The effect of rectus muscle re-approximation at cesarean delivery on pain perceived after operation: a randomized control trial

Cesarean section: One procedure, varied techniques. Detailed observations of 1013 first cesarean sections in a tertiary hospital in Ghana

OBJECTIVE

Cesarean sections (CS) are among the most performed surgical procedures in the world. Small variations in surgical techniques could have a significant impact on a global scale, for example, in postoperative complications. In the present study we aimed to observe and audit every single step used during first time CS.

METHODS

Descriptive cross-sectional study from January 1, 2018 to January 14, 2020 at a tertiary hospital in Ghana. Techniques used for CS were directly observed and thoroughly documented. Standard descriptive methods were used for data analysis.

RESULTS

Of the 1013 first time CS, 81.4% were emergency procedures. The mean (SD) gestational age at CS was 38.4 ± 3 weeks. Low transverse incision was used in 993/1013 (98%) of cases. Blunt dissection of subcuticular tissue was done in 48/1013 (4.7%), blunt separation of rectus fascia in 386/1013 (38.1%), blunt opening of peritoneum in 838/1013 (82.7%) and lower uterine segment incision with scalpel in 995/1013 (98.2%) women. A total of 916/1013 (90.4%) had double layered uterine closure, 961/1013 (94.9%) had uterus exteriorized for repair, 382/1013 (37.7%) had closure of the peritoneum, 655/1013 (64.7%) had non-closure of the rectus muscle, 677/1013 (66.8%) had subcutaneous tissue closed and 983/1013 (97.0%) had skin closed with subcuticular stitches. There were 493 different combinations of techniques observed performed by 85 surgeons for carrying out a complete first time CS.

CONCLUSION

There is a wide variety of methods used for first time CS. There is the need for training and retraining on the techniques for CS using evidence-based guidelines.

Rectus muscle reapproximation at cesarean delivery: a randomized controlled trial

OBJECTIVE

The aim of our study was to investigate the effect of rectus muscle reapproximation at cesarean delivery (CD) on postoperative pain and rectus muscle diastasis.

METHODS

Our study was planned as a prospective, randomized study in our clinic between December 2019 and March 2021. The study group included women >37 weeks of gestation, undergoing CD for the first time, with no prior history of pelvic or abdominal surgery, 18-40 years of age. Patients were randomly assigned to either the rectus muscle reapproximation group or the control group. Patients were evaluated at postoperative 1st day and 6th week. The primary outcome was the comparison of the Visual Analogue Scale (VAS) score and inter-rectus diatance (IRD) among the groups. Additionally, factors associated with rectus diastasis were also analyzed using logistic regression.

RESULTS

A total of 306 women undergoing primary cesarean sections were randomized, and 296 were included in the final analysis. There was no significant difference in terms of VAS score and postoperative analgesia need among the groups. IRD 2 cm below umbilicus was significantly shorter in rectus muscle reapproximation group at postoperative 6th week. The logistic regression analysis showed that rectus muscle reapproximation had a negative impact on the development of rectus diastasis below umbilicus (OR = 2.830, p = 0.013).

CONCLUSION

Rectus muscle reapproximation during CD resulted in less rectus diastasis below umbilicus. On the other hand it did not affect postoperative VAS score.

Implementing a bundle for evidence-based cesarean delivery may not be as beneficial as expected: a multicenter, pre- and post-study

BACKGROUND

Standardization of procedures improves outcomes. Though systematic reviews have summarized the evidence-based steps of cesarean delivery, their bundled implementation has not been investigated.

OBJECTIVE

In this preimplementation and postimplementation trial, we sought to ascertain if bundled evidence-based steps of cesarean delivery, compared with the surgeon's preference, improve outcomes.

STUDY DESIGN

A Standards for Reporting Implementation Studies compliant, multicenter preimplementation and postimplementation trial at 4 teaching hospitals was conducted. The preimplementation period consisted of cesarean delivery done on the basis of the physicians' preferences for 3 months; educational intervention (eg, didactics, badge cards, posters, video) occurred in the fourth month. Cesarean deliveries in the postimplementation period employed the bundled evidence-based steps. A preplanned 10% randomized audit of both groups assessed adherence and uptake of evidence-based steps. The primary outcome was composite maternal morbidity, which included estimated blood loss ≥1000 mL, blood transfusion, endometritis, postpartum fever, wound complications, sepsis, thrombosis, intensive care unit admission, hysterectomy, or death. The secondary outcome was composite neonatal morbidity, and some of its components were a 5-min Apgar score <7, positive pressure oxygen use, hypoglycemia, or sepsis. A priori Bayesian sample size calculation indicated 700 cesarean deliveries in each group were needed to demonstrate a 20% relative reduction (from 15% to 12%) of composite maternal morbidity with 75% certainty. Bayesian logistic regression with neutral priors was used to calculate the likelihood of net improvement in adjusted relative risk with 95% credible intervals.

RESULTS

A total of 1425 consecutive cesarean deliveries (721 in preimplementation and 704 in postimplementation group) were examined. Audited data indicated that the baseline evidence-based steps utilization rate during the preimplementation period was 79%; after the implementation of bundled evidence-based steps of cesarean delivery, the audited adherence was 89%-an uptake of 10.0% of the evidence-based steps. In 4 aspects, the maternal characteristics differed significantly in the preimplementation and postimplementation periods: race/ethnicity, hypertensive disorder, and the relative contribution of the 4 centers to the cohorts and the gestational age at delivery, but the indications for cesarean delivery and whether its duration was less or greater than 60 minutes did not. The rates of composite maternal morbidity in the preimplementation and postimplementation groups were 26% and 22%, respectively (adjusted relative risk, 0.88 [95% credible intervals, 0.73-1.04]), with a 94 % Bayesian probability of a reduction in composite maternal morbidity. The composite maternal morbidity occurred in 37% of the preimplementation and 41% of the postimplementation group (adjusted relative risk, 1.12 [95% credible intervals, 0.98-1.39]), with a 95% Bayesian probability of worsening in composite maternal morbidity. When composite maternal morbidity was segregated by preterm (<37 weeks) and term (≥37 weeks) cesarean delivery, the improvement in maternal outcomes persisted; when composite maternal morbidity was segregated by gestational age subgroups, the potential for worsening neonatal outcomes persisted as well.

CONCLUSION

Standardization of the evidence-based bundled steps of cesarean delivery resulted in a modest reduction of the composite maternal outcome; however, a paradoxical increase in neonatal composite morbidity was noted. Although individual evidence-based steps may be of value while awaiting additional intervention trials, a formal bundling of such steps is currently not recommended.

Evidence-based cesarean delivery: intraoperative management following placental delivery until skin closure (part 9)

This expert review provides recommendations for the cesarean delivery technique after placental delivery to skin closure. After placental delivery sponge curettage may be omitted as it has not been shown to decrease the risk of retained products of conception. Uterine irrigation and mechanical cervical dilation cannot be recommended. Either intra-abdominal or extra-abdominal repair of the hysterotomy is acceptable, with some possible benefits, such as decreased postoperative pain and nausea/vomiting with intra-abdominal repair. There is insufficient evidence to recommend one uterine closure technique over the other with regards to suture type, continuous versus interrupted, locking or non-locking, and one versus two-layer closure. Double-layer uterine closure has been shown to be more beneficial with regards to residual myometrial thickness, and full thickness bites (including the endometrium) should be considered. Glove change by the surgical team is recommended after placental delivery and before closure of the abdominal wall. The following techniques are not recommended: intra-abdominal irrigation, use of adhesion prevention barriers, peritoneal closure, and rectus muscle reapproximation. Based on non-cesarean delivery evidence, fascial closure bites should be at least 5 × 5 mm, with monofilament suture for vertical incisions. As an adjunct to postoperative pain control, surgeons may consider wound infiltration with local anesthesia, either supra- or subfascial. Before closure, subcutaneous irrigation may be performed using saline solution, and routine use of subcutaneous drains is not recommended. Although closure of the subcutaneous layer can be considered in all patients, it should occur when the depth is ≥2 cm. A monofilament absorbable suture, such as poliglecaprone, should be used to close the cesarean skin incision. There is no level 1 evidence evaluating the potential benefit of additional skin adhesive or sterile strips after suture skin closure. If a dressing is preferred over the skin incision, the following approaches may be considered: a dialkylcarbamoyl chloride-impregnated dressing if available or a standard gauze dressing is appropriate. Prophylactic negative pressure wound therapy can be considered in patients with obesity. Vaginal seeding during cesarean delivery is not recommended. El resumen está disponible en Español al final del artículo.

Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report

Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.

Impact of Intraoperative Factors on the Development of Postpartum Septic Complications

Background and Objectives: Triclosan-coated sutures (antibacterial sutures) can reduce the risk of postoperative surgical site infection. This study aimed to investigate the effect of intraoperative factors, including antibacterial sutures, on the risk of postpartum septic complications. Materials and Methods: The prospective study included patients who underwent caesarean section. The exclusion criterion was chorioamnionitis. The investigation group patient's (n = 67) uterus and fascial sheath of the abdominal wall were sutured with triclosan-coated polyglactin 910 sutures during surgery. The control group consisted of 98 patients using uncoated polyglactin 910 sutures only. The patients were contacted by phone after the 30th postoperative day. Results: No significant difference was found between the investigation group and the control group in the development of postpartum endometritis (11.7% in the investigation group vs. 8.4% in the control group, p = 0.401), wound infection (6.3% vs. 3.6%, p = 0.444) or patients experienced any septic complication (15.9% vs. 12%, p = 0.506). Postpartum endometritis was more common in patients who underwent instrumental uterine examination during the surgery (23.8% vs. 18%, p = 0.043). A moderately strong correlation was found for haemoglobin level on the third-fourth postoperative day with the development of postpartum septic complications, p < 0.001, Pearson coefficient -0.319. Post-caesarean delivery septic complications were not statistically more common in patients with blood loss greater than 1 L. The incidence of post-caesarean endometritis was 13.4%, and wound infection was 4.8% in this study's hospital, having five to six thousand deliveries per year. Conclusions: Using antibacterial sutures during caesarean section does not affect the incidence of postpartum septic complications. Instrumental uterine examination during caesarean section increases the risk of post-caesarean endometritis and is, therefore, not recommended. Haemoglobin level on the 3rd-4th postoperative day, rather than the estimated blood loss during surgery, affects the development of postpartum septic complications.

Post-cesarean section analgesia

Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.

Effect of Closure of Anterior Abdominal Wall Layers on Early Postoperative Findings at Cesarean Section: A Prospective Cross-sectional Study

OBJECTIVE

 To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings.

METHODS

 The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and during mobilization), analgesia requirement, and return of bowel motility.

RESULTS

 The postoperative pain scores were similar at the 2^nd, 6^th, 12^th, and 18^th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times.

CONCLUSION

 In the group with only parietal peritoneum closure, the pain scores at the 6^th and 12^th hours were higher. Rectus abdominis muscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees

In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.