Blood loss at time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision. Extraabdominal uterine exteriorization at cesarean section. A randomised, controlled study of uterine exteriorisation and repair at caesarean section. Uterine exteriorisation at caesarean section: influence on maternal morbidity.
The current study was undertaken to determine if blood loss at the time of cesarean section is affected by method of placental removal (spontaneous versus extracted) or uterine position for repair (in situ versus exteriorized). This prospective randomized study involved 100 women who were undergoing a cesarean section. The patients were placed into one of four groups--1, spontaneous placenta detachment, in situ uterine repair; 2, spontaneous placental detachment, exteriorized uterine repair; 3, manual placental removal, in situ uterine repair, and 4, manual placental removal, exteriorized uterine repair. Patients with spontaneous placental separation (groups 1 and 2) compared with manual removal (groups 3 and 4) revealed a significant decrease in blood loss (p < 0.001). Uterine position did not significantly affect blood loss in the spontaneous group (1 and 2; p = 0.971) or the manual placental removal groups (3 and 4; p = 0.061). The hematocrit values for all groups were similar preoperatively, but postoperatively, were significantly lower in the manual removal groups when compared with the spontaneous placental separation groups (p < 0.001). The method of placental removal and not the position of the uterus at the time of its repair has a significant role in blood loss during cesarean birth. A series of 386 consecutive cesarean sections is presented in which postpartum uteri were randomly exteriorized or left in situ for suturing the hysterotomy incision in an attempt to evaluate differences in morbidity. Both groups were shown to be similar with respect to overall morbidity, although a high-morbidity subgroup exhibiting increased blood loss was defined and included significantly more patients in the noneventrated group. Emesis occurred in 4 (3.4%) patients in the eventrated group and was directly related to fundal traction under regional anesthesia. Although a larger prospective series is needed to evaluate more serious morbidity, the data presented suggest that uterine eventration at cesarean section is not to be condemned. To determine the surgical and anaesthetic benefits and problems associated with the practice of routine exteriorisation of the uterus to facilitate repair at caesarean section.
                A randomised controlled study of women undergoing caesarean section. After establishment of anaesthesia, women were randomised to either exteriorisation and uterine repair or suture of the uterus in the abdomen.
                A maternity hospital in the United Kingdom.
                Peri-operative haemoglobin change, duration of operation, maternal morbidity and length of hospital stay. Intra-operative pain, nausea, vomiting, pulling or tugging sensations were secondary outcome measures.
                Three hundred and sixteen women were randomised, of whom 288 were subsequently analysed (139 women in whom the uterus was exteriorised and 149 where the uterus was not exteriorised). Exteriorisation of the uterus, an elective caesarean section and a spinal or general anaesthesia each had a statistically significant association with reduced blood loss (P < 0.05). There were no statistically significant differences between the two groups with regard to intra-operative complications or pain, nor were there any statistically significant difference in post-operative wound sepsis, pyrexia, deep vein thrombosis, blood transfusion or length of hospital stay.
                With effective anaesthesia, exteriorisation of the uterus for repair following caesarean delivery is not associated with significant problems and is associated with less blood loss. To compare the influence on caesarean section morbidity of uterine exteriorisation or in situ repair.
                Randomised controlled trial.
                Princess Anne Maternity Unit of the Royal Bolton Hospital, UK.
                One hundred and ninety-four women undergoing delivery by caesarean section.
                Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra- and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery.
                Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturation; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra- and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation.
                No clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra- and post-operative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups.
                We have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients. Exteriorising the uterus at caesarean section is a valid option.
There is no evidence from this review to make definitive conclusions about which method of uterine closure offers greater advantages, if any. However, these results are based on too few and too small studies to detect differences in rare, but severe, complications.
[Note: The 12 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]