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Meta-Analysis
. 2014 Jul 22;2014(7):CD004732.
doi: 10.1002/14651858.CD004732.pub3.

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

Jodie M Dodd  1 , Elizabeth R Anderson, Simon Gates, Rosalie M Grivell
Affiliations
Meta-Analysis

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

Jodie M Dodd et al. Cochrane Database Syst Rev. .

Abstract

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 healthcare resource use.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 September 2013) and reference lists of all identified papers.

Selection criteria: All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.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 review 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: Our search strategy identified 60 studies for consideration, of which 27 randomised trials involving 17,808 women undergoing caesarean section were included in the review. Overall, the methodological quality of the trials was variable, with 12 of the 27 included trials adequately describing the randomisation sequence, with less than half describing adequately methods of allocation concealment, and only six trials indicating blinding of outcome assessors.Two trials compared auto-suture devices with traditional hysterotomy involving 300 women. No statistically significant difference in febrile morbidity between the stapler and conventional incision groups was apparent (risk ratio (RR) 0.92; 95% confidence interval (CI) 0.38 to 2.20).Five studies were included in the review that compared blunt versus sharp dissection when performing the uterine incision involving 2141 women. There were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05). Mean blood loss (two studies; 1145 women; average mean difference (MD) -55.00 mL; 95% CI -79.48 to -30.52), and the need for blood transfusion (two studies; 1345 women; RR 0.24; 95% CI 0.09 to 0.62) were significantly lower following blunt extension.A single trial compared transverse with cephalad-caudad blunt extension of the uterine incision, involving 811 women, and while mean blood loss was reported to be lower following transverse extension (one study; 811 women; MD 42.00 mL; 95% CI 1.31 to 82.69), the clinical significance of such a small volume difference is of uncertain clinical relevance. There were no other statistically significant differences identified for the limited outcomes reported.A single trial comparing chromic catgut with polygactin-910, involving 9544 women reported that catgut closure versus closure with polygactin was associated with a significant reduction in the need for blood transfusion (one study, 9544 women, RR 0.49, 95% CI 0.32 to 0.76) and a significant reduction in complications requiring re-laparotomy (one study, 9544 women, RR 0.58, 95% CI 0.37 to 0.89).Nineteen studies were identified comparing single layer with double layer closure of the uterus, with data contributed to the meta-analyses from 14 studies. There were no statistically significant differences identified for the primary outcome, febrile morbidity (nine studies; 13,890 women; RR 0.98; 95% CI 0.85 to 1.12). Although the meta-analysis suggested single layer closure was associated with a reduction in mean blood loss, heterogeneity is high and this limits the clinical applicability of the result. There were no differences identified in risk of blood transfusion (four studies; 13,571 women; average RR 0.86; 95% CI 0.63 to 1.17; Heterogeneity: Tau² = 0.15; I² = 49%), or other reported clinical outcomes.

Authors' conclusions: Caesarean section is a common procedure performed on women worldwide. There is increasing evidence that for many techniques, short-term maternal outcomes are equivalent. Until long-term health effects are known, surgeons should continue to use the techniques they prefer and currently use.

PubMed Disclaimer

Conflict of interest statement

S Gates and E Anderson are both involved in the CAESAR trial comparing single with double layer uterine closure.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 1 Febrile morbidity.
1.2
1.2. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 2 Mean blood loss.
1.3
1.3. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 3 Duration of surgery.
1.4
1.4. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 4 Duration of postnatal stay.
1.5
1.5. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 5 Wound complications.
1.6
1.6. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 6 Need for blood transfusion.
1.7
1.7. Analysis
Comparison 1 Methods of performing the uterine incision: auto stapler versus conventional, Outcome 7 Endometritis.
2.1
2.1. Analysis
Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 1 Postoperative febrile morbidity (including endometritis).
2.2
2.2. Analysis
Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 2 Mean blood loss.
2.3
2.3. Analysis
Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 3 Need for blood transfusion.
2.4
2.4. Analysis
Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 4 Maternal death or serious morbidity.
2.5
2.5. Analysis
Comparison 2 Methods of performing the uterine incision: blunt versus sharp dissection, Outcome 5 Duration of surgery.
3.1
3.1. Analysis
Comparison 3 Methods of performing the uterine incision: transverse versus cephalad‐caudad blunt extension, Outcome 1 Mean blood loss.
3.2
3.2. Analysis
Comparison 3 Methods of performing the uterine incision: transverse versus cephalad‐caudad blunt extension, Outcome 2 Need for blood transfusion.
3.3
3.3. Analysis
Comparison 3 Methods of performing the uterine incision: transverse versus cephalad‐caudad blunt extension, Outcome 3 Duration of surgery.
4.1
4.1. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 1 Postoperative febrile morbidity (including endometritis).
4.2
4.2. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 2 Blood loss greater than 500 mL.
4.3
4.3. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 3 Need for blood transfusion.
4.4
4.4. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 4 Wound infection.
4.5
4.5. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 5 Operative procedure on wound.
4.6
4.6. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 6 Postoperative anaemia.
4.7
4.7. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 7 Complication of future pregnancy.
4.8
4.8. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 8 Postoperative pain present.
4.9
4.9. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 9 Complications post‐op requiring re‐laparotomy.
4.10
4.10. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 10 Length of hospital stay.
4.11
4.11. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 11 Death or serious maternal morbidity.
4.12
4.12. Analysis
Comparison 4 Single layer uterine closure versus double layer uterine closure, Outcome 12 Maternal readmission.
5.1
5.1. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 1 Postoperative febrile morbidity (including endometritis).
5.2
5.2. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 2 Need for blood transfusion.
5.3
5.3. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 3 Wound infection.
5.4
5.4. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 4 Operative procedure on wound.
5.5
5.5. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 5 Postoperative pain present.
5.6
5.6. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 6 Complications post‐op requiring re‐laparotomy.
5.7
5.7. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 7 Death or serious maternal morbidity.
5.8
5.8. Analysis
Comparison 5 Techniques for closing the uterus: chromic catgut versus polygactin‐910, Outcome 8 Maternal readmission.
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Update of

References

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Hauth 1992 {published data only}
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Lal 1988 {published data only}
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Moreira 2002 {published data only}
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Poonam 2006 {published data only}
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Rodriguez 1994 {published data only}
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Ansaloni 2001 {published data only}
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Behrens 1997 {published data only}
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Giacalone 2002 {published data only}
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Hohlagschwandtner {published data only}
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Lodh 2002 {published data only}
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Moroz 2008 {published data only}
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Naki 2011 {published data only}
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References to studies awaiting assessment

Belci 2005 {published data only}
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Borowski 2007 {published data only}
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Hagen 1999 {published data only}
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Mazhar 2004 {published data only}
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Mukhopadhyay 2000 {published data only}
    1. Mukhopadhyay B. Single layer ‐ vs ‐ two layer closure of uterus during caesarean section ‐ an institutional experience [abstract]. XVI FIGO World Congress of Obstetrics & Gynecology. Book 3; 2000 Sept 3‐8; Washington DC, USA. 2000:43.
Pandey 2006 {published data only}
    1. Pandey R, Kant A. Single layer closure of uterine incision without closure of visceral and parietal peritonium vs. double layer closure of uterine incision with visceral and parietal peritoneal closure ‐ a comparative study. 49th All India Congress of Obstetrics and Gynaecology; 2006 January 6‐9; Cochin, Kerala State, India. 2006:102.
Wojdemann 2010 {published data only}
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References to ongoing studies

Farajzadeh 2010 {published data only}
    1. Farajzadeh F. The comparison of outcomes of traditional and misgav‐ladach techniques in cesarean section. IRCT Iranian Registry of Clinical Trials (www.irct.ir) (accessed 6 December 2010) (accessed 6 December 2010).

Additional references

ACOG 1999
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Bujold 2002
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Chapman 1997
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Deeks 2001
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Tahilramaney 1984
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References to other published versions of this review

Dodd 2008
    1. 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. [DOI: 10.1002/14651858.CD004732.pub2] - DOI - PubMed
Enkin 2006
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Wilkinson 2006
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