Finger-assisted stretching technique for cesarean section

Blunt versus sharp uterine incision expansion during low transverse cesarean delivery: a metaanalysis

OBJECTIVE

We sought to review and update available evidence regarding outcomes after cesarean delivery (CD) using blunt vs sharp expansion of the uterine incision.

STUDY DESIGN

We queried the database of PubMed (US National Library of Medicine, 1946 through December 2013), the Cochrane Library Database of Systematic Reviews, ClinicalTrials.gov, and Web of Science. All relevant bibliographies were reviewed. Randomized controlled trials comparing blunt with sharp expansion of the lower segment during CD were evaluated for inclusion and methodological quality. The primary outcome was occurrence of unintended extensions. Secondary outcomes were drop in hematocrit or hemoglobin and estimated maternal blood loss, need for transfusion, operative time, use of uterotonics, rate of endometritis, and neonatal outcomes. Data extraction, analysis, and results were based on the preferred reporting items for systematic review and metaanalysis guidelines.

RESULTS

Six randomized controlled trials (2908 patients) were included. Blunt expansion technique was associated with lower drop in postoperative hematocrit (weighted mean difference [WMD], -1.07%; P = .05) and hemoglobin (WMD, -0.64 g/dL; P < .05), lower rate of unintended extensions (pooled relative risk, 0.47; P < .05), and a shorter operative time (WMD, -2 minutes; P < .05). Lower estimated blood loss was also observed but the difference was not significant (WMD, -88.07 mL; P > .05). There were no differences in the rates of blood transfusion, endometritis, use of uterotonics, and neonatal outcomes between both techniques.

CONCLUSION

Blunt expansion of uterine incision during CD is associated with less unintended extensions and favorable maternal outcomes. Although the drop in hemoglobin, hematocrit, and operative times were in favor of blunt expansion, the degree of reduction may not be clinically relevant.

Caesarean deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled trial

OBJECTIVE

This study was designed to compare the Pfannenstiel versus Joel-Cohen incisions during caesarean deliveries.

MATERIAL AND METHODS

Women undergoing caesarean deliveries (n=153) were randomly assigned to the conventional Pfannenstiel or the Joel-Cohen incision. The outcome measures included postoperative pain, requirement for analgesics, operative time and other postoperative data.

RESULTS

Maternal age, parity, gestational age and indications for caesarean delivery were similar across groups. Total operative time, postoperative recovery duration, time to get out of bed, to walk straight without support, to detect audible intestinal sounds and to pass gases or stools were shorter in the Joel-Cohen group. Postoperative haematocrit decreases and estimated intraoperative blood loss were similar between the two techniques. Moderate and severe pain at 6, 12 and 18 hours postoperatively was less frequent after the Joel-Cohen technique.

CONCLUSION

Joel-Cohen incision in the non-scarred abdomen may provide a faster technique for caesarean section with less postoperative pain and probably early postoperative recovery in our circumstances.

Blunt vs. sharp uterine expansion at lower segment cesarean section delivery: a systematic review with metaanalysis

OBJECTIVE

Blunt vs sharp expansion of the uterine incision at cesarean delivery has been investigated as a technique primarily to reduce intraoperative blood loss. The objective of this systematic review was to compare the effects of either intervention on maternal outcomes.

STUDY DESIGN

A systematic review with metaanalyses that used the DerSimonian and Laird random effects model was performed. The Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 4), MEDLINE (1948-Apr 2012), EMBASE (1947-Apr 2012), and the reference lists/citation history of articles were searched. Only randomized controlled trials were included.

RESULTS

Four trials (1731 patients) were evaluated. Data from one recently completed trial (535 patients) were not yet available. Metaanalyses revealed a trend towards reduced maternal blood loss with blunt expansion of the uterine incision that was statistically significant when measured by surgeon's estimation of volume lost, but not by comparison of pre- and postoperative hematocrit and hemoglobin levels or a requirement for blood transfusion. There was a trend towards fewer unintended extensions in the blunt group and no difference in the incidence of endometritis.

CONCLUSION

Blunt dissection of the uterine incision at cesarean delivery appears to be superior to sharp dissection in minimizing maternal blood loss. However, this conclusion could change when data from a new unpublished large trial are available.

Comparison between the use of the Joel-Cohen incision and its modification during Stark's cesarean section

OBJECTIVE

A comparative evaluation between the Joel-Cohen incision and its modification for the Stark's cesarean section (CS).

MATERIALS AND METHODS

In a retrospective study, 477 women who underwent a Stark's CS were evaluated: 204 with the Joel-Cohen incision (JC) and 273 with a modified Joel-Cohen incision (MJC). All patients were checked for the following parameters: febrile morbidity, the need for painkillers, duration of hospital stay, and ultrasound examination for blood collection (BC) on the third postoperative day. The collections, when diagnosed were divided into three groups: (1) in the abdominal wall, (2) in the pouch of Douglas, and (3) in the lower uterine segment (LUS). Those included in the study were low-risk primiparae at term, presenting for CS for breech presentation, macrosomia, and on demand, and who had combined spinal-epidural anesthesia. Statistical evaluation was performed using SAS/V12 software.

RESULTS

There were no statistical differences between the two groups with regard to febrile morbidity, duration of need for painkillers, and hospital stay. Statistically more blood collections were found in the MJC incision group (5.4% in the abdominal wall, 12.4% in the pouch of Douglas, and 11.7% in the LUS) than in the classical JC incision group (3.9% in the abdominal wall, 10.2% in the pouch of Douglas, and 8.8% in the LUS), however without any clinical significance.

CONCLUSIONS

The routine use of the classical JC incision during the Stark's CS seems to be more rational, and causes fewer blood collections.

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.

[Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision]

OBJECTIVE

The aim of this study was to compare the Joel-Cohen method for cesarean section to the traditional transrectal incision.

METHOD

Fifty-two patients requiring a caesarean section were enrolled in this prospective study. Overall morbidity and post-operative pain was assessed. Four surgeons participated to this study, each included 13 patients. The main judgement criterion was post-operative pain on the first day.

RESULTS

Post-operative pain on the first day was less important (50 vs 23% p=0.04) in Joel-Cohen's. This method was shorter compared to the transrectal incision (33.6+6.4 min vs 51.2+8 min p<0.0001). There was no difference in overall morbidity between the two groups.

CONCLUSION

Joel-Cohen's method decrease post-operative pain and is a shorter procedure compared to the transrectal incision.