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Antoine C, Timor-Tritsch IE, Agoha C, Alexander J. A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum. Am J Obstet Gynecol MFM 2022; 4:100744. [PMID: 36113718 DOI: 10.1016/j.ajogmf.2022.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/19/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation. OBJECTIVE This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential. STUDY DESIGN Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants. RESULTS The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques. CONCLUSION The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha).
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
| | - Chikadibia Agoha
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
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Antoine C, Alexander JS, Yaghoubian YC, Harary JM. Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae. J Perinat Med 2022; 50:1045-1052. [PMID: 35538677 DOI: 10.1515/jpm-2021-0485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/07/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Yasaman C Yaghoubian
- Department of Obstetrics and Gynecology, North Shore University Hospital/Long Island Jewish Medical, New York, NY, USA
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Antoine C, Young BK. Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly. J Perinat Med 2020; 49:5-16. [PMID: 32887190 DOI: 10.1515/jpm-2020-0305] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Bruce K Young
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
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Habek D, Cerovac A, Luetić A, Marton I, Prka M, Kulaš T, Ujević B. Modified Stark's (Misgav Ladach) caesarean section: 15 - year experience of the own techniques of caesarean section. Eur J Obstet Gynecol Reprod Biol 2020; 247:90-93. [PMID: 32087422 DOI: 10.1016/j.ejogrb.2020.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/10/2020] [Accepted: 02/13/2020] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Dubravko Habek
- University Department of Gynecology and Obstetrics, Clinical Hospital, Sveti Duh "Zagreb, Croatian Catholic University Zagreb, Croatia.
| | - Anis Cerovac
- Department of Gynecology and Obstetrics, General Hospital Tešanj, Bosnia and Herzegovina
| | - Ana Luetić
- University Department of Gynecology and Obstetrics, Clinical Hospital, Sveti Duh "Zagreb, Croatian Catholic University Zagreb, Croatia
| | - Ingrid Marton
- University Department of Gynecology and Obstetrics, Clinical Hospital, Sveti Duh "Zagreb, Croatian Catholic University Zagreb, Croatia
| | - Matija Prka
- University Department of Gynecology and Obstetrics, Clinical Hospital, Sveti Duh "Zagreb, Croatian Catholic University Zagreb, Croatia
| | - Tomislav Kulaš
- University Department of Gynecology and Obstetrics, Clinical Hospital, Sveti Duh "Zagreb, Croatian Catholic University Zagreb, Croatia
| | - Boris Ujević
- University Department of Gynecology and Obstetrics, Clinical Hospital, Sveti Duh "Zagreb, Croatian Catholic University Zagreb, Croatia
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Suture techniques in caesarean section. GINECOLOGIA.RO 2020. [DOI: 10.26416/gine.29.3.2020.3767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Yazici Yilmaz F, Aydogan Mathyk B, Yildiz S, Yenigul NN, Saglam C. Postoperative pain and neuropathy after caesarean operation featuring blunt or sharp opening of the fascia: a randomised, parallel group, double-blind study. J OBSTET GYNAECOL 2018; 38:933-939. [PMID: 29560766 DOI: 10.1080/01443615.2018.1437125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The purpose of this study was to compare postoperative pain and neuropathy after primary caesarean sections with either blunt or sharp fascial expansions. A total of 123 women undergoing primary caesarean sections were included in the study. The sharp group had 61 patients, and the blunt group had 62. In the sharp group, the fascia was incised sharply and extended using scissors. In blunt group, the fascia was bluntly opened by lateral finger-pulling. The primary outcome was postoperative pain. The long-term chronic pain scores were significantly lower in the blunt group during mobilisation (p = .012 and p = .022). Neuropathy was significantly more prevalent in the sharp group at both 1 and 3 months postoperatively (p = .043 and p = .016, respectively). The odds ratio (OR) and 95%CI for postoperative neuropathy at 1 and 3 months were as follows; OR 3.71, 95%CI 0.97-14.24 and OR 5.67, 95%CI 1.18-27.08, respectively. The OR for postoperative pain after 3 months was 3.26 (95%CI 1.09-9.73). The prevelance of postsurgical neuropathy and chronic pain at 3 months were significantly lower in the blunt group. Blunt fascial opening reduces the complication rate of postoperative pain and neuropathy after caesarean sections. Impact statement What is already known on this subject? The anatomic relationship of the abdominal fascia and the anterior abdominal wall nerves is a known fact. The fascia during caesarean sections can be opened by either a sharp or blunt extension. Data on the isolated impact of different fascial incisions on postoperative pain is limited. What do the results of this study add? The postoperative pain scores on the incision area are lower in the bluntly opened group compared to the sharp fascial incision group. By extending the fascia bluntly, a decrease in trauma and damage to nerves was observed. What are the implications of these findings for clinical practice and/or future research? The lateral extension of the fascia during caesarean sections must be done cautiously to prevent temporary damage to nerves and vessels. The blunt opening of the fascia by lateral finger pulling might be a preferred method over the sharp approach that uses scissors. We included only primary caesarean cases, however, comparisons of blunt and sharp fascial incisions in patients with more than one abdominal surgery should be explored in future studies.
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Affiliation(s)
- Fatma Yazici Yilmaz
- a Department of Obstetrics and Gynaecology , Sisli Etfal Research and Training Hospital , Istanbul , Turkey
| | - Begum Aydogan Mathyk
- a Department of Obstetrics and Gynaecology , Sisli Etfal Research and Training Hospital , Istanbul , Turkey.,b Department of Obstetrics and Gynecology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Serhat Yildiz
- a Department of Obstetrics and Gynaecology , Sisli Etfal Research and Training Hospital , Istanbul , Turkey
| | - Nefise Nazli Yenigul
- c Department of Obstetrics and Gynaecology , Esenler Women Health and Children's Hospital , Istanbul , Turkey
| | - Ceren Saglam
- a Department of Obstetrics and Gynaecology , Sisli Etfal Research and Training Hospital , Istanbul , Turkey
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Stark M, Mynbaev O, Vassilevski Y, Rozenberg P. Could Revision of the Embryology Influence Our Cesarean Delivery Technique: Towards an Optimized Cesarean Delivery for Universal Use. AJP Rep 2016; 6:e352-e354. [PMID: 28078171 PMCID: PMC5045307 DOI: 10.1055/s-0036-1593444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Until today, there is no standardized Cesarean Section method and many variations exist. The main variations concern the type of abdominal incision, usage of abdominal packs, suturing the uterus in one or two layers, and suturing the peritoneal layers or leaving them open. One of the questions is the optimal location of opening the uterus. Recently, omission of the bladder flap was recommended. The anatomy and histology as results from the embryological knowledge might help to solve this question. The working thesis is that the higher the incision is done, the more damage to muscle tissue can take place contrary to incision in the lower segment, where fibrous tissue prevails. In this perspective, a call for participation in a two-armed prospective study is included, which could result in an optimal, evidence-based Cesarean Section for universal use.
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Affiliation(s)
- Michael Stark
- The New European Surgical Society (NESA), Berlin, Germany; ELSAN Hospital Group, Paris, France
| | - Ospan Mynbaev
- N.I.Pirogov Russian National Research Medical University, Moscow, Russian Federation; Moscow Institute of Physics and Technology (MIPT) (State University), Dolgoprudny, Russian Federation
| | - Yuri Vassilevski
- Institute of Numerical Mathematics, Russian Academy of Sciences, Moscow Institute of Physics and Technology, Moscow, Russian Federation
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Versailles University Hospital, Poissy, France
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Gizzo S, Andrisani A, Noventa M, Di Gangi S, Quaranta M, Cosmi E, D’Antona D, Nardelli GB, Ambrosini G. Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review. PLoS One 2015; 10:e0114190. [PMID: 25646621 PMCID: PMC4315586 DOI: 10.1371/journal.pone.0114190] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 11/05/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Salvatore Gizzo
- Department of Women’s and Children’s Health—University of Padua, Padua, Italy
| | | | - Marco Noventa
- Department of Women’s and Children’s Health—University of Padua, Padua, Italy
| | - Stefania Di Gangi
- Department of Women’s and Children’s Health—University of Padua, Padua, Italy
| | - Michela Quaranta
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Erich Cosmi
- Department of Women’s and Children’s Health—University of Padua, Padua, Italy
| | - Donato D’Antona
- Department of Women’s and Children’s Health—University of Padua, Padua, Italy
| | | | - Guido Ambrosini
- Department of Women’s and Children’s Health—University of Padua, Padua, Italy
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Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev 2014; 2014:CD004732. [PMID: 25048608 PMCID: PMC11182567 DOI: 10.1002/14651858.cd004732.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Elizabeth R Anderson
- Royal Liverpool University HospitalDepartment of Genito‐urinary MedicinePrescot StreetLiverpoolUKL7 8XP
| | - Simon Gates
- Division of Health Sciences, Warwick Medical School, The University of WarwickWarwick Clinical Trials UnitGibbet Hill RoadCoventryUKCV4 7AL
| | - Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
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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: 122] [Impact Index Per Article: 11.1] [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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Dodd JM, Anderson ER, Gates S. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev 2008:CD004732. [PMID: 18646108 DOI: 10.1002/14651858.cd004732.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Jodie M Dodd
- School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006.
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Abstract
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.
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Affiliation(s)
- G J Hofmeyr
- University of the Witwatersrand, Department of Obstetrics and Gynaecology, East London Hospital Complex, Frere and Cecilia Makiwane Hospitals, Private Bag X 9047, East London, Eastern Cape, South Africa, 5200.
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