The purpose of this study is to compare the rate of vaginal cuff dehiscence between two different methods of closure in patients undergoing robotic-assisted total laparoscopic hysterectomy and explore variables related to postoperative breakdown. This was a prospective, randomized controlled study with two arms. The control group (Arm 1) underwent single-layer continuous closure while the study group (Arm 2) had three additional imbricating figure-of-X sutures placed in addition to the standard protocol. Of the 263 patients who completed the study, 4 patients (1.49 %) experienced dehiscence of the vaginal cuff. Three of the four patients with dehiscence received the standard single vaginal cuff closure (Arm 1) and the one remaining case of dehiscence underwent the protocol with additional sutures (Arm 2). All patients who experienced dehiscence were current smokers. Our study suggests that there may be benefit in adding additional sutures to the standard single-layer vaginal cuff closure procedure. Physicians should evaluate smoking status before deciding on a vaginal cuff closure method.

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INTRODUCTION: To examine the effects of a Collaborative Laborist and Certified Nurse Midwife (CNM) Model on the rates of induction, primary and repeat cesarean sections, vaginal birth after cesarean (VBAC), and nursing staff satisfaction with this model of care. METHODS: This was a prospective cohort study at the largest birthing center in South Dakota between 2008-2016. Rates of induction, primary and repeat cesarean section, VBAC, and nursing staff satisfaction were compared over three 2 year time periods: before and after Laborist Model initiated and with the addition of CNM to the model. Linear regression and two-way ANOVA were used to compare trends of primary cesarean, repeat cesarean, VBAC, and induction. A two-tailed t-test compared values of nursing satisfaction. RESULTS: The primary cesarean delivery and induction rate decreased from 15.9% to 13.5% (P < .005 95% CI 0.67–0.22) and 49.38% to 30.75% (P < .006 95% CI 7.24–1.23) respectively. VBAC success rates increased from 1.55% to 2.21% (P < .017 95% CI .07-.23) of all deliveries. There was a significant increase in respect between physician and staff (P < .01 8.9% difference), NICU communication (p < .001 16.2% difference), and provider involvement in triage (P < .001 27.9%) This difference was shown following addition of CNM's. CONCLUSION: The rates of primary cesarean section and induction are significantly decreasing at the same time as the rate of VBAC is increasing. These results represent an overall positive outcome of employing the Laborist and CNM Collaboration Model.

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