A randomised controlled study of uterine exteriorisation and repair at caesarean section



We read with interest the article by Wahab et al.1 and congratulate them on addressing the issue of uterine exteriorisation at caesarean section. Whilst the benefits of uterine exteriorisation include increased uterine artery tamponade when securing haemostasis, leading to a reduction in blood loss at caesarean section, the potential drawbacks include increased tissue handling which may increase morbidity. Indeed the authors own results suggest a trend towards longer operations and increased hospitalisation after the operation. Also and more importantly the complications of this procedure appear to include two cases of conversion of regional anaesthetic to general anaesthetic.

Addressing the issue of blood loss, they have introduced a subjective and unvalidated assessment asking the surgeon to compare with the average, but this does not stage what the average is or indeed whether the uterus was exteriorised or left in situ was the surgeon's previous practice. Unfortunately the authors have made no attempt at an objective measure of blood loss or haematoma formation post-operatively.

They have demonstrated that there is a smaller reduction in haemoglobin in the exteriorised group but whilst this reaches statistical significance it is doubtful that this is of clinical significance as there is no assessment of pulse or fatigue post delivery; in addition the transfusion rate is higher (but not significantly so) in the exteriorised group. However what is of interest is the different blood loss with spinal and epidural anaesthetic which is almost certainly of greater significance (non-exteriorised uterus with spinal anaesthesia: mean reduction in haemoglobin 1.3 g/dL, compared with 1.9 g/dL in women with epidural anaesthesia where the uterus was exteriorised.

Unfortunately the statistical methods are not included and certainly the data appears to be non-parametric and hence parametric tests may not be appropriate unless the data are transformed.

We would conclude from the data that the mode of anaesthetic is more significant than whether the uterus is exteriorised or not, and while this is an extremely useful technique when there is difficulty closing the uterus due to excessive blood loss peroperatively, the conversion rate to general anaesthetic, with its associated risks, increased tissue handling and increased operative time suggest that it should not, as suggested, be the routine surgical technique performed.