cesarean section technique: what’s new in the evidence

Cesarean Section Technique: What’s New in the Evidence Base?

Marya G. Zlatnik, MD, MMS

Maternal Fetal Medicine

UCSF

Hamano, Teisuke. 1880. Kainin no kokoroe (Information on pregnancy). Japanese Woodblock Print Collection, Archives & Special Collections, UCSF Library & Center for Knowledge Management.

No Disclosures

Learning Objectives

• Review new techniques & literature re: C/S

– “Gentle” cesarean

– ERAS

– Infection prevention

– (Pain control)

– Hemorrhage

– Sutures

• Evidence‐base (according to me)

Cesarean Rates Continue to Rise

Low‐risk cesarean delivery is defined as a cesarean delivery among term (37 or more completed weeks), singleton, vertex births to women giving birth for the first time. (NTSV)

Osterman MJK, Martin JA. Trends inlow‐risk cesarean delivery in the United States, 1990–2013. NationalVital statistics reports; vol 63 no 6. Hyattsville, MD: National Center for Health Statistics. 2014

Cesarean Section Technique• Family‐friendly

• ERAS

• Prophylactic Atbx

• Prep

• Remove FSE

• Abdominal Incision

• Bladder flap

• Uterine incision

• Placental delivery

• Exteriorization of uterus

• Uterine incision closure

• Peritoneal closure

• Irrigation

• Fascial closure

• Subcutaneous closure

• Staples/skin

• Special dressings

Family‐Centered or “Gentle” Cesarean

UCSF Family‐Centered Cesarean

• Buy in from OB, Peds, Nursing, Anesthesia

• Clear double drapes

• Staffing (extra RN)

• UCSF Protocol created by Dr. Robyn Lamar

UCSF Family‐Centered Cesarean

• Mother may choose music to be played in OR

• Double drape (with clear window) used

• Anesthesia places ECG leads away from mother’s chest

• Mother’s chest warmed prior to skin‐to‐skin with instant hot pack

• Elevate head of bed, to facilitate viewing the birth & skin‐to‐skin

• After delivery of head, OB delivers body slowly

• After delivery of head, drape dropped if mother desires to see birth

• Consider delayed cord clamping for 30‐60 seconds

• Pediatricians receive the baby as usual; 1 min APGAR on warmer; goal to be

back to mom by 5 minutes for skin‐to‐skin

• After close, while drapes are removed & mother is cleaned, partner may help

with weighing baby & observe other routine care

• Once mother is on recovery bed, baby placed skin‐to‐skin again & the dyad

transported together to recovery

+Ev

+Ev

+Ev

Music Therapy for C/S

• RCT in Taiwan: music to decrease anxiety – 64 pts, planned C/S, nl babies

– Headphones, low volume of classical, new age or Chinese religious music

– Decreased anxiety scores

– More satisfied with C/S experience

– No difference in physiologic measures of anxiety

Chang 2005

Family‐Centered or “Gentle” Cesarean

Contraindications:• Prematurity• Emergency cesarean• Anticipated resuscitation (ex: anomalies, nonreassuringFHR)

Protocol inappropriate in some situations & clinical judgment always takes precedent•Ex: with vasa previa, slow delivery of body inadvisable•Ex: increased BMI, elevating the head of the bed may impact surgical visualization •Ex: insufficient nursing staff to remain with baby in OR

Enhanced Recovery After Surgery (ERAS)

• Emphasis on evidence‐based care

• Pre‐op preparation

– Nutrition

– Expectations

• Intra‐op

– Multimodal pain Rx

• Post‐op care

– Bowel recovery

Enhanced Recovery After Surgery (ERAS)

• Retro cohort

• Prepost, n= 531

• Decreased post‐op LOS by 7.8% or 4.86 hrs overall (P<.001)

• Decreased post‐op direct costs by 8.4% or $642.85 per pt (P<.001)

• No difference readmissions

Fay AJOG 2019

Enhanced Recovery After Surgery

• No cesarean guidelines yet on ERAS Society site

• AJOG published guidelines 2018‐2019

ERAS at UCSF• In the clinic: antepartum

– Confirm eligibility

– Mostly education

– Treat anemia

ERAS at UCSF• In the clinic: pre‐op visit

– Education re: anesthesia

– Carb drink (Boost Breeze): drink at home (2 hrsbefore)

– CHG wash: night before

ERAS at UCSF• Day of: pre‐op

– Acetaminophen 1000 mg PO x1

– CHG wash, clipping

ERAS at UCSFIntra‐op

• Zofran, Reglan

• Toradol IV x1

• Duramorph or TAP blocks

ERAS at UCSFPACU

• Pain control

• Nausea control

• Incentive spirometry

ERAS at UCSF

Post‐op

• Day 0:

– Scheduled acetaminophen & ketorolac

– Hydromorphone PCA if inadequate

– Aggressive bowel regimen

– Regular diet

– Ambulate

– Foley out at 8 hours if ambulating ok

• Day 1:

– Ibuprofen scheduled, d/c PCA PO opioids

ERAS at UCSFPost‐op

• Day 0‐1

ERAS at UCSF

Post‐op

• Day 2:

– Scheduled acetaminophen & ibuprofen

– Prn opioids

– Prep for d/c home

• Day 3:

– d/c home

Prophylactic Antibiotics

• Decrease infection?

• Side effects

• Single or multiple doses

• Which generation?

• When?

Prophylactic Antibiotics

• Cochrane Review

– 4700 pts

– RR 0.42 (95%CI 0.28‐0.65) morbidity/death

– Effect bigger if labor

• Decreased fever, SSI, endometritis, UTI, LOS (RR ~0.4)

• No benefit to multi‐dosesSmaill Cochrane 2010

Prophylactic Antibiotics Single vs Multiple Doses

Hopkins & Smaill Cochrane Database of Systematic Reviews 1999, 2010

Prophylactic Atbx—Fever 1st Generation vs. 2nd or 3rd

Alfirevic Cochrnae 2010Hopkins Cochrane 1999

Same result with Ampicillin vs. Ceph

Pre‐incision Atbx: Decreased SSI vs After Cord Clamp

26

p= 0.002

p= 0.014

p= 0.020

Kaimal SMFM 2008

0

2

4

6

8

Overall Endometritis Cellulitis

SS

I (%

)

2005-2006n= 800

After 2006n= 516

2013 Clinical Practice Guidelines: Antimicrobial Prophylaxis in Surgery

• American Society Health‐System Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, Society for Healthcare Epidemiology of America

• Based on pharmacokinetic dosing studies, 1g cefazolin is often not enough but no RCT

• At UCSF we use cefazolin 2g (3g if BMI >120kg)

• Re‐dose if 4> hrs from 1st dose or EBL >1500 cc

Bratzler 2013

Prophylactic Atbx—Extended Spectrum Regimens

• RCT adding metronidazole vag gel– 224 pts; vaginal gel vs placebo gel

– Less endometritis (7 vs 17%), trend towards less fever; no difference in wound infxn, LOS

• Ureasplasma increases risk for C/S SSI

– Cephalosporin doesn’t cover

– Post‐cord‐clamp cefotetan plus placebo or doxy+azithro

Andrews 2003

Pitt 2001

Extended spectrum Prophylaxis

• UAB studies over 14 years– In 2000, IV cefotetan or cefazolin & IV azithro at cord clamp

– Decreased endometritis

– Decreased wound infections

29

Tita ObGyn 2009Tita AJOG 2008


• Multicenter RCT: C/SOAP Trial– 2013 pts, C/S in labor or ROM (chorio excluded)– Ave BMI 35 (>60% had BMI >30)– Std atbx + Azithro prior to incision– Fewer SSIs, fevers, PP readmits

30 Tita NEJM 2016


• Multicenter RCT: C/SOAP Trial

31

Tita NEJM 2016

Extended spectrum Prophylaxis?

• UCSF baseline rate much lower (<1%)

• Hesitant to extend atbx spectrum for all C/S pts

– Concerns re: atbx resistance, messing up microbiome

• Selectively extend atbx spectrum– eg, pt w/ DM/obesity

– Cefazolin 2‐3g IV preop + azithro 500mg IV after cord clamp (mix in 250mL/give over 1 hr )

32

Abdominal Prep

• Several small RCTs: different solutions

– No clear winner

– Magann 1993, Brown 1984, Weed 2011

• CHG better than povidone‐iodine in G. Surg (has persistence)

– Darioche 2010

• Bundled CHG cleanse + OR prep + other interventions decreased SSI rate

– Rauk 2010

Vaginal Prep prior to C/S

• Povidone‐iodine prep ‐> decreased endometritis, esp w/ ROM

• No difference in fever or wound complications

• ? benefit if already chorio

• Possible effect on neonatal thyroid studies

• Risk of vaginal lac (case at ZSFG)

• Dahlke gives a “B”

• Done at ZSFG

– Cochrane 2014, Reid 2001, Rouse 1997, Starr 2005

ZMG2

Vaginal Cleansing prior to C/S

• Meta‐analysis Sept 2017

• Povidone‐iodine prep ‐> decreased endometritis, fever, esp w/ labor/ROM

• No difference in wound complications

• Only 6 of 16 specified pre‐incision atbx

• ? benefit if already chorio

– Caissutti ObGYN 2017

ZMG2

Bladder Flap

• 2 RCTs: Total 360 pts• 1 & RC/S: Bladder BladFlap vs Not

• No bladder flap:– Shorter incis del time by 1 min in 1C/S

– +/‐ Shorter op time, Less Hgb drop, Microhematuria, Pain

• Not powered for bladder injury (would need 40K pts)

Hohlagschwandtner 2001Tuuli 2012

Uterine Incision—Blunt vs. Sharp Extension

RCTs: Blood loss greater with sharp– More transfusions

– Rodriguez 1994, Magann 2002, Cochrane 2008

• Cephalad to caudadextension

– Less blood loss, fewerextensions

– Cromi 2008, Sekhavat 2010

Uterine Incision: BABE

• B: Breathe. Pause before making the hysterotomy

• A: Allis clamps. Use Allis clamps, if needed, to help elevate the hysterotomy

• B: Blunt. Use a single digit to sweep over hysterotomy bluntly between each scalpel pass

• E: Extend. Extend hysterotomy bluntly (stretch laterally or vertically)

Betsy Encarnacion O’Donnell 2012

Placenta: Manual Removal

• Manual extraction: bigger Hct drop, more endometritis (vs spontaneous)

Cochrane 1995

Anorlu Cochrane 2008

Exteriorization of Uterus

• Easier repair? (easier to teach)

• ? Infection, bleeding risk

• Anesthesiologist blames you for emesis

• No real differences in complications, including emesis

Cochrane 2006, 2009

Management of Hemorrhage

• CMQCC hemorrhage toolkit V2.0 (revised March 2015)https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit

Photo courtesy of CMQCC and David Lagrew, MD

Every hospital will need to customize the protocol—but the point is every hospital

needs one

CMQCC OB Hemorrhage Emergency Management Plan

Copyright California Department of Public Health, 2014; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Hemorrhage Taskforce Visit: www.CMQCC.org for details

Obstetric Hemorrhage Emergency Management Plan: Table Chart Format version 2.0

Assessments Meds/Procedures Blood Bank

Stage 0 Every woman in labor/giving birth Stage 0 focuses on risk assessment and active management of the third stage.

Assess every woman for risk factors for hemorrhage

Measure cumulative quantitative blood loss on every birth

Active Management 3rd Stage:

Oxytocin IV infusion or 10u IM

Fundal Massage-vigorous, 15 seconds min.

If Medium Risk: T & Scr If High Risk: T&C 2 U If Positive Antibody

Screen (prenatal or current, exclude low level anti-D from RhoGam):T&C 2 U

Stage 1 Blood loss: > 500ml vaginal or >1000 ml Cesarean, or VS changes (by >15% or HR 110, BP 85/45, O2 sat <95%)

Stage 1 is short: activate hemorrhage protocol, initiate preparations and give Methergine IM.

Activate OB Hemorrhage Protocol and Checklist

Notify Charge nurse, OB/CNM, Anesthesia

VS, O2 Sat q5’ Record cumulative

blood loss q5-15’ Weigh bloody materials Careful inspection with

good exposure of vaginal walls, cervix, uterine cavity, placenta

IV Access: at least 18gauge Increase IV fluid (LR) and

Oxytocin rate, and repeat fundal massage

Methergine 0.2mg IM (if not hypertensive) May repeat if good response to first dose, BUT otherwise move on to 2nd level uterotonic drug (see below)

Empty bladder: straight cath or place foley with urimeter

T&C 2 Units PRBCs (if not already done)

Stage 2 Continued bleeding with total blood loss under 1500ml

Stage 2 is focused on sequentially advancing through medications and procedures, mobilizing help and Blood Bank support, and keeping ahead with volume and blood products.

OB back to bedside (if not already there) Extra help: 2nd OB,

Rapid Response Team (per hospital), assign roles

VS & cumulative blood loss q 5-10 min

Weigh bloody materials Complete evaluation

of vaginal wall, cervix, placenta, uterine cavity

Send additional labs, including DIC panel

If in Postpartum: Move to L&D/OR

Evaluate for special cases: -Uterine Inversion -Amn. Fluid Embolism

2nd Level Uterotonic Drugs: Hemabate 250 mcg IM or Misoprostol 800 mcg SL

2nd IV Access (at least 18gauge)

Bimanual massage Vaginal Birth: (typical order) Move to OR Repair any tears D&C: r/o retained placenta Place intrauterine balloon Selective Embolization

(Interventional Radiology) Cesarean Birth: (still intra-op) (typical order) Inspect broad lig, posterior

uterus and retained placenta

B-Lynch Suture Place intrauterine balloon

Notify Blood Bank of OB Hemorrhage

Bring 2 Units PRBCs to bedside, transfuse per clinical signs – do not wait for lab values

Use blood warmer for transfusion

Consider thawing 2 FFP (takes 35+min), use if transfusing > 2u PRBCs

Determine availability of additional RBCs and other Coag products

Stage 3 Total blood loss over 1500ml, or >2 units PRBCs given or VS unstable or suspicion of DIC

Stage 3 is focused on the Massive Transfusion protocol and invasive surgical approaches for control of bleeding.

Mobilize team -Advanced GYN surgeon -2nd Anesthesia Provider -OR staff -Adult Intensivist Repeat labs including

coags and ABG’s Central line Social Worker/ family

support

Activate Massive Hemorrhage Protocol Laparotomy: -B-Lynch Suture -Uterine Artery Ligation -Hysterectomy Patient support -Fluid warmer -Upper body warming device -Sequential compression stockings

Transfuse Aggressively Massive Hemorrhage Pack Near 1:1 PRBC:FFP 1 PLT apheresis pack per 4-6 units PRBCs

Unresponsive Coagulopathy: After 8-10 units PRBCs and full coagulation factor replacement: may consult re rFactor VIIa risk/benefit

Blood Loss:1000-1500 ml

Stage 2

SequentiallyAdvance through

Medications &Procedures

Pre-Admission

Time of admission

Identify patients with special consideration:Placenta previa/accreta, Bleeding disorder, or those who decline blood products

Follow appropriate workups, planning, preparing of resources, counseling and notification

Screen All Admissions for hemorrhage risk:Low Risk, Medium Risk and High Risk

Low Risk: Draw blood and hold specimenMedium Risk: Type & Screen, Review Hemorrhage ProtocolHigh Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol

All women receive active management of 3rd stageOxytocin IV infusion or 10 Units IM, 10-40 U infusion

Standard Postpartum Management

Fundal Massage

Vaginal Birth:Bimanual Fundal MassageRetained POC: Dilation and CurettageLower segment/Implantation site/Atony: Intrauterine BalloonLaceration/Hematoma: Packing, Repair as RequiredConsider IR (if available & adequate experience)

Cesarean Birth:Continued Atony: B-Lynch Suture/Intrauterine BalloonContinued Hemorrhage: Uterine Artery Ligation

To OR (if not there); Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts 6:4:1 or 4:4:1

IncreasedPostpartum Surveillance

Definitive SurgeryHysterectomy

Conservative SurgeryB-Lynch Suture/Intrauterine BalloonUterine Artery LigationHypogastric Ligation (experienced surgeon only)Consider IR (if available & adequate experience)

Fertility Strongly Desired

Consider ICUCare; Increased

Postpartum Surveillance

Verify Type & Screen on prenatal record;

if positive antibody screen on prenatal or current labs (except low level anti-D from Rhogam), Type & Crossmatch 2

Units PBRCs

CALL FOR EXTRA HELPGive Meds: Hemabate 250 mcg IM -or-

Misoprostol 600-800 SL or PO

Cumulative Blood Loss>500 ml Vag; >1000 ml CS>15% Vital Sign change -or-

HR ≥ 110, BP ≤ 85/45 O2 Sat <95%, Clinical Sx

Ongoing Evaluation:

Quantification of blood loss and

vital signs

Unresponsive Coagulopathy:After 10 Units PBRCs and full

coagulation factor replacement,may consider rFactor VIIa

HEMORRHAGE CONTINUES

Blood Loss:>1500 ml

Stage 3

Activate Massive

Hemorrhage Protocol

Blood Loss: >500 ml Vaginal

>1000 ml CS

Stage 1Activate

Hemorrhage Protocol

NO

Stage 0All Births

Transfuse 2 Units PRBCs per clinical signs

Do not wait for lab valuesConsider thawing 2 Units FFP

YES

YES NO

On

goin

g C

um

ula

tive

Blo

od L

oss

Eva

lua

tion

Cumulative Blood Loss>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV Oxytocin RateMethergine 0.2 mg IM (if not hypertensive)Vigorous Fundal massage; Empty Bladder; Keep WarmAdminister O2 to maintain Sat >95%Rule out retained POC, laceration or hematomaOrder Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage ProtocolCALL FOR EXTRA HELP

Continued heavy bleeding

Increased Postpartum Surveillance

NO

NO

CONTROLLED

INCREASED BLEEDING

California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for detailsThis project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014

Management of HemorrhageNPR.org

Management of Hemorrhage: TXA

• Tranexemic Acid

Pacheco ObGyn 2017

TPA

Fibrin degradation

Management of PPH: TXA

WOMAN Trial Lancet 2017

• WOMAN trial: 20,060 women with PPH after VD or CS

• RCT: 1g IV TXA or placebo

• Outcomes: death from hemorrhage, death from all causes, or hysterectomy

• Funding: London School of Hygiene & Tropical Medicine, Pfizer, UK Dept Health, Wellcome Trust, Bill & Melinda Gates Foundation



Maternal Death



Laparotomy for bleeding by subgroup




Tranexamic Acid (TXA) Protocol


Topical recombinant activated Factor VII Case series, 5 pts with previa, 5 controls, Denmark

“swab” soaked in saline containing recombinant activated Factor VII (1 mg in 246 ml) applied to placental bed, repeated x1 prn

Median EBL 490 ml (300-800 ml)

No changes in thrombin, fibrinogen, PTT, INR, plts

Schjoldager AJOG 2017

CORONIS Trial Lancet 2016

• International, pragmatic trial 2x2x2x2x2

• 19 sites in S. America, Africa, India, Pakistan

• 1st or 2nd C/S, follow up at 3 yrs

• 15,633 women studied:– Blunt vs. sharp abdominal entry

– Repair of uterus in or out

– 1 vs. 2 layer closure of uterus

– Closure vs. non‐closure of peritoneum

– Chromic vs. polyglactin‐910 for uterus

• Outcomes of subsequent pregnancies, pain

Incision Type, Uterine Repair, Etc.

– CORONIS Trial 2016


• No differences

CORONIS Trial 2016


• No differences

CORONIS Trial 2016

Closure of Uterine Incision: 1 vs. 2 Layers

• Short term:

– OR time

– Hemostasis/Blood loss

– Endometritis

• Long term:

– Scar strength/VBAC risk

Short Term Outcomes: 1 vs. 2 Layer Closure

• Hauth’s RCT, UAB + 9 other studies

• No difference in use of extra hemostatic stitches

• Less blood loss

• Less post‐op pain

• 5‐7 min shorter OR timeHauth 1992, Cochrane 2008

1 vs. 2 Layer Closure:Scar Strength

• Follow‐up from Hauth’s RCT

• 906 pts in RCT164 preg again

• 83 previous 1‐layer, 81 previous 2‐layer

• 56/70 vs 64/75 successful VBACs

• No difference in PPH, infxn, LOS

• One dehiscence in 1‐layer group, no ruptures (power only .07)

Chapman 1997

1 vs. 2 Layer Closure: Scar Strength TOLAC

• Retrospective data conflicting whether rupture risk increased or not

• Risk of uterine rupture after 1‐layer closure notsignificantly different from 2‐layer closure overall (OR 1.34; 95% CI 0.24–4.82) Sardo 2017– risk increased after locked 1‐layer closure (OR 4.96) but not after unlocked 1‐layer closure (OR 0.49) compared w/ 2‐layer closure Robwerge 2011

– 2‐layer closure thicker scar Sardo 2017

• Need RCT Bujold 2002, Dumwald 2003, Roberge 2011, Sardo 2017 (ISUOG metanalysis)

Knot Slips/Types of Knots

• Square

• Surgeon’s square (least likely to slide undone, but can’t tighten after 2nd throw)

• Square slip (can slip, even after 5 throws; inadvertently tied by one‐handed technique)

• Granny (not a bad knot, but easy to accidentally make granny slip knot)

• Granny slip (not secure)

Loop‐to‐Strand Knots (e.g.when tying fascia suture in midline)• 0 & 2‐0 Monocryl, 6 throws , stretched until failure

(breakage or slippage)• Loop‐to‐single strand, sliding knot

– 55‐85% untied– 112 newtons to break knot

• Loop‐to‐single strand, flat square knot– 5‐15% untied– 117 newtons to break knot

• Strand‐to‐single strand, flat square knot– NONE untied– 132 newtons to break knot

Hurt 2004

Failure of WoundType of Suture Material

• Metaanalysis from General Surgery lit.

• Nonabsorbable vs. absorbable

– NNT = 50 for incisional hernia

• Risk of hernia not increased with PDS, is increased with Vicryl

Hodgson 2000

• Monocryl & Chromic no good for sheep C/SGreenberg 2011

Wound Irrigation

• RCT in cattle

– C/S for macrosomia

– Wounds irrigated with betadine vs nothing

– No difference in wound infections

• Only a few RCTs in humans

– Study design flaws

– Saline vs nothing

– No difference in wound complications, more nausea with irrigation

de Kruif 1987

Bamigboye, Harrigill 2003Cochrane 2006, Viney 2010

Peritoneal Closure vs. Not

• Short term outcomes vs. long term outcomes

• Short‐term: Non‐closure better

– Shorter OR time

– Less fever

– Shorter LOS

– Trend less analgesia need & wound infection

Bamigboye, Cochrane 2010,2014

Long Term Outcomes: Non‐Closure of Peritoneum

• Cohort & retrospective studies mixed on what causes fewer adhesions

• 2 pseudo RCT suggest nonclosure better

• 1 RCT non‐closure fewer adhesions

Lyell 2005, Stark 1995, Lyell 2012

Weerawetwat 2004, Komoto 2006

Kapustian 2012

Failure of Wound: Fascial Suturing Technique• No RCT data in human C/S

• Suture tears through fascia = most common cause

• Fascia tears—less likely with 1 cm wide suture bites based on lab data, general surgery literature

– Stitches 1 cm back from edge (SL/WL ratio)

– Not strangulating

– Mass closure

Adamsons 1966, Hogstrom 1985

Skin Closure: Re‐approximation of subQ

• A few meta‐analyses– Some included all pt, others included those with > 2cm subQ fat

– 3‐0 plain gut, 2‐0 polyglactin, 3–0 polyglycolic mostly running stitches

– Decreased wound complications, NNT = 16

Pergialiotis BJOG 2017, Chelmow2004, Cochrane 2006

Skin Staples, Suture, or Glue? Staples vs. SubQ Suture

• A few RCTs, 2 meta‐analyses

• Staples quicker (by ~5‐9 min)

• Pts often prefer suture

• Sutures fewer wound infections/ breakdowns

– NNT 16

• Sew if there is time

Frishman 1997, Tuuli 2011, Clay 2011Mackeen 2014

Suture vs. Suture

• Comparison of Subcuticular Suture Type for Skin Closure After Cesarean Delivery: A Randomized Controlled Trial

• RCT: Monocryl vs Vicryl

• Composite wound measure: 8.8% vs 14.4%

• No difference when analyzed by actual suture used

Buresch, AM et al. Obstetrics & Gynecology130(3):521-526, September 2017.doi: 10.1097/AOG.0000000000002200

SubQ Suture vs Skin Glue

• A few small studies, 1 RCT (107 pts)

• No difference:

– OR time

– wound disruption (?)

– scar scores

– NOT POWERED

Daykan AJOG 2017

Silver‐Impregnated Dressing

Connery AJOG 2019

• RCT, n=657

• Silver nylon vs gauze dressings

• Primary outcome similar – 4.6% silver nylon group

– 4.2% gauze group, P = 0.96

• Similar rates of superficial SSI <1 wk (1.2% vs 0.9%) & <6 wks (4.6% vs 4.2%) after delivery (P >.99)

• Adjusting for confounding variables, current smoking (aOR 4.9; 95% CI 1.8−13.4) body mass index ≥40 kg/m2 (aOR 3.08; 95% CI 1.3−6.8), & surgery length (minutes) (aOR 1.02; 95% CI 1.002−1.04), but not use of gauze dressing, were associated with superficial SSI

Negative Pressure Wound Therapy (prophylactic, in obese women)

• Systematic review/meta‐analysis 2017

– n= 1,830, incl retrosp.; n= 230 ( 5 RCTs)

• No difference:

– Wound complications or infections

Smid Obs Gyn 2017

Negative Pressure Wound Therapy (prophylactic, in obese women)

• Systematic review/meta‐analysis 2018

– 9 studies, included cohort studies in meta‐analysis, n= 1,702, incl retrosp.; 6 RCTs

• Yes difference:

– Wound complications RR 0.68 (0.49‐0.94), but including RCTs only RR 0.82 (0.57‐1.18)

– SSI RR 0.55 (0.35‐0.87)

– Senior author with $120K research funding from KCI

Yu Ajog 2018

Conclusions

• Yes:– Prophylactic Atbx (pre‐incision, add azithro if risk mod‐high)

– Blunt or sharp abdominal entry

– Repair of uterus in or out

– 1 or 2 layer closure of uterus

– TXA for PPH

– Monocryl for skin

• Maybe:– ERAS

– Family‐friendly

– Add azithro

– Prep vagina

– Wound vac

• No: – Not ready for aF7

– Gluing, stapling skin

– Silver dressing

cesarean section technique: what’s new in the evidence

Documents