This is not the most recent version of the article. View current version (22 JUL 2014)

Intervention Review

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

  1. Jodie M Dodd1,*,
  2. Elizabeth R Anderson2,
  3. Simon Gates3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 16 JUL 2008

Assessed as up-to-date: 29 APR 2008

DOI: 10.1002/14651858.CD004732.pub2


How to Cite

Dodd JM, Anderson ER, Gates S. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004732. DOI: 10.1002/14651858.CD004732.pub2.

Author Information

  1. 1

    The University of Adelaide, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

  2. 2

    Royal Liverpool University Hospital, Department of Genito-urinary Medicine, Liverpool, UK

  3. 3

    Division of Health Sciences, Warwick Medical School, The University of Warwick, Warwick Clinical Trials Unit, Coventry, UK

*Jodie M Dodd, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, 5006, Australia. jodie.dodd@adelaide.edu.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 16 JUL 2008

SEARCH

This is not the most recent version of the article. View current version (22 JUL 2014)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

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 methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2007). We updated this search on 31 May 2012 and added the results to the awaiting classification section.

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All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.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

[Note: The 34 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Surgical techniques involving the uterus at caesarean section

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.