.*

#### **References**

© 2020 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).


**3. Radiation techniques in head and neck cancers**

The treatment of head and neck cancer (HNC) using external beam radiotherapy is commonly done with three field techniques, which involves bilateral parallel opposed beams and one anterior lower neck field. Conventional treatment is based on 2D fluoroscopic images where there is no facility to shield the organs at risk like parotid [1]. The most common side effect of such conventional radiotherapy treatment is xerostomia. This damage to salivary glands causes a reduction in saliva, dryness of mouth, difficulty in chewing, and speech alterations [2, 3]. Dental caries, which results in impaired nutrition, weight loss and significant degradation of quality of life, so their management and prevention is important for radiotherapy. The incidence of radiotherapyrelated xerostomia varies depending on the specific radiotherapy technique used and the dose delivered to the parotid glands.

With the advancement in imaging and treatment planning techniques, CT-based conformal radiotherapy has come into existence which delivers radiation to the target with precision and gives minimal dose to the parotids. These techniques involve three-dimensional conformal radiotherapy (3D-CRT), intensitymodulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT). The evolution of imaging methods from 2D portals to 3D-CBCT (Cone beam CT) has established the role of image-guided radiotherapy in improving the inter and intra-fractional variations during Radiotherapy of HNC [4]. These high precision techniques have led to an improvement in dose distribution and significant sparing of OARs (in this case parotid) and reduction in radiation-induced xerostomia [1]. The various radiotherapy treatment planning techniques in HNC have been discussed here.


Preface

As teachers of immunobiology, we have become increasingly aware of the lack of detailed material in many undergraduate medical courses on experimental approaches to drugs and their effective delivery in the treatment of cancers and infectious diseases. This book provides much-needed information about lipidic nanoscale carriers to deliver drugs to treat cancers and infectious diseases, their mechanism of action, and the pressing issue of evolving drug resistance.

The book addresses the perceived needs of both medical school and undergraduate curricula by synthesizing key concepts in the rapidly advancing and dynamic field of drug delivery. The choice of what is most important is based on what is most clearly established by experimentation, what our students find puzzling, and what explains the efficiency of drugs to treat cancers, infectious and inflammatory disorders. In-vitro and animal models are used to study the mechanism of action of existing and novel drugs. Lipid-based nanoparticles and their engineered versions are used for the effective delivery of drugs and candidate antigens. These drug carriers are of the utmost importance in reducing cytotoxicity while maintaining maximum therapeutic effects and the antigenic potential of drugs and antigens. This book discusses the role of nanoscale drug carriers in the delivery of antigens and vaccine candidates for the maximum therapeutic effect and vaccination potential against infectious diseases as well as cancers. It is a timely addition to the existing literature on delivery vehicles and a useful resource for those working in the field of the immunobiology of cancers and infectious diseases.

> **Rajeev K. Tyagi** Division of Cell Biology and Immunology, Biomedical Parasitology and Nano-immunology Lab, CSIR-Institute of Microbial Technology (IMTECH), Chandigarh, India

**1**

Section 1

Liposomes as a Drug Carrier

Section 1


**4. Classification of caesarean section**

Traditionally, caesarean section has been classified as emergency or elective. However, with advanced practice in obstetrics and more complicated deliveries encountered, this definition has become too simplistic, and more detailed categories are needed. Some authors have also suggested that the term "elective caesarean delivery" should probably be eliminated because a caesarean delivery is either "medically/obstetrically indicated" or "on maternal request" and never truly "elective" [8]. Such authors advocate for terms as *scheduled or planned* caesarean delivery in which the decision to perform an indicated caesarean delivery may be made antepartum and *unscheduled or unplanned* caesarean section where decision to perform an indicated caesarean delivery is made as a result of concerns identified after labour has begun. The decision to perform an unscheduled caesarean section may also arise even when labour has not occurred such as in abruption placentae with a live baby and no labour pains or absent foetal movement with abnormal umbilical artery Doppler studies not in labour.

Also distinguishing between prelabour caesarean section (which may be scheduled/elective or emergency/unscheduled) and intrapartum caesarean delivery (which is, by default, emergency) is preferable [14].

Lucas and colleagues [15] developed the classification of caesarean delivery based on urgency approved by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Anaesthetists in the UK after it was developed further into the most consistent method recommended by National Confidential Enquiry into Perioperative Deaths [16].

The initial classification by Lucas et al. [15] was a four-grade classification system including:

#### **Table 1.**

*Classification of caesarean section.*

1.Immediate threat to life of woman or foetus

2.Maternal or foetal compromise which is not immediately life-threatening

3.Needing early delivery but no maternal or foetal compromise

4.At a time to suit the patient and maternity team

Based on this the following classification of caesarean delivery was proposed (**Table 1**) [3].

### **5. Techniques for caesarean section**

Caesarean operation has undergone a number of technical changes as the procedure has evolved. Many different practitioners extol the benefits of various techniques of skin incision, uterine incision, uterine closure, and many other technical aspects of the operation. However, there are relatively few randomised trials to support many of the commonly used practices at caesarean section. As such there is no standard technique for caesarean delivery although there are a few evidencebased recommendations for the surgical technique.

#### **5.1 Abdominal opening**

Abdominal opening is accomplished through either transverse (Pfannenstiel and Joel-Cohen) or vertical skin incisions, each of which has advantages and disadvantages. Incision of about 12–15 cm is usually adequate for access [3, 14]. Historically, a vertical midline skin incision was implemented; however, this scar is cosmetically less acceptable and is associated with higher incidence of postoperative wound discomfort, dehiscence, infection, and hernia formation [3]. It may still be necessary if access is required to the upper uterus or to other abdominal organs. At present, the most frequently used type of skin incision is the Pfannenstiel incision since it is associated with less postoperative pain, greater wound strength and better cosmetic results than the vertical midline incision [17]. The use of scalpel is preferred although there are no randomised trials comparing scalpel to electrocautery which can also be used during caesarean delivery.

**91**

*Caesarean Section in Low-, Middle- and High-Income Countries*

Opening the subcutaneous tissue layer is achieved bluntly preferred to sharp dissection as blunt dissection has been associated with shorter operative times and less chance of injury to vessels [18]. However, there are no randomised trials comparing techniques for incision and dissection of the subcutaneous tissues at caesarean delivery. There are no randomised trials comparing different techniques of opening the fascia. A small transverse incision is usually made medially with the scalpel and then extended laterally with scissors. Alternatively, the fascial incision can be extended bluntly by inserting the fingers of each hand under the fascia and then

Rectus muscles are separated bluntly in most cases. Avoiding transection of muscles preserves muscle strength. Dissection of the rectus fascia from the rectus sheath and muscles is unnecessary [19] but has not been studied separately in a randomised trial. Opening the peritoneum can be achieved using the fingers bluntly to minimise the risk of inadvertent injury to the bowel, bladder or other organs that may be adherent to the underlying surface [18, 19]. However blunt versus sharp entry into

Opening of the bladder flap may or may not be performed. Some surgeons choose to open the bladder flap if difficult delivery is anticipated such as when the foetal head is deep in the pelvis or when the bladder is attached well above the lower uterine segment after a previous caesarean delivery. In these cases, creation of the bladder flap may help to keep the bladder dome out of the surgical field if the uterine incision extends.

The uterine incision may be transverse or vertical. The type of incision depends upon several factors, including the position and size of the foetus, location of the placenta, presence of leiomyomas and development of the lower uterine segment. The principal consideration is that the incision must be large enough to allow atraumatic delivery of the foetus. Transverse incision along the lower uterine segment is recommended. Compared with vertical incisions, advantages of the transverse incision include less blood loss, less need for bladder dissection, easier approximation and a lower risk of rupture in subsequent pregnancies [19]. Low vertical and classical incisions may also be performed in certain circumstances. Low vertical incision is performed in the lower uterine segment and appears to be as strong as the low transverse incision [20]. The major disadvantage of the low vertical incision is the possibility of extension cephalad into the uterine fundus or caudally into the bladder, cervix or vagina. It is also difficult to determine that the low vertical incision is truly low, as the separation between lower and upper uterine segments is not easily identifiable clinically. Classical incision is rarely performed at or near term because in subsequent pregnancies it is associated with a higher frequency of uterine dehiscence/rupture than low vertical and low transverse incisions. The generally accepted indications for considering a vertical uterine incision are:

• Poorly developed lower uterine segment in a setting in which more than normal intrauterine manipulation is anticipated (e.g. extremely preterm breech

• Lower uterine segment pathology that precludes a transverse incision (e.g.

presentation, back down transverse lie)

• Densely adherent bladder

• Postmortem delivery

large leiomyoma, anterior placenta praevia or accreta)

*DOI: http://dx.doi.org/10.5772/intechopen.88573*

pulling in a cephalad-caudad direction [17, 18].

**5.2 Hysterotomy/opening the uterus**

the peritoneum has not been compared in a randomised trial.

*Caesarean Section in Low-, Middle- and High-Income Countries DOI: http://dx.doi.org/10.5772/intechopen.88573*

*Recent Advances in Cesarean Delivery*

**Classification Indication**

Grade 1: emergency caesarean section

section

**Table 1.**

Grade 2: urgent caesarean

Grade 3: nonscheduled caesarean section

Grade 4: scheduled, also referred to as elective caesarean section

*Classification of caesarean section.*

1.Immediate threat to life of woman or foetus

*Reproduced from The Global Library of Women's Medicine.*

out of hours)

4.At a time to suit the patient and maternity team

based recommendations for the surgical technique.

which can also be used during caesarean delivery.

proposed (**Table 1**) [3].

**5.1 Abdominal opening**

**5. Techniques for caesarean section**

2.Maternal or foetal compromise which is not immediately life-threatening

(antepartum) or uterine rupture (intrapartum)

intrauterine growth restriction, preeclampsia, etc.

Immediate threat to the life of the woman or the foetus, i.e. placental abruption

No immediate risk to the life of the woman or baby, but delivery should be achieved as soon as possible, e.g. three previous caesarean sections, membranes are ruptured with meconium-stained liquor (antepartum) or non-reassuring cardiotocograph and foetal blood sampling are not possible or contraindicated

Delivery is needed but can fit in with delivery suite workload and allow for fasting/steroid administration and some degree of planning, e.g. preterm

No urgency whatsoever and procedure planned to suit the mother, staff, delivery suite, etc. and carried out at 39 weeks' gestation during the working day (i.e. not

3.Needing early delivery but no maternal or foetal compromise

Based on this the following classification of caesarean delivery was

Caesarean operation has undergone a number of technical changes as the procedure has evolved. Many different practitioners extol the benefits of various techniques of skin incision, uterine incision, uterine closure, and many other technical aspects of the operation. However, there are relatively few randomised trials to support many of the commonly used practices at caesarean section. As such there is no standard technique for caesarean delivery although there are a few evidence-

Abdominal opening is accomplished through either transverse (Pfannenstiel and Joel-Cohen) or vertical skin incisions, each of which has advantages and disadvantages. Incision of about 12–15 cm is usually adequate for access [3, 14]. Historically, a vertical midline skin incision was implemented; however, this scar is cosmetically less acceptable and is associated with higher incidence of postoperative wound discomfort, dehiscence, infection, and hernia formation [3]. It may still be necessary if access is required to the upper uterus or to other abdominal organs. At present, the most frequently used type of skin incision is the Pfannenstiel incision since it is associated with less postoperative pain, greater wound strength and better cosmetic results than the vertical midline incision [17]. The use of scalpel is preferred although there are no randomised trials comparing scalpel to electrocautery

**90**

Opening the subcutaneous tissue layer is achieved bluntly preferred to sharp dissection as blunt dissection has been associated with shorter operative times and less chance of injury to vessels [18]. However, there are no randomised trials comparing techniques for incision and dissection of the subcutaneous tissues at caesarean delivery.

There are no randomised trials comparing different techniques of opening the fascia. A small transverse incision is usually made medially with the scalpel and then extended laterally with scissors. Alternatively, the fascial incision can be extended bluntly by inserting the fingers of each hand under the fascia and then pulling in a cephalad-caudad direction [17, 18].

Rectus muscles are separated bluntly in most cases. Avoiding transection of muscles preserves muscle strength. Dissection of the rectus fascia from the rectus sheath and muscles is unnecessary [19] but has not been studied separately in a randomised trial.

Opening the peritoneum can be achieved using the fingers bluntly to minimise the risk of inadvertent injury to the bowel, bladder or other organs that may be adherent to the underlying surface [18, 19]. However blunt versus sharp entry into the peritoneum has not been compared in a randomised trial.

#### **5.2 Hysterotomy/opening the uterus**

Opening of the bladder flap may or may not be performed. Some surgeons choose to open the bladder flap if difficult delivery is anticipated such as when the foetal head is deep in the pelvis or when the bladder is attached well above the lower uterine segment after a previous caesarean delivery. In these cases, creation of the bladder flap may help to keep the bladder dome out of the surgical field if the uterine incision extends.

The uterine incision may be transverse or vertical. The type of incision depends upon several factors, including the position and size of the foetus, location of the placenta, presence of leiomyomas and development of the lower uterine segment. The principal consideration is that the incision must be large enough to allow atraumatic delivery of the foetus. Transverse incision along the lower uterine segment is recommended. Compared with vertical incisions, advantages of the transverse incision include less blood loss, less need for bladder dissection, easier approximation and a lower risk of rupture in subsequent pregnancies [19]. Low vertical and classical incisions may also be performed in certain circumstances. Low vertical incision is performed in the lower uterine segment and appears to be as strong as the low transverse incision [20]. The major disadvantage of the low vertical incision is the possibility of extension cephalad into the uterine fundus or caudally into the bladder, cervix or vagina. It is also difficult to determine that the low vertical incision is truly low, as the separation between lower and upper uterine segments is not easily identifiable clinically. Classical incision is rarely performed at or near term because in subsequent pregnancies it is associated with a higher frequency of uterine dehiscence/rupture than low vertical and low transverse incisions. The generally accepted indications for considering a vertical uterine incision are:

#### **5.3 Delivery of the baby and placenta**

Extraction of the foetus at caesarean delivery is usually uncomplicated but may be made more difficult by extreme prematurity, a deeply impacted or floating foetal head or an abnormal lie. However, careful attention to the duration of prolonged uterine incision to delivery time is important especially in a foetus with a nonreassuring foetal heart rate assessment prior to the onset of surgery.

Cord clamping. Delayed, rather than immediate, cord clamping results in greater neonatal haemoglobin levels and appears to be beneficial for preterm, and some term, infants. However, in asphyxiated baby, the cord should be quickly clamped and cut.

Delivery of the placenta is best achieved with controlled cord traction and aided by oxytocin administration instead of manual delivery which is associated with postoperative endometritis and greater blood loss. To ensure that all of the placenta has been removed, the uterus is usually explored with one hand holding a sponge to remove any remaining membranes or placental tissue, while the other hand is placed on the fundus to stabilise the uterus. These manipulations further stimulate uterine contraction.

#### **5.4 Closure of the uterus**

The uterus may or may not be exteriorized. No approach is superior to the other. Closing the uterus after caesarean section is best performed with a double-layer technique using continuous closure with delayed absorbable synthetic suture incorporating all of the muscle in order to avoid bleeding from the incision edges. Some obstetricians prefer locking the sutures instead of continuous [21]. Recently, Lambert's suture technique for the second layer is being promoted. The bladder peritoneum may or may not reperitonised.

#### **5.5 Closure of the abdomen**

The peritoneal layer may or may not be closed. Nonclosure might allow the enlarged uterus to adhere to the anterior abdominal wall or impede spontaneous closure of the peritoneum, while closure might cause a foreign body reaction to sutures and tissue damage [22]. A systematic review of peritoneal nonclosure and adhesion formation after caesarean delivery found some evidence that nonclosure was associated with greater adhesion formation than closure of the parietal layer or both visceral and parietal layers [23].

Rectus muscles are believed to reapproximate naturally, and suturing them together may cause unnecessary pain when the woman starts to move after surgery [17]. There is no randomised trial that has evaluated rectus muscle closure versus nonclosure.

Fascial closure is a critical aspect of incisional closure as this provides the majority of wound strength during healing. Care should be taken to avoid too much tension when closing the fascia since reapproximation, not strangulation, is the goal. The closure is best achieved with a simple running technique using no 1 or 2 delayed absorbable monofilament suture [22].

The subcutaneous adipose layer is closed with interrupted delayed absorbable sutures if the layer is ≥2 cm. Closure of the dead space seems to inhibit accumulation of serum and blood, which can lead to a wound seroma and subsequent wound breakdown [24]. The point of this layer is to support the skin layer, so Scarpa's fascia should be deliberately included in it [14].

**93**

*Caesarean Section in Low-, Middle- and High-Income Countries*

subcuticular suture, absorbable sutures such as Vicryl may be used.

Reapproximation of the skin may be performed with staples or subcuticular suture. No approach is superior to the other [25] although stables are associated with a doubling of wound complications (infection and wound separation) [26]. Subcuticular stitches have been associated with less immediate postoperative pain and are more cosmetically appealing at 6 weeks than the stapling device [27]. For

Although a life-saving procedure for either the mother or the baby or both, caesarean section comes with a number of complications including but not

1.Infections including endometritis and wound infections. Necrotizing fasciitis

2.Septic pelvic thrombophlebitis including ovarian vein thrombophlebitis and

3.Haemorrhage. The mean blood loss at caesarean is approximately 1000 mL;

4.Urinary tract and blood problems including ileus, urinary tract and bowel

5.Venous thrombosis and embolism whose risk is increased during the postoperative period. Early ambulation and thromboprophylaxis for high-risk mothers

6.Disruption (or opening) of the caesarean laparotomy wound is common, especially in women with risk factors such as obesity, diabetes, history of wound

7.Foetal and neonatal birth risks such as iatrogenic prematurity and birth trauma, transient tachypnea of the newborn, respiratory distress syndrome, etc.

10.Subfertility. Women whose first birth is by caesarean are less likely to have a subsequent pregnancy than women whose first birth is a spontaneous vaginal

11.Scar complications including hysterotomy scar pregnancy, numbness and

13.Abdominal adhesions that may predispose to bowel obstruction, strangulation, infertility and visceral injury during subsequent abdominal operations.

*DOI: http://dx.doi.org/10.5772/intechopen.88573*

**6. Complications of caesarean section**

is rare but can occur after caesarean section.

however, estimates of blood loss are not very reliable.

are recommended to decrease the risk of thromboembolism.

deep septic pelvic thrombophlebitis.

disruption, vertical incision, etc.

9.Abnormal placentation in subsequent pregnancy.

12.Uterine rupture in a subsequent pregnancy.

8.Maternal mortality.

incisional endometriosis.

delivery.

limited to [28]:

injuries.

*Recent Advances in Cesarean Delivery*

clamped and cut.

uterine contraction.

**5.4 Closure of the uterus**

**5.5 Closure of the abdomen**

peritoneum may or may not reperitonised.

both visceral and parietal layers [23].

delayed absorbable monofilament suture [22].

should be deliberately included in it [14].

versus nonclosure.

**5.3 Delivery of the baby and placenta**

Extraction of the foetus at caesarean delivery is usually uncomplicated but may be made more difficult by extreme prematurity, a deeply impacted or floating foetal head or an abnormal lie. However, careful attention to the duration of prolonged uterine incision to delivery time is important especially in a foetus with a non-

Delivery of the placenta is best achieved with controlled cord traction and aided by oxytocin administration instead of manual delivery which is associated with postoperative endometritis and greater blood loss. To ensure that all of the placenta has been removed, the uterus is usually explored with one hand holding a sponge to remove any remaining membranes or placental tissue, while the other hand is placed on the fundus to stabilise the uterus. These manipulations further stimulate

The uterus may or may not be exteriorized. No approach is superior to the other. Closing the uterus after caesarean section is best performed with a double-layer technique using continuous closure with delayed absorbable synthetic suture incorporating all of the muscle in order to avoid bleeding from the incision edges. Some obstetricians prefer locking the sutures instead of continuous [21]. Recently, Lambert's suture technique for the second layer is being promoted. The bladder

The peritoneal layer may or may not be closed. Nonclosure might allow the enlarged uterus to adhere to the anterior abdominal wall or impede spontaneous closure of the peritoneum, while closure might cause a foreign body reaction to sutures and tissue damage [22]. A systematic review of peritoneal nonclosure and adhesion formation after caesarean delivery found some evidence that nonclosure was associated with greater adhesion formation than closure of the parietal layer or

Rectus muscles are believed to reapproximate naturally, and suturing them together may cause unnecessary pain when the woman starts to move after

surgery [17]. There is no randomised trial that has evaluated rectus muscle closure

The subcutaneous adipose layer is closed with interrupted delayed absorbable sutures if the layer is ≥2 cm. Closure of the dead space seems to inhibit accumulation of serum and blood, which can lead to a wound seroma and subsequent wound breakdown [24]. The point of this layer is to support the skin layer, so Scarpa's fascia

Fascial closure is a critical aspect of incisional closure as this provides the majority of wound strength during healing. Care should be taken to avoid too much tension when closing the fascia since reapproximation, not strangulation, is the goal. The closure is best achieved with a simple running technique using no 1 or 2

Cord clamping. Delayed, rather than immediate, cord clamping results in greater neonatal haemoglobin levels and appears to be beneficial for preterm, and some term, infants. However, in asphyxiated baby, the cord should be quickly

reassuring foetal heart rate assessment prior to the onset of surgery.

**92**

Reapproximation of the skin may be performed with staples or subcuticular suture. No approach is superior to the other [25] although stables are associated with a doubling of wound complications (infection and wound separation) [26]. Subcuticular stitches have been associated with less immediate postoperative pain and are more cosmetically appealing at 6 weeks than the stapling device [27]. For subcuticular suture, absorbable sutures such as Vicryl may be used.


IntechOpen Book Series Environmental Sciences

### Volume 7

### Aims and Scope of the Series

Scientists have long researched to understand the environment and man's place in it. The search for this knowledge grows in importance as rapid increases in population and economic development intensify humans' stresses on ecosystems. Fortunately, rapid increases in multiple scientific areas are advancing our understanding of environmental sciences. Breakthroughs in computing, molecular biology, ecology, and sustainability science are enhancing our ability to utilize environmental sciences to address real-world problems.

The four topics of this book series - Pollution; Environmental Resilience and Management; Ecosystems and Biodiversity; and Water Science - will address important areas of advancement in the environmental sciences. They will represent an excellent initial grouping of published works on these critical topics.