Comparative study of Misgav-Ladach and Pfannenstiel-Kerr cesarean techniques: a randomized controlled trial

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.

Modified Stark's (Misgav Ladach) caesarean section: 15 - year experience of the own techniques of caesarean section

OBJECTIVE

A 15-year-experience of the personal modification of Misgav Ladach (ML) caesarean section in relation to the Dörffler method.

STUDY DESIGN

A retrospective clinical randomized observational study included 822 transperitoneal cesarean sections: 557 were performed via modified ML (without bladder catheterization, small transverse fascial incision with muscular stretching and non-preparation of vesicouterine plica) vs. 265 Dörffler (Pfannenstiel - Kerr) method.

RESULTS

Perioperative and postoperative complications were significantly more frequent in the Dörffler method (p < 0.0005) (perioperative hemorrhage, more frequent adhesions, plastic peritonitis in repeated caesarean sections, as well as two bladder lesions). Postoperative febrility, dehiscence and wound seroma were more frequent in the first study group (p < 0.0005). More frequent paralytic ileus, uroinfections and bladder atony, which we did not observe in our own technique (p < 0.0005). The use of antibiotics and analgesics was prolonged until the fifth postoperative day in the first group compared to the second group where it was reduced to only 10 % on the second day (p < 0.0005). Also, the incidence of anemia and the need for blood transfusions were higher in the first study group, as well as the need for revision behind caesarean section and two hysterectomies due to massive postoperative intraperitoneal and retroperitoneal bleeding (p < 0.0005).

CONCLUSION

Our fifteen-year study highlighted the importance of our own published modified ML caesarean section in minimizing technique of surgery and the reduction of perioperative morbidity and significantly faster recovery of operated patients in the current era of enormous caesarean section increase.

Evidence-Based Cesarean Delivery for the Nonobstetrician

Cesarean delivery (CD) is one of the most common major surgeries performed in the United States and worldwide. Surgical techniques evaluated in well-designed randomized controlled trials (RCTs) that demonstrate maternal benefit should be incorporated into practice. The objective of this review is to provide a summary of surgical techniques of the procedure and review the evidence basis for them for the nonobstetrician. The following techniques with the strongest evidence should be commonly performed, when feasible: (1) prophylactic antibiotics with a single dose of ampicillin or first-generation cephalosporin prior to skin incision; (2) postpartum hemorrhage prevention with oxytocin infusion of 10 to 40 IU in 1 L crystalloid over 4 to 8 hours; (3) low transverse skin incision; (4) blunt or sharp subcutaneous and fascial expansion; (5) blunt, cephalad-caudad uterine incision expansion; (6) spontaneous placental removal; (7) blunt-tip needle usage during closure; (8) subcutaneous suture closure (running or interrupted) if thickness is ≥2 cm; and (9) skin closure with suture. Although the number of RCTs designed to optimize maternal and neonatal outcomes of this common procedure is encouraging, further work is needed to minimize surgical morbidity. Optimal methods for postpartum hemorrhage prevention, adhesion prevention, and venous thromboembolism prophylaxis remain ongoing areas of active research, with outcomes that could markedly improve maternal morbidity and mortality. If evidence of a surgical technique appears preferred over another, clinicians should be comfortable adopting the evidence-based technique when performing and teaching CD.

Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon's experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: "acute pain", "chronic pain", "Pfannenstiel incision", "Misgav-Ladach", "Joel Cohen incision", in combination with "Caesarean Section", "abdominal incision", "numbness", "neuropathic pain" and "nerve entrapment". Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required.

Surgical techniques for uterine incision and uterine closure at the time of caesarean section

BACKGROUND

Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator.

OBJECTIVES

To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and healthcare resource use.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 September 2013) and reference lists of all identified papers.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently.

MAIN RESULTS

Our search strategy identified 60 studies for consideration, of which 27 randomised trials involving 17,808 women undergoing caesarean section were included in the review. Overall, the methodological quality of the trials was variable, with 12 of the 27 included trials adequately describing the randomisation sequence, with less than half describing adequately methods of allocation concealment, and only six trials indicating blinding of outcome assessors.Two trials compared auto-suture devices with traditional hysterotomy involving 300 women. No statistically significant difference in febrile morbidity between the stapler and conventional incision groups was apparent (risk ratio (RR) 0.92; 95% confidence interval (CI) 0.38 to 2.20).Five studies were included in the review that compared blunt versus sharp dissection when performing the uterine incision involving 2141 women. There were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05). Mean blood loss (two studies; 1145 women; average mean difference (MD) -55.00 mL; 95% CI -79.48 to -30.52), and the need for blood transfusion (two studies; 1345 women; RR 0.24; 95% CI 0.09 to 0.62) were significantly lower following blunt extension.A single trial compared transverse with cephalad-caudad blunt extension of the uterine incision, involving 811 women, and while mean blood loss was reported to be lower following transverse extension (one study; 811 women; MD 42.00 mL; 95% CI 1.31 to 82.69), the clinical significance of such a small volume difference is of uncertain clinical relevance. There were no other statistically significant differences identified for the limited outcomes reported.A single trial comparing chromic catgut with polygactin-910, involving 9544 women reported that catgut closure versus closure with polygactin was associated with a significant reduction in the need for blood transfusion (one study, 9544 women, RR 0.49, 95% CI 0.32 to 0.76) and a significant reduction in complications requiring re-laparotomy (one study, 9544 women, RR 0.58, 95% CI 0.37 to 0.89).Nineteen studies were identified comparing single layer with double layer closure of the uterus, with data contributed to the meta-analyses from 14 studies. There were no statistically significant differences identified for the primary outcome, febrile morbidity (nine studies; 13,890 women; RR 0.98; 95% CI 0.85 to 1.12). Although the meta-analysis suggested single layer closure was associated with a reduction in mean blood loss, heterogeneity is high and this limits the clinical applicability of the result. There were no differences identified in risk of blood transfusion (four studies; 13,571 women; average RR 0.86; 95% CI 0.63 to 1.17; Heterogeneity: Tau² = 0.15; I² = 49%), or other reported clinical outcomes.

AUTHORS' CONCLUSIONS

Caesarean section is a common procedure performed on women worldwide. There is increasing evidence that for many techniques, short-term maternal outcomes are equivalent. Until long-term health effects are known, surgeons should continue to use the techniques they prefer and currently use.

Evidence-based surgery for cesarean delivery: an updated systematic review

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.

Surgical techniques for uterine incision and uterine closure at the time of caesarean section

BACKGROUND

Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator.

OBJECTIVES

To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and health care resource use.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2007).

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently.

MAIN RESULTS

We identified 30 studies, of which 15 (3972 women) were included. Ten trials compared single layer uterine closure with double layer uterine closure (2531 women), two trials compared blunt with sharp dissection at the time of the uterine incision (1241 women), and two trials compared auto-suture devices with traditional hysterotomy (300 women). Blunt dissection was associated with a reduction in mean blood loss at the time of the procedure when compared with sharp dissection of the uterine incision (one study, 945 women, mean difference (MD) -43.00, 95% confidence interval (CI) -66.12 to -19.88). There was no statistically significant difference related to need for blood transfusion (one study, 945 women, risk ratio (RR) 0.22, 95% CI 0.05 to 1.01). The use of an auto-suture instrument when compared with traditional methods of hysterotomy was associated with no difference in the amount of blood loss during the procedure (one study, 200 women, MD -87.00, 95% CI -175.09 to 1.09), but a statistically significant increase in the duration of the procedure (one study, 197 women, MD 3.30, 95% CI 0.02 to 6.62). Single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss (three studies, 527 women, MD -70.11, 95% CI -101.61 to -38.60); duration of the operative procedure (four studies, 645 women, MD -7.43, 95% CI -8.41 to -6.46); and presence of postoperative pain (one study, 158 women, RR 0.69, 95% CI 0.52 to 0.91).

AUTHORS' CONCLUSIONS

While caesarean section is a common procedure performed on women worldwide, there is little information available to inform the most appropriate surgical technique to adopt.

Techniques for caesarean section

BACKGROUND

Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique.

OBJECTIVES

To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers.

SELECTION CRITERIA

Randomised controlled trials of intention to perform caesarean section using different techniques.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data.

MAIN RESULTS

'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes).

AUTHORS' CONCLUSIONS

'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.