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Sentilhes L, Schmitz T, Madar H, Bouchghoul H, Fuchs F, Garabédian C, Korb D, Nouette-Gaulain K, Pécheux O, Sananès N, Sibiude J, Sénat MV, Goffinet F. [The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:7-34. [PMID: 36228999 DOI: 10.1016/j.gofs.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.
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Affiliation(s)
- L Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France.
| | - T Schmitz
- Service de gynécologie obstétrique, hôpital Robert-Debré, université Paris Diderot, AP-HP, Paris, France
| | - H Madar
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - H Bouchghoul
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - F Fuchs
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Montpellier, Montpellier, France
| | - C Garabédian
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Lille, Lille, France
| | - D Korb
- Service de gynécologie obstétrique, hôpital Robert-Debré, université Paris Diderot, AP-HP, Paris, France
| | - K Nouette-Gaulain
- Service d'anesthésie, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - O Pécheux
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Lille, Lille, France
| | - N Sananès
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Strasbourg, Strasbourg, France
| | - J Sibiude
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, AP-HP Louis-Mourier, Colombes, France
| | - M-V Sénat
- Service de gynécologie-obstétrique, hôpital Bicêtre, AP-HP Le Kremlin-Bicêtre, Paris, France
| | - F Goffinet
- Maternité Port-Royal, groupe hospitalier Cochin Broca, Hôtel-Dieu, université Paris-Descartes, AP-HP, Paris, France
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Punchuklang W, Nivatpumin P, Jintadawong T. Total failure of spinal anesthesia for cesarean delivery, associated factors, and outcomes: A retrospective case-control study. Medicine (Baltimore) 2022; 101:e29813. [PMID: 35801788 PMCID: PMC9259130 DOI: 10.1097/md.0000000000029813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Spinal anesthesia is the anesthetic technique of choice for patients undergoing cesarean delivery. In the present study, total spinal anesthesia failure was defined as a case when an absent blockade or inadequate surgery required general anesthesia administration with an endotracheal tube. This study aimed to investigate factors related to this condition and report its maternal and neonatal outcomes. This retrospective matched case-control study was conducted by recruiting 110 patients with failed spinal anesthesia and 330 control patients from September 1, 2016, to April 30, 2020, in the largest university hospital, Thailand. Of 12,914 cesarean deliveries, 12,001 patients received single-shot spinal anesthesia (92.9%) during the study period. Total spinal anesthesia failure was experienced by 110/12,001 patients, giving an incidence of 0.9%. Factors related to the failures were a patient body mass index (BMI) ≤29.5 kg/m2 (adjusted odds ratio 1.9; 95% confidence interval 1.2-3.1; P = .010) and a third-year resident (the most senior trainee) performing the spinal block (adjusted odds ratio 2.4; 95% confidence interval 1.5-3.7; P < .001). In the group with failed spinal anesthesia, neonatal Apgar scores at 1 and 5 minutes were lower than those of the control group (both P < .001). Two patients in the failed spinal anesthesia group (2/110; 1.8%) had difficult airways and desaturation. Independent factors associated with total spinal anesthesia failure were a BMI of ≤29.5 kg/m2 and a third-year resident performing the spinal block. Although the incidence of total failure was infrequent, there were negative consequences for the mothers and neonates. Adjusting the dose of bupivacaine according to the weight and height of a patient is recommended, with a higher dose appropriate for patients with a lower BMI.
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Affiliation(s)
- Wiruntri Punchuklang
- Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patchareya Nivatpumin
- Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Patchareya Nivatpumin, Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University2 Wanglang Road, Bangkok Noi, Bangkok 10700, Thailand (e-mail: )
| | - Thatchanan Jintadawong
- Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Bhat A, Jaffer D, Keasler P, Kamath K, Kelly J, Singh P. Uterine externalization versus in-situ repair of hysterotomy during cesarean delivery: a systematic review, equivalence meta-analysis, and trial sequential analysis. Int J Obstet Anesth 2022; 50:103271. [DOI: 10.1016/j.ijoa.2022.103271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/18/2022] [Accepted: 02/05/2022] [Indexed: 10/19/2022]
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Tan HS, Taylor CR, Sharawi N, Sultana R, Barton KD, Habib AS. Uterine exteriorization versus in situ repair in Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2021; 69:216-233. [PMID: 34811700 DOI: 10.1007/s12630-021-02142-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/20/2021] [Accepted: 09/09/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE We conducted an updated systematic review and meta-analysis on maternal outcomes associated with uterine exteriorization compared with in situ repair in women undergoing Cesarean delivery. METHODS We searched for randomized controlled trials comparing uterine exteriorization with in situ repair during Cesarean delivery. Primary outcomes were intraoperative nausea and vomiting (IONV) and perioperative decrease in hemoglobin concentration. Secondary outcomes were postoperative nausea and vomiting (PONV), estimated blood loss, fever, endometritis, wound infection, intraoperative and postoperative pain, postoperative analgesic use, duration of surgery and hospital stay, and time to return of bowel function. RESULTS Twenty studies with 20,909 parturients were included. Exteriorization was associated with higher risk of IONV (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.66 to 2.63; I2 = 0%), with no difference in perioperative hemoglobin concentration decrease (mean difference, - 0.06 g·dL-1; 95% CI, - 0.20 to 0.08; I2 = 97%) compared with in situ repair. There were no significant differences in estimated blood loss, transfusion requirement, PONV, duration of surgery, duration of hospital stay, time to return of bowel function, fever, endometritis, or wound infection. Postoperative pain (incidence of pain graded > 5/10) at six hours (OR, 1.64; 95% CI, 1.31 to 2.03; I2 = 0%) was higher with exteriorization, but there was no difference in need for rescue analgesia (OR, 2.48; 95% CI, 0.89 to 6.90; I2 = 94%) or pain scores at 24 hr compared with in situ repair. CONCLUSIONS In this updated systematic review and meta-analysis, uterine exteriorization was associated with an increased risk of IONV but no significant change in perioperative hemoglobin decrease compared with in situ repair. STUDY REGISTRATION PROSPERO (CRD42020190074); registered 5 July 2020.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Cameron R Taylor
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Karen D Barton
- Medical Center Library and Archives, Duke University Medical Center, Durham, NC, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA.
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Kükrer S, Pepekal Kükrer A. Delivery method of the placenta in cesarean deliveries and the effect of uterine incision repair area on morbidity: A randomized controlled study. Turk J Obstet Gynecol 2021; 18:92-102. [PMID: 34082521 PMCID: PMC8191328 DOI: 10.4274/tjod.galenos.2021.05873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective We evaluated the effects of spontaneous or manual delivery of the placenta and repair of uterine incision inside or outside the abdomen on intraoperative blood loss, postoperative infection morbidity, and postoperative hospitalization time. Materials and Methods We conducted a prospective randomized controlled study with 150 patients among 160 patients who were indicated to undergo emergency cesarean procedures in our tertiary hospital. We divided the patient population into four groups. These four groups were formed by comparing the way the placenta was delivered manually and by spontaneous traction with the repair of the uterus inside and outside the abdomen. Blood loss was determined using quantitative and gravimetric methods. A numeric rating scale was used, which is a one-dimensional method used for uterine sensitivity distribution and pain measurement. Results The amount of bleeding was 339 mL in group 1, 237 mL in group 2, 470 mL in group 3, and 490 mL in group 4, which were significantly different (p<0.001). The mean surgical time was 30.8±5.5 minutes in group 1, 30.7±4.4 minutes in group 2, 38.5±6.9 minutes in group 3, and 43.9 minutes in group 4 (p<0.001). When the distribution of uterine tenderness among the groups was examined in the fundus examinations performed on the postpartum 1st day of the patients, we found a significant difference (p<0.001). When all groups were compared, there was a significant difference between group 1 and group 4 in terms of hospital stay (p<0.004). Among the contributing factors were endometritis, maternal body weight (p<0.053), advanced gestational week (p<0.004), prolonged surgical time (p<0.009), and the presence of meconium. Conclusion Manual removal of the placenta resulted in higher blood loss, increased uterine tenderness, and longer hospitalization compared with the spontaneous separation method. The uterine incision repair site did not affect morbidity.
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Affiliation(s)
- Sadık Kükrer
- University of Health Sciences Turkey, Adana City Training and Research Hospital, Clinic of Obstetrics and Gynecology, Adana, Turkey
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Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M, Bhambhani S, Carvalho B. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean. Anesth Analg 2021; 132:1362-1377. [PMID: 33177330 DOI: 10.1213/ane.0000000000005257] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.
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Affiliation(s)
- Laurent Bollag
- From the Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Ruth Landau
- Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mark Zakowski
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Sumita Bhambhani
- Department of Anesthesiology, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
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Riemma G, Schiattarella A, Cianci S, La Verde M, Morlando M, Sisti G, Esposito I, Della Corte L, Sansone P, De Franciscis P. Transversus abdominis plane block versus wound infiltration for post-cesarean section analgesia: A systematic review and meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2021; 153:383-392. [PMID: 33368204 DOI: 10.1002/ijgo.13563] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/12/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Transversus abdominis plane (TAP) block and wound infiltration (WI) with local anesthetics are used for postoperative analgesia after cesarean section (CS), reducing the need for administration of opioids. OBJECTIVE To compare the analgesic effect of TAP block related to WI. SEARCH STRATEGY MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Cochrane Library, and CINAHL were searched from inception until April 2020. SELECTION CRITERIA Randomized controlled trials (RCTs) about women who underwent TAP block or WI after CS. DATA COLLECTION AND ANALYSIS Relevant data were extracted and tabulated. Review Manager 5.3 was used for data analysis. Primary outcome was cumulative opioid consumption (COC) 24 and 48 h after CS. MAIN RESULTS Five RCTs, enrolling 268 women, were included. There were no significant differences between the interventions regarding COC at 24 (mean difference [MD] -1.68, 95% confidence interval [CI] -6.29 to 2.93) and 48 hours (MD 1.28, 95% CI -10.44 to 13.00). Adverse effects (relative risk [RR] 0.93, 95% CI 0.75-1.16), gastrointestinal reactions (RR 1.30, 95% CI 0.46-3.68), or mild-moderate sedation (RR 1.12, 95% CI 0.72-1.74), pain scores, satisfaction of women, and withdrawals were similar between groups. CONCLUSIONS There might be no significant advantages selecting TAP block over WI for post-CS analgesia.
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Affiliation(s)
- Gaetano Riemma
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Schiattarella
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stefano Cianci
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco La Verde
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maddalena Morlando
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Sisti
- Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Irene Esposito
- Anesthesiology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Pasquale Sansone
- Anesthesiology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pasquale De Franciscis
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
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Wang LH, Seow KM, Chen LR, Chen KH. The Health Impact of Surgical Techniques and Assistive Methods Used in Cesarean Deliveries: A Systemic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6894. [PMID: 32967222 PMCID: PMC7558715 DOI: 10.3390/ijerph17186894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022]
Abstract
Cesarean delivery is one of the most frequently performed surgeries in women throughout the world. However, the most optimal technique to minimize maternal and fetal morbidities is still being debated due to various clinical situations and surgeons' preferences. The contentious topics are the use of vacuum devices other than traditional fundal pressure to assist in the delivery of the fetal head and the techniques of uterine repair used during cesarean deliveries. There are two well-described techniques for suturing the uterus: The uterus can be repaired either temporarily exteriorized (out of abdominal cavity) or in situ (within the peritoneal cavity). Numerous studies have attempted to compare these two techniques in different aspects, including operative time, blood loss, and maternal and fetal outcomes. This review provides an overview of the assistive method of vacuum devices compared with fundal pressure, and the two surgical techniques for uterine repair following cesarean delivery. This descriptive literature review was performed to address important issues for clinical practitioners. It aims to compare the advantages and disadvantages of the assistive methods and surgical techniques used in cesarean deliveries. All of the articles were retrieved from the databases Medline and PubMed using the search terms cesarean delivery, vacuum, and exteriorization. The searching results revealed that after exclusion, there were 9 and 13 eligible articles for vacuum assisted cesarean delivery and uterine exteriorization, respectively. Although several studies have concluded vacuum assistance for fetal extraction as a simple, effective, and beneficial method during fetal head delivery during cesarean delivery, further research is still required to clarify the safety of vacuum assistance. In general, compared to the use of in situ uterine repairs during cesarean delivery, uterine exteriorization for repairs may have benefits of less blood loss and shorter operative time. However, it may also carry a higher risk of intraoperative complications such as nausea and vomiting, uterine atony, and a longer time to the return of bowel function. Clinicians should consider these factors during shared decision-making with their pregnant patients to determine the most suitable techniques for cesarean deliveries.
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Affiliation(s)
- Li-Hsuan Wang
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan;
| | - Kok-Min Seow
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 10449, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 30010, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan;
- School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
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The incidence and factors associated with intraoperative nausea and vomiting during cesarean section under spinal anesthesia, July 2019. An institution based cross sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hardy-Fairbanks AJ, Mackenzie T, McCarthy M, Goldman MB, Lauria MR. A randomized controlled trial comparing two types of retractors at caesarean delivery . J OBSTET GYNAECOL 2017. [PMID: 28635352 DOI: 10.1080/01443615.2017.1316972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim of this study was to determine if the use of a self-retaining, symmetrical retractor (OB/Mobius®) during caesarean delivery is associated with differences in post-operative pain experience. Consenting women undergoing caesarean delivery were randomly assigned to OB/Mobius® versus conventional retraction instruments. Women were blinded to retractor type and filled out surgical pain surveys each post-operative day. Additional outcome variables were collected through a provider survey and chart review. Of the 154 randomised women, 144 completed the study. There was no difference in the symmetry, quality or intensity of postoperative pain based on the method of retraction. The OB/Mobius® retractor did not confer an improvement in the quality or intensity of post-caesarean discomfort in the first three days following delivery. Nor did the groups differ in operative times, blood loss or pain medication usage. However, the retractor may offer improved visualisation and retraction in obese women. Impact statement Use of a plastic sheath self-retaining retractor has been minimally studied in caesarean deliveries. Recently it was found that the use of such a retractor reduced wound infection, but another study in obese women did not show improved rates of infection (Hinkson et al. 2016 ; Scolari Childress et al. 2016 ). The study of sheath self-retaining retractors to decrease post-operative pain has not been reported previously. This study offers an investigation into a generalisable population of parturients who undergo caesarean delivery and if the primary use of a self-retaining retractor versus sole use of traditional hand-held retractors decreased post-operative pain while in the hospital. Although this study did not show an improvement in post-operative pain, provider experience reports demonstrated some improvement in visualisation, particularly in the obese population with the use of this novel retractor, thus making it an option for providers who do caesarean deliveries without an assistant and find hand-held retractors inadequate.
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Affiliation(s)
- Abbey J Hardy-Fairbanks
- a Department of Obstetrics and Gynaecology , University of Iowa Hospitals and Clinics , Iowa City , IA , USA
| | - Todd Mackenzie
- c Department of Medicine , Dartmouth-Hitchcock Medical Center , Lebanon , PA , USA
| | - Martin McCarthy
- d Department of Preventive Medicine , Feinberg School of Medicine, Northwestern University , Chicago , IL , USA
| | - Marlene B Goldman
- e Department of Obstetrics and Gynaecology, Division of Clinical Research , Dartmouth-Hitchcock Medical Center and Geisel School of Medicine , Lebanon , PA , USA
| | - Michele R Lauria
- b Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine , Dartmouth-Hitchcock Medical Center , Lebanon , PA , USA
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Scolari Childress KM, Gavard JA, Ward DG, Berger K, Gross GA. A barrier retractor to reduce surgical site infections and wound disruptions in obese patients undergoing cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol 2016; 214:285.e1-285.e10. [PMID: 26440690 DOI: 10.1016/j.ajog.2015.09.096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/08/2015] [Accepted: 09/28/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are an important cause of morbidity following cesarean delivery, particularly in obese patients. Methods to reduce SSIs after cesarean delivery would have an important impact in obese obstetric patients. OBJECTIVE The purpose of this study was to determine whether the Alexis O cesarean delivery retractor, a barrier self-retaining retractor, reduces SSIs and wound disruptions in obese patients undergoing cesarean delivery. STUDY DESIGN This was a randomized controlled trial of obese women (body mass index ≥ 30 kg/m(2)) undergoing nonemergent cesarean delivery. Patients were randomized to the treatment group (using the Alexis O cesarean delivery retractor) or to the control group (using conventional handheld retractors). The primary outcome was SSI or wound disruption during the 30 day postoperative period. Secondary outcomes included operative time, estimated blood loss, change in hemoglobin, antiemetic use, length of postoperative hospital stay, hospital readmission, and other postoperative complications. RESULTS A total of 301 patients were enrolled in the study. One hundred forty-four patients were randomized to the treatment group and 157 to the control group. Baseline characteristics and indications for cesarean delivery were similar between the 2 groups. Median body mass index was 40.1 kg/m(2). There were no significant differences between the treatment and the control group in the primary outcome of SSI or wound disruption rates at the 30 day assessment (20.6% vs 17.6%, P = .62), during the postoperative inpatient hospitalization or at the 1-2 week postoperative visit. There were also no differences in the primary outcome when adjusting for obesity class or thickness of the subcuticular layer. Patients in the treatment group had lower rates of uterine exteriorization (54.3% vs 87.3%, P < .001), but there were no differences in all other outcomes. CONCLUSION Use of the Alexis retractor in cesarean delivery deliveries did not decrease SSI or wound disruption rates in an obese population. Its use as a retractor should be left to the discretion of the surgeon and clinical circumstances.
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Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2015; 62:1209-20. [DOI: 10.1007/s12630-015-0448-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 06/01/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022] Open
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TELNES A, SKOGVOLL E, LONNÉE H. Transversus abdominis plane block vs. wound infiltration in Caesarean section: a randomised controlled trial. Acta Anaesthesiol Scand 2015; 59:496-504. [PMID: 25786679 DOI: 10.1111/aas.12498] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/25/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multiple studies suggest that transversus abdominis plane (TAP) block (without intrathecal morphine) after Caesarean section (CS) reduces post-operative morphine consumption. In our study, we wanted to compare the analgesic effect of TAP block with infiltration of the wound after CS. METHODS We included 60 pregnant women scheduled for elective CS under spinal anaesthesia in a randomised, single-centre, double-blind study. Thirty patients received ultrasound-guided TAP block using 20 ml bupivacaine 0.25% with adrenaline 5 μg/ml bilaterally and 20 ml normal saline as wound infiltration (TAP group). The other 30 patients (the control group) received normal saline 20 ml bilaterally in the TAP, and 20 ml bupivacaine 0.25% with adrenaline 5 μg/ml as wound infiltration. The main outcome was cumulative morphine consumption at 48 h after surgery. In addition, continuous morphine consumption, pain scores and side effects were registered. RESULTS Fifty-seven patients completed the study. Cumulative morphine consumption at 48 h (mean±standard deviation) was 41±34 mg in the TAP group and 38±27 mg in the control group (P=0.7); a difference of 3 mg (95% confidence interval -13 to 19 mg). Morphine consumption at any time up to 48 h was virtually identical in both groups. Side effects were similar, except for a higher degree of sedation in the TAP group (P=0.04). CONCLUSION Compared with wound infiltration with local anaesthetics, TAP block did not reduce cumulative morphine consumption following CS. The TAP block was associated with more pronounced sedation.
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Affiliation(s)
- A. TELNES
- Department of Anaesthesia and Intensive Care; St Olav's University Hospital; Trondheim Norway
| | - E. SKOGVOLL
- Department of Anaesthesia and Intensive Care; St Olav's University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - H. LONNÉE
- Department of Anaesthesia and Intensive Care; St Olav's University Hospital; Trondheim Norway
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El-Khayat W, Elsharkawi M, Hassan A. A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery. Int J Gynaecol Obstet 2014; 127:163-6. [PMID: 25005057 DOI: 10.1016/j.ijgo.2014.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/11/2014] [Accepted: 06/12/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair. METHODS The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012-2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n=500) and in situ repair in group 2 (n=500). The primary outcome measure was the surgery duration. RESULTS Surgery duration was significantly longer in group 1 than group 2 (49.9±2.3 minutes vs 39.9±1.8 minutes; P<0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P=0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P<0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0±2.7 hours vs 14.0±1.9 hours; P<0.001). CONCLUSION In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement. ClinicalTrials.gov:NCT01723605.
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Affiliation(s)
- Waleed El-Khayat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Mohamed Elsharkawi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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The effect on perioperative bleeding of placental extraction from an exteriorized uterus during caesarean section. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:384-390. [PMID: 24927289 DOI: 10.1016/s1701-2163(15)30583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the effect on perioperative bleeding of an alternative technique for Caesarean section, in which placental extraction is performed while the uterus is exteriorized. METHODS We performed a retrospective matched cohort study using data obtained through chart review. Group 1 included women who had CS performed using the technique of placental removal while the uterus was exteriorized, and group 2 included women who had CS performed using the conventional method of placental removal from a non-exteriorized uterus. Women in each group were matched for number of previous Caesarean sections, indications for CS, and gestational age. The primary outcome was the difference between preoperative and postoperative hemoglobin concentrations. Secondary outcomes included the incidence of blood transfusion, estimated blood loss (EBL), operative time, the incidence of postoperative endometritis, and length of hospital stay. RESULTS A total of 90 charts were reviewed (45 per group). Baseline clinical characteristics were similar in both groups. The mean decrease in hemoglobin concentration was 22% less in women who had placental extraction from an exteriorized uterus than in those who had the conventional placental extraction (13.2g/L vs. 16.9 g/L, P=0.016). Among secondary outcomes, women in group 1 had a lower mean EBL (531.1 mL vs. 691.1 mL, P<0.05) and a shorter mean duration of surgery (28.0 minutes vs. 40.5 minutes, P<0.05). CONCLUSION Exteriorizing the uterus prior to removal of the placenta during CS may decrease intraoperative and immediate postoperative bleeding compared with the conventional technique. Further studies on this technique are indicated.
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Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol 2013; 209:294-306. [PMID: 23467047 DOI: 10.1016/j.ajog.2013.02.043] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/24/2013] [Accepted: 02/25/2013] [Indexed: 11/26/2022]
Abstract
The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.
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Hardy-Fairbanks AJ, Lauria MR, Mackenzie T, McCarthy M. Intensity and unpleasantness of pain following vaginal and cesarean delivery: a prospective evaluation. Birth 2013; 40:125-33. [PMID: 24635467 DOI: 10.1111/birt.12039] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND To date, most studies evaluating pain associated with cesarean birth have focused on delivery procedures or postoperative pain control methods rather than on the nature or severity of the pain experience of women, despite the increasing incidence and maternal requests for cesarean delivery. The objective in this study was to evaluate sensory, affective, and laterality aspects of pain after cesarean delivery and vaginal delivery. METHODS A prospective cohort study using a seven-item visual analog scale assessed pain at rest and with activity, and the unpleasantness and location of pain on postpartum days 1 and 2. Chart review identified demographic and clinical factors influencing pain. Multivariable regression and propensity score analyses were used to evaluate patient-level outcomes. RESULTS Of 126 consenting women, 48 underwent cesarean delivery and 78 had vaginal delivery. No statistically significant differences in pain at rest and pain unpleasantness were found between groups on postpartum day 1, but women undergoing cesarean delivery reported more pain with activity than those who had a vaginal delivery (p < 0.0002). On postpartum day 2, cesarean delivery women reported significantly more pain when compared with those with a vaginal delivery (p < 0.04), and more cesarean delivery women reported lateralized pain (p < 0.0001). In multivariate regression analyses, cesarean delivery was the most significant predictor of activity-related pain on postpartum day 1 (p < 0.00001), followed by current substance abuse (p < 0.01). Women undergoing cesarean delivery required twice the dosage of analgesics on postpartum day 1 and four times greater amounts on postpartum day 2 relative to those with a vaginal delivery (p < 0.01 and p < 0.001). CONCLUSIONS Cesarean delivery was associated with higher levels of pain, more unpleasant pain, more lateralized pain, and greater narcotic use than vaginal delivery. Evaluation of factors associated with postpartum pain can help practitioners to counsel women better about their delivery alternatives and can promote improved management of women undergoing both types of delivery experiences.
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Affiliation(s)
- Abbey J Hardy-Fairbanks
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Dieterich M, Müller-Jordan K, Stubert J, Kundt G, Wagner K, Gerber B. Pain management after cesarean: a randomized controlled trial of oxycodone versus intravenous piritramide. Arch Gynecol Obstet 2012; 286:859-65. [PMID: 22622852 DOI: 10.1007/s00404-012-2384-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/08/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Primary objective was to assess whether oral analgesia with oxycodone offers superior pain relief after cesareans than patient controlled analgesia (PCA). Secondary outcomes were additional pain medication, time to first mobilization, therapeutic side effects, postoperative restrictions, overall satisfaction and costs. MATERIALS AND METHODS Randomized controlled trial at a University Hospital conduct between July 2009 and November 2009. Of the 1,112 patients, 257 met the inclusion criteria and 239 agreed to participate. Patients were randomly assigned to either receive intravenous piritramide PCA (2 mg piritramide/ml 0.9 % saline) or oral oxycodone (20 mg). Pain was assessed on a visual analog pain scale (VAS) at 2, 12, 24, 32, 40, 48 and 72 h after cesarean. RESULTS No differences in VAS scores were observed within the general study population. Pain scores of oxycodone versus PCA were comparable at 24 h. Patients randomized to PCA demonstrated increased demand for rescue medication 48 h after cesarean (p = 0.057). In the PCA group, patients with previous cesarean had increased operative times, a trend towards increased VAS scores after 48 h (p = 0.081) and increased VAS scores in comparison to patients who did not have cesarean before (p = 0.044). For this subgroup, no difference was seen in the oxycodone patients (p = 0.883). CONCLUSION General satisfaction with both treatment regimes was high. The results support the potential use of oral pain regimes and emphasis the importance of a multimodal approach to treat post-cesarean pain. Oral oxycodone is a not expensive, convenient and comparable analgesic to PCA devices with opioids after cesarean. Trial registration at clinicaltrials.gov identifier: NCT 01115101.
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Affiliation(s)
- Max Dieterich
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany.
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Doğanay M, Tonguc EA, Var T. Effects of method of uterine repair on surgical outcome of cesarean delivery. Int J Gynaecol Obstet 2010; 111:175-8. [DOI: 10.1016/j.ijgo.2010.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 06/03/2010] [Accepted: 07/09/2010] [Indexed: 11/25/2022]
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Breeze E. Minimum effective bolus dose of oxytocin during elective Caesarean delivery. Br J Anaesth 2010; 104:783; author reply 783-5. [PMID: 20460573 DOI: 10.1093/bja/aeq104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lavand’homme P. Chronic pain after vaginal and cesarean delivery: a reality questioning our daily practice of obstetric anesthesia. Int J Obstet Anesth 2010; 19:1-2. [DOI: 10.1016/j.ijoa.2009.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/23/2009] [Indexed: 11/28/2022]
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Walsh CA, Walsh SR. Extraabdominal vs intraabdominal uterine repair at cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2009; 200:625.e1-8. [PMID: 19344883 DOI: 10.1016/j.ajog.2009.01.009] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 11/12/2008] [Accepted: 01/13/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cesarean section delivery is a commonly performed surgical procedure, and rates of cesarean delivery are increasing. Previous randomized trials that compared extraabdominal and intraabdominal uterine repair at cesarean section delivery have yielded conflicting results. STUDY DESIGN We conducted a metaanalysis of published randomized controlled trials that addressed the method of uterine repair at cesarean delivery. The primary outcome was incidence of perioperative complications. The secondary outcomes were operative time, estimated blood loss, and hospital stay. Pooled odds ratios were calculated for categoric variables with random effects models. Continuous variables were compared by means of weighted mean differences. RESULTS No significant differences in either postoperative or intraoperative complications were demonstrated between the extraabdominal (n = 1605) and intraabdominal repair (n = 1578) groups. Operative time, estimated blood loss, and hospital stay were all unaffected by repair technique. This study cannot exclude differences in rare complications, such as serious venous air embolism or maternal death. CONCLUSION No differences in complication rates were found between extraabdominal and intraabdominal repair at cesarean section delivery; both techniques are valid surgical options.
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Shahin AY, Osman AM. Parietal peritoneal closure and persistent postcesarean pain. Int J Gynaecol Obstet 2008; 104:135-9. [DOI: 10.1016/j.ijgo.2008.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 09/11/2008] [Accepted: 09/11/2008] [Indexed: 10/21/2022]
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Dede M, Yilmaz A. Comment on treatment of incidental adnexal masses at cesarean section: a retrospective study. Int J Gynecol Cancer 2007. [DOI: 10.1111/j.1525-1438.2007.01012.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Siddiqui M, Goldszmidt E, Fallah S, Kingdom J, Windrim R, Carvalho JCA. Complications of Exteriorized Compared With In Situ Uterine Repair at Cesarean Delivery Under Spinal Anesthesia. Obstet Gynecol 2007; 110:570-5. [PMID: 17766602 DOI: 10.1097/01.aog.0000277712.67230.22] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare intraoperative complications of exteriorized and in situ uterine repair during elective cesarean delivery under spinal anesthesia. METHODS This study was a randomized, single-blinded trial in 80 women undergoing elective cesarean delivery under spinal anesthesia. Patients were randomly assigned to exteriorized or in situ uterine repair. Obstetricians were asked to perform assisted delivery of the placenta. Spinal anesthesia and oxytocin management were standardized. Phenylephrine was used to maintain systolic blood pressure within 10% of the baseline. The primary outcome was intraoperative, postdelivery nausea or vomiting. RESULTS Postdelivery nausea or vomiting (18% compared with 38%; P=.04) and tachycardia (3% compared with 18%; P=.03) were significantly reduced in the in situ group compared with the exteriorized group. The duration of uterine repair was significantly shorter in the exteriorized group (median 10 minutes [first and third quartiles 9, 13], compared with 11 minutes [9, 15]) (P=.04). The duration of surgery (36 minutes [30, 41] compared with 37 minutes [30, 45]) and estimated blood loss (mean+/-standard deviation 625+/-489 mL compared with 653+/-416 mL) were similar between the in situ and the exteriorized groups. There was no correlation between duration of uterine repair and estimated blood loss. CONCLUSION Exteriorization of the uterus for repair is associated with an increased incidence of nausea and vomiting and tachycardia during cesarean delivery under spinal anesthesia. Uterine repair should be done in situ where possible. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00452972 LEVEL OF EVIDENCE I.
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Affiliation(s)
- Mughina Siddiqui
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Onatario, Canada
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Mahajan NN, Gaikwad NL, Mahajan KN. Comment on treatment of incidental adnexal masses at cesarean section: a retrospective study. Int J Gynecol Cancer 2007; 17:1181; author reply 1182. [PMID: 17506838 DOI: 10.1111/j.1525-1438.2007.00982.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Jacobs‐Jokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section. Cochrane Database Syst Rev 2004; 2004:CD000085. [PMID: 15494988 PMCID: PMC7051025 DOI: 10.1002/14651858.cd000085.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Different techniques have been described to reduce morbidity during caesarean section. After the baby has been born by caesarean section and the placenta has been extracted, temporary removal of the uterus from the abdominal cavity (exteriorisation of the uterus) to facilitate repair of the uterine incision has been postulated as a valuable technique. This is particularly so when exposure of the incision is difficult and when there are problems with haemostasis. Several clinical trials have been done, with varying results, including substantial reduction in the rate of postoperative infection and morbidity with extra-abdominal closure of the uterine incision, and less associated peri-operative haemorrhage. Subsequent studies suggest that the method of placental removal rather than method of closure of the uterine incision influences peri-operative morbidity. OBJECTIVES To evaluate the effects of extra-abdominal repair of the uterine incision compared to intra-abdominal repair. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to July 2003) and PubMed (1966 to 2003). SELECTION CRITERIA Randomised controlled trials involving a comparison of uterine exteriorisation with intra-abdominal repair of the uterine incision in women undergoing caesarean section. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the trials identified for inclusion. We compared categorical data using relative risks and 95% confidence intervals and continuous data using the weighted mean difference with 95% confidence intervals. We tested for statistical heterogeneity between trials using the I squared test. Where no significant heterogeneity (greater than 50%) existed, we pooled data using a fixed effect model. If significant heterogeneity existed, a random effects model was used. MAIN RESULTS Six studies were included, with 1294 women randomised overall, and 1221 women included in the analysis. There were no statistically significant differences between the groups in most of the outcomes identified, except for febrile morbidity and length of hospital stay. With extra-abdominal closure of the uterine incision, febrile morbidity was lower (relative risk 0.41, 95% confidence interval (CI) 0.17 to 0.97), and the hospital stay was longer (weighted mean difference 0.24 days, 95% CI 0.08 to 0.39). REVIEWERS' CONCLUSIONS There is no evidence from this review to make definitive conclusions about which method of uterine closure offers greater advantages, if any. However, these results are based on too few and too small studies to detect differences in rare, but severe, complications.
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Affiliation(s)
| | - G Justus Hofmeyr
- University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of HealthDepartment of Obstetrics and Gynaecology, East London Hospital ComplexFrere and Cecilia Makiwane HospitalsPrivate Bag X 9047East LondonEastern CapeSouth Africa5200
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