Max Sänger - father of the modern caesarean section

Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae

OBJECTIVES

To assess the diversity of uterine closure techniques (UCTs) among providers in one institution and evaluate concurrent consideration of adverse outcomes for patient counseling, provisional care, and prevention.

METHODS

Forty-four obstetricians at NYU Langone Health were emailed a survey of their uterine closure technique, patient counseling, and practice experience. Results were stratified by years of practice: ≤5, 5-20, and 20-40 years.

RESULTS

Thirty-nine obstetricians (88.6%) completed the survey. Among those, a blunt uterine opening was preferred by 29 (74.4%), and a mid-lower segment location was favored by 34 (87.2%). At uterine closure, the endometrium was included by 20 (51.3%), with half a centimeter or more incorporated in the myometrial closure, whereas 15 (38.5%) did not factor in the endometrium's presence. Closure duration varied from 1 to 20 min, with 21 (53.9%) lasting 1-5 min and 12 (30.8%) lasting 5-10 min. All physicians were familiar with the potential post-cesarean complications and counseled their patients accordingly; 25 (64.1%) at the first post-op visit while 14 (35.9%) did so before the next conception. Practitioners with fewer years in practice endorsed the safety of up to five consecutive cesarean births, while those with more experience approved up to ten. Thirty-two obstetricians (82.1%) stated that the risk of abnormal placentation is exclusively associated with the number of cesarean sections, whereas five (12.8%) senior obstetricians asserted that individual surgical techniques are most impactful.

CONCLUSIONS

The survey illustrates that various UCTs are performed irrespective of potential adverse sequelae and without consideration for subsequent patient counseling and care. Ongoing research must study the impact of UCT on scar healing to formulate preventive strategies for post-cesarean complications.

Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly

In present-day obstetrics, cesarean delivery occurs in one in three women in the United States, and in up to four of five women in some regions of the world. The history of cesarean section extends well over four centuries. Up until the end of the nineteenth century, the operation was avoided because of its high mortality rate. In 1926, the Munro Kerr low transverse uterine incision was introduced and became the standard method for the next 50 years. Since the 1970's, newer surgical techniques gradually became the most commonly used method today because of intraoperative and postpartum benefits. Concurrently, despite attempts to encourage vaginal birth after previous cesareans, the cesarean delivery rate increased steadily from 5 to 30-32% over the last 10 years, with a parallel increase in costs as well as short- and long-term maternal, neonatal and childhood complications. Attempts to reduce the rate of cesarean deliveries have been largely unsuccessful because of the perceived safety of the operation, short-term postpartum benefits, the legal climate and maternal request in the absence of indications. In the United States, as the cesarean delivery rate has increased, maternal mortality and morbidity have also risen steadily over the last three decades, disproportionately impacting black women as compared to other races. Extensive data on the prenatal diagnosis and management of cesarean-related abnormal placentation have improved outcomes of affected women. Fewer data are available however for the improvement of outcomes of cesarean-related gynecological conditions. In this review, the authors address the challenges and opportunities to research, educate and change health effects associated with cesarean delivery for all women.

A comparison of two techniques of uterine closure in caesarean section

OBJECTIVE

To compare the results of two different techniques of uterine closure in caesarean section operations in which assistant surgeons participated.

METHODS

A total of 765 patients were separated into two groups.In Group1(n = 380), the assistant surgeon, while pulling the suture in a caudal direction with the left hand, held the uterine wall from the joined site with the right hand to prevent upward tension of tissue. In Group 2 (n = 385), the suture was placed by the assistant surgeon by pulling it in the cephalic direction with the right hand. These two techniques were evaluated in respect of the postoperative decrease in haemoglobin level ,the need for additional sutures and operative outcomes.

RESULTS

The need for additional sutures was determined as statistically high in Group 2 at mean 0.5 ± 0.6 compared to mean 0.2 ± 0.5 in Group1 (p < 0.001). The mean operating time was determined as statistically significantly longer in Group 2 (Group1, 38.0 ± 5.6 mins and Group2, 41.3 ± 4.3 mins) (p < 0.001). The postoperative decrease in hb was statistically significantly greater in Group 2 (Group1, 1.1 ± 0.4, Group2, 1.2 ± 0.4) (p = 0.002).

CONCLUSION

The cephalic direction placement of the suture with the right hand of the assistant surgeon in uterine closure leads to bleeding due to tissue cuts in the lower wound lip and thereby creating a need for additional sutures. Therefore, the suture should be placed in a caudal direction with the left hand.

A prospective observational study of emergency caesarean section rates and the effect of the labour ward experience

The National Sentinel Audit found that one in five births in England and Wales was by caesarean section. The reasons for the increase in caesarean section rates are multi-factorial. Anecdotally, it is suggested that obstetric intervention rates and caesarean section rates vary among obstetricians without a difference in fetal and maternal outcomes. The aim of this prospective observational study of 817 deliveries was to assess the effect of experience on the caesarean section rates for different obstetricians. Obstetricians with greater than 3 years of 2nd on-call labour ward experience had a statistically significant lower caesarean rate than less experienced obstetricians 10.25% vs 25.49%, respectively (p < 0.05). Differences in instrument deliveries was also studied.