Subcuticular interrupted versus continuous skin suturing in elective cesarean section in obese women: a randomized controlled trial

Abstract

Objective: To compare the interrupted subcuticular skin closure with continuous one in obese women undergoing cesarean delivery.

Materials and methods: A randomized controlled study conducted on 169 obese women with term uncomplicated singleton pregnancy who underwent elective cesarean delivery. They were randomized to either skin closure through continuous subcuticular sutures using vicryl 3/0 or interrupted subcuticular suturing using vicryl 3/0. The primary outcome parameter was occurrence of wound infection. Secondary outcomes included other skin complications, postoperative pain, operative duration and hospital stay

Results: There was a statistically higher number of cases with wound hematoma (20 vs. 10, p?=?.04), infection (30 vs. 15, p?=?.008) and those who needed reclosure of wound (8 vs. 0, p?=?.004) in the continuous when compared to women in the interrupted subcuticular group, respectively. Healing with secondary intension was significantly higher in women in the continuous subcuticular group (52 vs. 26, respectively, p?<?.001). The number of cases with wound seroma and keloid formation was not statistically different between the two groups (25 vs. 19, p?=?.272 and 12 vs. 5, p?=?.069 in the continuous vs. interrupted groups, respectively). The duration of CS was longer in those who underwent interrupted closure when compared to continuous ones. However, that was statistically insignificant (40.95?+?6.376 vs. 37.05?+?6.455, p?=?0.14).

Conclusions: Most surgical wound complications were reduced if skin closure with continuous subcuticular sutures is replaced with interrupted one.     

Intrauterine cleaning after placental delivery at cesarean section: a randomized controlled trial

Objective: The objective of this study is to evaluate whether omission of intrauterine cleaning increases intraoperative and postoperative complications among women who deliver via cesarean section.

Methods: We randomized 206 women undergoing primary elective cesarean deliveries to intrauterine cleaning or omission of cleaning. Postpartum endomyometritis rates across groups were the primary outcome. We also examined secondary outcomes. To detect a 20% difference in infection rate between the cleaned and the non-cleaned groups (two-tailed [alpha]?=?0.05, [beta]?=?0.2), 103 women were required per group. Analysis was by intention-to-treat.

Results: Two hundred and six were randomized as follows: 103 to intrauterine cleaning and 103 to omission of cleaning after placental delivery. There were no statistically significant differences in the rate of endomyometritis between the two groups (2.0% versus 2.9%, RR =0.60; 95% CI 0.40–1.32). There were no statistically significant differences in postpartum hemorrhage rates (5.8% versus 7.7%, RR 0.75; 95% CI 0.6–1.2), hospital readmission rates (2.9 versus 3.8%, RR 0.75; 95% CI 0.5–1.6), time to return of gastrointestinal function, need for repeat surgery, or quantitated blood loss between the two groups.

Conclusions: Our randomized controlled trial provides evidence suggesting that omission of intrauterine cleaning during cesarean deliveries in women at low risk of infection does not increase intraoperative or postoperative complications.     

Staples vs subcuticular sutures for skin closure at cesarean delivery: a metaanalysis of randomized controlled trials

Recently published randomized trials examining skin closure technique on postcesarean wound complications have produced conflicting results. We performed a metaanalysis of trials comparing staples and subcuticular sutures for skin closure at cesarean section (CS). Pooled outcome measures were calculated using random effects models. Primary outcomes were rates of wound dehiscence (separation) and a composite wound complication rate. Secondary outcomes were patient satisfaction, operating time, and postoperative pain. A total of 877 women from 5 trials were included. Both wound separation (pooled odds ratio, 4.01; P < .0001) and composite wound complication (pooled odds ratio, 2.11; P = .003) rates were higher with staples. The use of staples reduced operating time (weighted mean difference, -5.05 minutes; P = .021). Data on postoperative pain and patient satisfaction were insufficient for metaanalysis. Our findings suggest a possible benefit with subcuticular sutures compared to skin staples for skin closure at CS. However, the optimal skin closure technique at CS demands further study.     

A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage

Objective

The purpose of this study was to determine whether postcesarean section administration of ketorolac tromethamine reduces pain and narcotic usage.

Study design

A double-blinded randomized, placebo-controlled trial of ketorolac tromethamine was performed. Patients were randomly assigned to receive either ketorolac tromethamine or placebo. Patient-controlled analgesia (PCA) was used for pain control. Visual analog scales (VAS) were administered postoperatively to assess pain levels. Morphine equivalents and attempts were recorded.

Results

There were 22 patients in each arm of the study. There was no significant difference between patient demographics, blood loss, and type of anesthesia. Pain scores were significantly different at 2, 3, 4, 6, 12, and 24 hours by analysis of variance (ANOVA) (P = .033). There was a significant decrease in pain medication usage (P = .008) in the study group.

Conclusion

Ketorolac tromethamine is efficacious in reducing postoperative pain and narcotics usage after cesarean section.     

Comparative study of Misgav-Ladach and Pfannenstiel-Kerr cesarean techniques: a randomized controlled trial

Aim.?To compare Pfannenstiel-Kerr (PKM) and Misgav-Ladach (MLM) methods in terms of operation-related features and neonatal outcome in primary cesarean deliveries.

Methods.?A total of 180 pregnant women randomized into PKM (n?=?90) or MLM (n?=?90) groups were included in this study. Primary outcome measures were total operative and extraction times, Apgar score, blood loss, wound complications, and the suture use. Secondary outcome measures were wound seroma and infection incidence, time of bowel restitution, and the perceived pain.

Results.?Total operation and extraction times were significantly shorter and less suture material was used in the MLM group than the PKM group (p?<?0.001). Initially, higher scores obtained for 6 h-VAS in the MLM group (p?<?0.05) were normalized after 24?h of the operation. PKM and MLM were similar in terms of preoperative and postoperative levels of hemoglobin and hematocrit, wound complication, bowel restitution, fever, seroma, infection, wound dehiscence and the need for transfusion, antibiotic, and analgesics.

Conclusion.?The operation-related morbidity of the MLM and PKM for primary C/S seem to be comparable; however, the MLM seems to be superior in terms of operation time and the amount of suture usage but inferior in pain scores in the early postoperative period.     

Continuous vs interrupted sutures for single-layer closure of uterine incision at cesarean section

In a non-randomized cohort study, we compared continuous with interrupted sutures for the closure of the lower uterine segment at cesarean section. Eighty-two women, who underwent cesarean section at the Department of Obstetrics at the University Hospital of Vienna between January and May 2000, were included in the study. Thirty-eight patients had single-layer closure of the lower uterine segment and 43 patients had closure with interrupted sutures. There were significant differences in total operating-time (32 min vs 40 min, P=0.001) and in the pre- and postoperative maternal hemoglobin (DeltaHb 0.6 g/dl vs 1.1 g/dl, P<0.01), but there was no significant difference in sonographically diagnosed hematomas (32% vs 21%, P=0.27).No woman had fever, the median hospitalization time was 6 days, and there were no re-admissions. In both groups, the median need for analgesics was 150 mg diclofenac ( P=0.22). Continuous single-layer closure of the lower uterine segment at cesarean section saves operating time, reduces blood loss, and introduces less foreign material into the wound.     

A randomized study comparing non-closure and closure of visceral and parietal peritoneum during cesarean section

Objectives

To assess the short term morbidity of non-closure of the visceral and parietal peritoneal at caesarean section as compared to suture peritonization.

Methods

A prospective randomized controlled trial of 200 women undergoing cesarean section was done; randomized into non-closure and closure groups. Perioperative, intraoperative and postoperative details were recorded in the proforma. Chi-square/student t-test were used to compared outcome between the two groups.

Results

Operating time, anesthesia time and time of ambulation were significantly shorter in non-closure group (p<0.0001). There was less postoperative pain, analgesic requirement and febrile morbidity in non-closure group; however it was not statistically significant.

Conclusion

Avoiding the closure of visceral and parietal peritoneum at cesarean is associated with lesser operating time, decreased febrile morbidity and lesser need for postoperative analgesics. Hence routine closure of peritoneum at cesarean can be avoided.     

Techniques for wound closure at caesarean section: a randomized clinical trial

Objective

It is unclear which technique for skin closure should be used at caesarean section (CS) in order to get the best cosmetic result.

Study design

We conducted a randomized controlled trial to assess the cosmetic result of different techniques for skin closure after CS. A two-center single-blind randomized controlled trial was performed in The Netherlands. Women undergoing their first CS were eligible for the trial. In a factorial design, women were randomly allocated to (1) closure of the fat layer versus non-closure and (2) staples or intracutaneous stitches for skin closure. The cosmetic result was assessed using the Patient and Observer Scar Assessment Scale (POSAS).

Results

We included 124 women. In the stitches group 63% [39/62] women judged the scar as satisfactory, versus 63% [38/60] in the staples group (RR 1.01; 95% CI 0.64–1.6). When the subcutaneous fat layer was closed, 52% [33/63] of the women scored the scar as satisfactory, versus 75% [44/59] of the women in whom the fat layer was not separately closed (RR 0.53; 95% CI 0.32–0.89). This effect was independent of the subcutaneous thickness (p-value for interaction 0.64). Of the secondary outcomes, subcutaneous closure of the fat layer was associated with a longer admission time (median 4 days; IQR 3–5 versus 3 days; IQR 3–5, p-value 0.023).

Conclusions

The choice of staples or stitches does not affect the cosmetic result after a caesarean section. Closing of the subcutaneous fat layer, however, negatively affects the cosmetic result and is associated with a longer admission time.     

Carbetocin versus syntometrine for prevention of postpartum hemorrhage after cesarean section

Objective: To compare effectiveness and tolerability of carbetocin versus syntometrine in prevention of postpartum hemorrhage (PPH) after cesarean section (CS).

Methods: A double-blind randomized study conducted on 300 pregnant subjected randomly either to single 100?μg IV dose of carbetocin (150 women) or combination of 5?IU oxytocin and 0.2?mg ergometrine (150 women) after fetal extraction and before placental removal. Primary outcome parameter was the occurrence of PPH. Other parameters were hemoglobin and hematocrit changes, the need of additional oxytocic, hemodynamic changes and occurrence of side effects.

Results: There was no significant difference between the two study groups regarding hemoglobin and hematocrit at start of CS and after 2 days of surgery and mean blood loss during the operation (p?>?0.05). There was a highly significant difference between the two study groups regarding incidence of primary PPH (2.7% versus10%) and the need of additional oxytocic (3.3% versus17.3%). Women in oxytocin group showed a statistically significant lower systolic and diastolic blood pressure at 1, 5 and 30?min than women in carbetocin group. Women in carbetocin group experienced more metallic taste, flushing, headache, dizziness, dyspnea and itching, while women in oxytocin methergine group experienced more palpitations.

Conclusions: Carbetocin is a reasonable effective alternative to syntometrine in prevention of PPH after cesarean delivery.     

Treatment of incidental adnexal masses at cesarean section: a retrospective study

In this study, we evaluated the management of incidental adnexal masses observed at the time of cesarean section in our clinic during January 1992 to January 2005. The number of total live births was 35,153 and 8330 of them were by cesarean section (23.69%). There were 68 cases of incidental adnexal masses greater than 5 cm (68/8330, 0.8%). All of the masses were removed at cesarean section. The pathologic diagnosis of the masses were as follows: benign-benign cystic teratoma 20 (29.4%), simple serous cyst 8 (11.8%), simple mucinous 9 (13.2%), endometrioma 3 (4.4%), cystadenoma 14 (20.6%), and paraovarian-paratubal cyst 13 (19.1%) and malignant-struma ovarii 1 (1.5%). Cystectomy procedure during cesarean section did not alter the morbidity of the operation. So, we recommend resection of such incidental adnexal masses at cesarean section to avoid possible surgical procedures in future for the patient, although there is controversial data in literature.     

Manual removal versus spontaneous delivery of the placenta at cesarean section in developing countries: a randomized controlled trial and review of literature

Purpose: Cesarean section (CS) rates have increased; this is especially concerning in developing countries. The mode of placental delivery contributes to morbidity associated with CS and determines blood loss during CS. We aimed to compare manual removal versus spontaneous delivery of the placenta at CS.

Methods: In a randomized controlled trial, 574 women admitted for primary or repeat elective CS were randomized into two groups. In group A, the placenta was manually removed, whereas in group B, the placenta was left for spontaneous delivery. Blood loss, operative and postoperative data were recorded.

Results: Blood loss was 875.2?±?524.2?ml in group A versus 731.8?±?426.7?ml in group B (p?=?.001), with a significant drop in postoperative HB (p?=?.015) and HCT (p?=?.031). In group A, odds ratios for blood loss (>1000?ml), HB drop (>?4g/dl), postpartum hemorrhage and blood transfusion were 2.581, 2.850, 2.614 and 1.665, respectively. However, the total operative time (p?=?.326), duration of hospital stay (p?=?.916) and intensive care unit (ICU) admission (p?=?.453) were not statistically different between the two groups.

Conclusions: Manual removal of the placenta at CS is associated with a higher risk of blood loss, postpartum hemorrhage and blood transfusion, with no decrease in operative time.     

剖宫产手术子宫瘘的诊治

剖宫产手术子宫瘘主要发生于发展中国家,随着社会经济的发展,其在我国的发病率逐渐降低,但是近年来凶险性前置胎盘的发病率升高,术中损伤增加。因此,剖宫产后的子宫瘘仍需引起大家的重视。文章对剖宫产手术最常见的子宫瘘进行阐述,以期为其诊治提供参考和依据。