Routine cervical dilatation during elective caesarean section. Should we continue?

Routine cervical dilatation at caesarean section and its influence on postoperative pain and complications in obese women: a double blind randomized controlled trial

INTRODUCTION

Numerous surgical techniques regarding cesarean section performance were assessed. The usefulness of cervical dilatation during cesarean section, are still based on restricted research obtained data.

PURPOSE

To assess the impact of intraoperative digital dilatation of cervix on postoperative pain.

MATERIAL AND METHODS

The current research study is a Prospective parallel group randomized controlled double blind research trial that was conducted in obstetrics and gynecology hospital, Faculty of Medicine, Cairo University and Algezeera Hospital, Egypt from the period May 2018 until February 2018.

RESULTS

The visual analog scale scoring level was statistically significantly higher in noncervical dilatation research group at 8th, 30th, 48 hours and 7th day postoperative (p values <.001, .001, .001, and .001, respectively). On the other hand at the 4th day postoperative, there was no statistical significant difference concerning VAS scoring level.

CONCLUSIONS

Manual cervical dilatation during cesarean section is an innovative procedure to reduce postoperative pain in obese women. We thought that according to the results of the present study, cervical dilatation leads to proper continuous adequate evacuation and drainage of the intracavitary contents that leads to decrease the uterine subinvolution, retained blood and so, decreased postoperative pain and postoperative blood loss.

CLINICALTRIALS.GOV ID

NCT03513237.

The impact of mechanical cervical dilatation during elective cesarean section on postpartum scar integrity: a randomized double-blind clinical trial

Objective

The current study aimed to evaluate the impact of mechanical cervical dilatation during elective cesarean section (CS) on postpartum scar integrity at 6 months post operation.

Methods

A randomized double-blind clinical trial (UMIN000027946) was conducted at a tertiary university hospital in the period between July 1, 2017 and April 30, 2018. The study included pregnant women with a singleton fetus at term ≥37 weeks of gestation scheduled for elective CS. Eligible participants were allocated either to the study group (women with intraoperative cervical dilatation) or the control group (women with no intraoperative cervical dilatation). The patients were followed up at 6 months after CS by 3D ultrasonography to check for the scar integrity and quality. The primary outcome was the difference in sonographic parameters of the scar integrity between the two groups.

Results

Four hundred twenty two women were approached to participate in the study. There was no statistically significant difference regarding the baseline characteristics of both the groups. Scar width and depth were significantly higher in the cervical dilatation group (P=0.002 and 0.001, respectively). Fewer cases with scar defects (niche) were found in the cervical dilatation group than in the control group (5.03% vs 11.04%, respectively, P=0.048). There was no significant difference regarding the rate of wound infection or endometritis in both the groups (P=0.717 and 0.227, respectively). The incidence of febrile morbidity was higher in the no cervical dilatation group (10.5%) compared to (5.0%) the cervical dilatation group (P=0.045).

Conclusion

Cervical dilatation during elective CS is associated with thick scars with low incidence of scar defects.

The effect of mechanical cervical dilatation during scheduled cesarean section on the blood loss: a randomized controlled trial

Objective: This study evaluates the effects of mechanical cervical dilatation during scheduled cesarean section (CS) on intra- and postoperative blood loss.Methods: A single-center randomized double-blind controlled trial (NCT03444792) conducted at a tertiary University Hospital in the period between 1 April 2017 and 31 March 2018 included all women scheduled for scheduled CS under spinal anesthesia if they met our inclusion criteria. Eligible participants were randomized to one of two groups. Group (I): Women with intraoperative cervical dilatation and Group (II): women with no intraoperative cervical dilatation. The primary outcome of this study was the mean volume of total blood loss during CS. The secondary outcomes included the mean reduction in the hemoglobin and hematocrit, the rate of primary postpartum hemorrhage, the duration of surgery, the duration of hospital stay, the rate of wound infection and endometritis.Results: No statistical significant difference between both study groups regarding the baseline characteristics. No significant difference in the intraoperative blood loss between both groups (p = .21); however, there was significantly more postoperative blood loss in group II (p = .001). The total blood loss was significantly higher in group II (912.6 ± 242.1 versus 845.8 ± 188.9 mL) in group I (p = .029). There were significantly lower postoperative hemoglobin and hematocrit levels in group II (p = .014 and .033 respectively). The mean duration of CS was significantly shorter in the cervical dilatation group (p = .002). No difference between both groups regarding the rate of postpartum hemorrhage (PPH) (p = .21), the duration of hospital stay (p = .17), the rate of wound infection (p = .32), the rate of endometritis (p = .82).Conclusions: Mechanical cervical dilatation during scheduled CS could be associated with lower postoperative blood loss, higher postoperative hemoglobin & hematocrit levels and shorter duration of CS.

Mechanical dilatation of the cervix during elective caeserean section before the onset of labour for reducing postoperative morbidity

BACKGROUND

During elective (planned) caesarean sections, some obstetricians routinely dilate the cervix intraoperatively, using sponge forceps, a finger, or other instruments, because the cervix of women not in labour may not be dilated, and this may cause obstruction of blood or lochia drainage. However, mechanical cervical dilatation during caesarean section may result in contamination by vaginal micro-organisms during dilatation, and increase the risk of infection or cervical trauma.

OBJECTIVES

To determine the effects of mechanical dilatation of the cervix during elective caesarean section on postoperative morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved studies on 20 September 2017.

SELECTION CRITERIA

We included all randomised, quasi-randomised, and cluster-randomised controlled trials comparing intraoperative cervical dilatation using a finger, sponge forceps, or other instruments during elective caesarean section versus no mechanical dilatation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included eight studies with a total of 2227 women undergoing elective caesarean section. Of these, 1097 underwent intraoperative cervical dilatation with a double-gloved index finger or Hegar dilator inserted into the cervical canal to dilate, and 1130 did not undergo intraoperative cervical dilatation. Six of the eight included trials had high risk of bias for some of the risk of bias domains.Very low-quality evidence suggested it was unclear whether cervical dilatation had any impact on postpartum haemorrhage (estimated blood loss greater than 1000 mL; risk ratio (RR) 1.97, 95% confidence interval (CI) 0.48 to 8.13; 5/205 versus 3/242; one study, 447 women).Low- or very low-quality evidence showed no clear difference for the need for blood transfusion (RR 3.54, 95% CI 0.37 to 33.79; two studies, 847 women); postoperative haemoglobin (mean difference (MD -0.05, 95% CI -0.15 to 0.06; three studies, 749 women), or haematocrit (MD 0.01%, 95% CI -0.18 to 0.20; one study, 400 women); the incidence of drop from baseline haemoglobin above 0.5 g/dL (RR 0.92, 95% CI 0.64 to 1.31; two studies, 722 women), or amount of haemoglobin drop (MD -0.01 g/dL, 95% -0.14 to 0.13; three studies, 796 women); the incidence of secondary postpartum haemorrhage within six weeks (RR 1.18, 95% CI 0.07 to 18.76; one study, 447 women); febrile morbidity (RR 1.18, 95% CI 0.76 to 1.85; seven studies, 2126 women); endometritis (RR 0.94, 95% CI 0.35 to 2.52; four studies, 1536 women); or uterine subinvolution (RR 0.34, 95% CI 0.08 to 1.36; two studies, 654 women); the results crossed the line of no effect for all of the outcomes. There were no data for cervical trauma.We found a slight improvement with mechanical dilatation for these secondary outcomes, not prespecified in the protocol: mean blood loss, endometrial cavity thickness, retained products of conception, distortion of uterine incision, and healing ratio. The evidence for these outcomes was based on one or two studies. Cervical dilatation did not have a clear effect on these secondary outcomes, not prespecified in the protocol: wound infection, urinary tract infection, operative time, infectious morbidity, and integrity of uterine scar.

AUTHORS' CONCLUSIONS

At this time, the evidence does not support or refute the use of mechanical dilatation of the cervix during elective caesarean section for reducing postoperative morbidity.Further large, well-designed studies are required to compare the effect of intraoperative mechanical dilatation of the cervix with no intraoperative mechanical cervical dilatation for reducing postoperative morbidity.