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.     

Chlorhexidine gluconate versus povidone iodine at cesarean delivery: a randomized controlled trial

Background/Aims: To compare the prevalence of positive bacterial cultures at the cesarean delivery (CD) incision site in patients with pre-operative application of chlorhexidine gluconate (CG) versus povidone iodine (PI).

Methods: Women undergoing a scheduled CD at ≥36 gestational weeks were randomly assigned to receive CG or PI. A swab of the incision site was performed at 3?min after disinfectant application and at 18 post-operative hours, and the prevalence of cultures with any detected bacterial growth was compared for the two groups.

Results: Of the 60 participants, 33 (55.0%) were in the PI group. There were no differences detected at 3?min, with 9.1% positive in the PI group versus 0% positive in the CG group (p?=?0.2499). However, at 18?h, women in the PI group were seven times more likely than women in the CG group to have a positive culture (16/33 [48.5%] versus 3/27 [11.1%], OR?=?7.53 [95% CI 1.67–38.83], p?=?0.0023). Multivariate logistic regression demonstrated similar results: OR?=?7.33 (95% CI 1.77–30.35), p?=?0.0060.

Conclusion: The prevalence of positive bacterial cultures obtained at the site of the skin incision 18?h after CD was higher in the PI versus the CG group.     

Random placenta margin incision for control hemorrhage during cesarean delivery complicated by complete placenta previa: a prospective cohort study

Introduction: Complete placenta previa (CPP) is one of the most problematic types of abnormal placenta, which is further complicated by placenta accreta or percreta that can unexpectedly lead to catastrophic blood loss, infection, multiple complications, emergency hysterectomy, and even death. The present study aimed to assess the efficacy of random placenta margin incision in controlling intraoperative and total blood loss during cesarean section for CPP women.

Methods: A prospective cohort study, including a total of 100 consecutive pregnant women with CPP, was performed at a tertiary university-affiliated medical center between March 2016 and July 2017. All of them underwent random placenta margin incision, and intraoperative and total blood loss were analyzed. Through antenatal diagnosis using color Doppler, women were further divided into abnormally invasive placenta (AIP) and non-AIP groups, and anterior and posterior placenta groups. The protocol was registered with the Clinical Trial Registry under registration number NCT02695069.

Results: Mean maternal age and gestational age at delivery were 32.26?±?5.03 years old and 36.21?±?2.07 weeks, respectively. Total duration of the surgical procedure time was 52.50 (42.43–64.00) min. Median estimated intraoperation blood loss was 746.43 (544.44–1092.86) ml. Total blood loss was 875.00 (604.50–1196.67) ml, and 38 (38.0%) had post-partum hemorrhage. The change from baseline in the median hemoglobin level was ?0.33 (6.00–13.20). No women underwent hysterectomy due to massive hemorrhage during the study period. No women had an intraoperative urinary bladder injury, postoperative wound infection, and required relaparotomy, owing to intra-abdominal bleeding. The median hospitalization time was 5.41 (4.18–7.58) d.

Conclusion: The random placenta margin incision may be a potentially valuable surgical procedure to control the volumes of intraoperative and postoperative blood loss and reduce the incidence of postpartum hemorrhage among women with complete placenta previa.     

Combination of motherwort injection and oxytocin for the prevention of postpartum hemorrhage after cesarean section

Objective: To evaluate the efficacy and safety of motherwort injection combined with oxytocin for preventing postpartum hemorrhage (PPH) after cesarean section (CS).

Methods: From March 2011 and February 2013, a randomized study was conducted on 165 primipara undergoing CS. 83 and 82 cases were placed into the combination of oxytocin and motherwort group and oxytocin group, respectively. Blood loss was calculated and measured during three periods: from placental delivery to the end of CS, from the end of CS to 2?h postpartum and from 2?h postpartum to 24?h postpartum. Vital signs were also measured.

Results: Blood loss in the period from placental delivery to the end of CS was similar (P?=?0.58) in these two arms. The quantity of total blood loss from the end of CS to 2?h postpartum (P?=?0.03) and from 2?h postpartum to 24?h postpartum (P?=?0.01) were significantly reduced in the combination of oxytocin and motherwort group. No significant abnormal vital signs were observed. Mild, transient side effects occurred more often in the combination of oxytocin and motherwort group.

Conclusions: It is efficacious and safe that combination use of motherwort injection and oxytocin could reduce blood loss and prevent PPH after CS.     

Different routes and forms of uterotonics for treatment of retained placenta: a randomized clinical trial*

Objectives: To compare between three different uterotonics (oxytocin, carbetocin and misoprostol) given via three different routes (intraumbilical, intravenous and sublingual, respectively) in reducing the need for manual removal of placenta (MROP).

Methods: A randomized trial for cases with retained placenta 30?min following vaginal delivery. They received intraumbilical oxytocin, intravenous carbetocin or sublingual misoprostol. Main outcome measures were delivery of the placenta within 30?min following drug administration, and need for MROP. Secondary outcome measures were injection to placental delivery time, post-delivery hemoglobin, need for blood transfusion or additional uterotonics.

Results: The overall success rate was 66.7% (64/96), 71.3% (67/94) and 63.7% (58/91) for oxytocin, carbetocin and misoprostol groups, respectively (p?>?0.05). When time needed to achieve placental delivery considered, a significant difference was observed with the shortest time for carbetocin (16.61?±?3.76?min), then oxytocin (18.28?±?3.34?min) and lastly misoprostol (23.00?±?3.38?min) (p?<0.001). Again, carbetocin group needed less additional uterotonics to achieve adequate uterine contractions (p?<0.001).

Conclusions: Although we aimed to exploit the advantage of certain drug over another, all seemed to have close efficacy but it would be important that further research should highlight availability, cost, ease of administration and storage requirements to determine which agent would best be used in this clinical scenario.     

Delayed uterine rupture occurred 4 weeks after cesarean section following sexual intercourse: A case report and literature review

ObjectiveSpontaneous delayed uterine rupture is life-threatening and extremely rare following sexual intercourse in postpartum. Here, we present a case of delayed uterine rupture that occurred 4 weeks after cesarean section following intercourse.Case reportA 31-year-old postpartum woman, gravida 4, para 1, abortion 3, underwent a cesarean section for prolonged labor. She was transferred to our hospital in shock status with brisk vaginal bleeding following intercourse 4 weeks after delivery. An emergency subtotal hysterectomy was performed to stop the bleeding. The pathology confirmed tissue necrosis and suture granuloma at the previous surgical wound.ConclusionThe presented case demonstrated that delayed uterine rupture may occur even 4 weeks after delivery following intercourse, without any obvious abdominal pain or infection signs, which deserved the attention of obstetricians.     

Barbed sutures versus conventional sutures for uterine closure at cesarean section; a randomized controlled trial

Introduction: The aim of this randomized control trial was to compare the operative data and the early postoperative outcomes of cesarean sections in which the uterine incision was closed with a barbed suture (STRATAFIX? Spiral PDO Knotless Tissue Control Device, SXPD2B405, Ethicon Inc.) with those of cesarean sections in which the uterine incision was closed with a conventional smooth suture (VICRYL^?; Ethicon Inc.).

Materials and methods: One hundred pregnant patients were randomized in a 1:1 ratio to the Stratafix group or the Vicryl group. The uterine incision was closed by two layers of sutures in both groups. In the Vicryl group, the first layer was continuous and the second layer was interrupted. In the Stratafix group, both layers were continuous.

Results: The uterine closure time was significantly lower in the Stratafix group (224?±?46 versus 343?±?75?s, p?p value?=?.009). The mean blood loss during closure of uterine incision and mean hospital stay were lower in the Stratafix group but these differences failed to reach statistical significance.

Conclusion: The use of barbed suture for uterine incision closure at cesarean section is associated with shorter uterine closure time and similar early perioperative complications compared with conventional smooth suture. The difference between both groups in the technique of suturing the second layer of the uterine incision may be the cause of the reduction in the uterine closure time and the need for additional sutures to achieve hemostasis during suturing the uterine incision with a barbed suture. Further, well designed randomized controlled trials should be conducted to investigate the association between the type of suture (barbed or conventional smooth) and remote complications of cesarean section (infertility, pelvic pain, abnormal placentation and rupture uterus).     

Carbetocin versus oxytocin for the prevention of postpartum hemorrhage: A meta-analysis of randomized controlled trials in cesarean deliveries

Objective

Postpartum hemorrhage remains the leading cause of maternal mortality in developing countries and a significant proportion of these cases are attributable to uterine atony. In contrast to the advances made in the treatment of postpartum hemorrhage, there has been few novel prophylactic agents. This study was undertaken to analyze the effectiveness of carbetocin compared to oxytocin for the prevention of postpartum hemorrhage, in the context of cesarean deliveries.

Efficacy of oxytocin versus carbetocin in prevention of postpartum hemorrhage after cesarean section under general anesthesia: a prospective randomized clinical trial

Objective: To compare the use of carbetocin and oxytocin in the prevention of postpartum hemorrhage after cesarean section.

Methods: The present study was a prospective double-blind randomized controlled clinical trial performed in two university-based hospitals in Tehran, Iran. Two hundred and twenty women with the gestational age of more than 37 weeks, who needed cesarean operation, participated in the study. Patients were assigned to receive either a single 100?μg IV dose of carbetocin or a standard 30-international unit IV infusion of oxytocin during 2?h after delivery of placenta. The primary outcome measures were postpartum hemorrhage requiring additional uterotonic drugs, bleeding volume, and the hemoglobin drops.

Results: There were meaningful differences in carbetocin versus oxytocin group regarding the hemoglobin drops (1.01 versus 2.05, p?=?.01), bleeding volume (430.68?CC versus 552.6?CC, p?p?p?Conclusions: It may be concluded that carbetocin is a good alternative modality to conventional uterotonic agents such as oxytocin for the prevention of postpartum hemorrhage after cesarean sections.

Registration ID in IRCT: NCT02079558     

Intra-abdominal saline irrigation at cesarean section: a systematic review and meta-analysis

Objective: The aim of this study was to examine the evidence guiding intraoperative saline irrigation at cesarean sections.

Methods: We searched “cesarean sections”, “pregnancy”, “saline irrigation” and “randomized clinical trials” in ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, AJOL, MEDLINE, LILACS and CINAHL from inception of each database to April 2015. The primary outcomes were predefined as intraoperative nausea and emesis. The pooled results were reported as relative risk (RR) with 95% confidence interval (95% CI).

Results: Three randomized trials including 862 women were analyzed. Intraoperative saline irrigation was associated with a 68% increased risk of developing intraoperative nausea (RR?=?1.68, 95% CI 1.36–2.06), 70% increased risk of developing intraoperative emesis (RR?=?1.70, 95% CI 1.28–2.25), 92% increased risk of developing post-operative nausea and 84% increased risk of using anti-emetics post-operatively (RR?=?1.84, 95% CI 0.21–2.78) when compared with controls. There were no significant differences between intraoperative saline irrigation and no treatment for post-operative emesis (RR?=?1.65, 95% CI 0.74–3.67), estimated blood loss, time to return of gastrointestinal function, postpartum endometritis (RR?=?0.95, 95% CI 0.64–1.40), urinary tract infection and wound infection.

Conclusion: Intraoperative saline irrigation at cesarean delivery increases intraoperative and post-operative nausea, requiring increasing use of anti-emetics without significant reduction in infectious, intraoperative and postpartum complications. Routine abdominal irrigation at cesarean section is not supported by current data.     

Effect of grape seed extract ointment on cesarean section wound healing: A double-blind,randomized, controlled clinical trial

Backgroundand purpose: Complications of the delayed recovery of cesarean section (CS) wound can include stress, discomfort, and dissatisfaction of the mother in the postpartum period. This study tried to determine the effect of grape seed extract ointment on CS wound healing.Materials and methodsThis is a double-blind, randomized, controlled clinical trial incorporating 129 women eligible for CS in eastern Iran. Participants were selected through convenience sampling method and were subsequently randomly assigned into three groups: 2.5% grape seed extract ointment, 5% grape seed extract ointment, and petrolatum. CS wound healing indices were assessed before the intervention, and 6 and 14 days after the intervention using the REEDA scale (redness, edema, ecchymosis, discharge, and approximation).ResultsThe mean scores on days 6 and 14 after intervention were respectively 2.02 ± 0.52 and 0.98 ± 0.61 in the 5% ointment group, 2.83 ± 0.54 and 1.58 ± 0.67 in the 2.5% ointment group, and 2.91 ± 0.51 and 1.55 ± 0.74 in the petrolatum group. While the mean score in the 5% ointment group was significantly different from those of 2.5% ointment and petrolatum groups (P < 0.001), the mean score in the 2.5% ointment group was not significantly different from that of the petrolatum group on days 6 and 14 after intervention (P = 0.38 and P = 0.79, respectively).ConclusionThe current results suggest that 5% grape seed extract may have beneficial therapeutic effects in promoting CS wound healing.     

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.     

A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery

Objective

To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair.

Methods

The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012–2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n = 500) and in situ repair in group 2 (n = 500). The primary outcome measure was the surgery duration.

Results

Surgery duration was significantly longer in group 1 than group 2 (49.9 ± 2.3 minutes vs 39.9 ± 1.8 minutes; P < 0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P = 0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P < 0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0 ± 2.7 hours vs 14.0 ± 1.9 hours; P < 0.001).

Conclusion

In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement.ClinicalTrials.gov:NCT01723605     

Vaginal versus cesarean section oriented approaches in the management of breech delivery

In a 5-year retrospective study, 543 singleton breech presented infants weighing more than 1000 g were reviewed in two obstetric departments. Department "A" actively conducted the labor with lower cesarean section rate (26%). Department "B" attempted a trial of labor with less invasive procedures and performed more cesarean sections (38% P less than 0.05 S). The management of labor, fetal and maternal outcome were compared between the two departments. Both vaginal and abdominal routes of delivery in fetuses weighing more than 1500 g resulted in the same fetal and maternal outcome. For fetuses weighing 1000-1500 g cesarean section is probably the recommended delivery route.