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

Abstract

Caesarean section is a common abdominal operation for surgical delivery of a baby and the placenta. Techniques vary depending on the clinical situation and surgeon preferences. Safe delivery is important for mother and infant. Any potential reduction of birth trauma to the infant has to be balanced against increased ill-health for the mother. Factors include not only the duration of the surgical procedure and maternal blood loss but also postoperative pain, continuing blood loss and development of anaemia, fever and wound infection, problems with passing urine or breastfeeding and possible longer-term fertility problems, complications in future pregnancies (uterine rupture) or increased risks associated with future surgery. The review authors searched the medical literature for randomised controlled trials to inform the most appropriate surgical techniques to use. Fifteen trials involving 3972 women from a number of different countries contributed to the review. None of these trials assessed the type of uterine incision (transverse lower uterine segment incision versus other types of uterine incision), the materials to suture the uterus or techniques of suture closure (continuous suture versus interrupted suture, locking versus unlocked sutures). Results from 10 randomised trials (2531 women) contributed to reports that single layer closure of the uterine incision was associated with a reduction in blood loss (by some 70 ml, range 39 to 102 ml; from three studies), duration of the procedure (some seven minutes, range 6.5 to eight minutes; four studies), presence of postoperative pain (one study only) and length of hospital stay. There were no clear differences for heavy blood loss, fever or wound infection. In these studies the surgical procedure for entering the abdominal cavity also differed and could have contributed to blood loss and duration of surgery. Two trials compared blunt with sharp dissection at the time of the uterine incision (1241 women) and a further two trials auto-suture devices with standard hysterotomy (300 women). Blunt surgery was associated with a reduction in mean blood loss at the time of the procedure (one trial). The use of an auto-suture instrument did not clearly reduce procedural blood loss (one study) but increased the duration of the procedure (by some three minutes, range 0 to 6.6 minutes). Overall, trials focussed on blood loss and duration of the operative procedure rather than clinical outcomes for the women.