Cephalad-caudad versus transverse blunt expansion of the low transverse hysterotomy during cesarean delivery decreases maternal morbidity: a meta-analysis

Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews

“…The overview includes 38 SRs 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 (16 Cochrane and 22 non-Cochrane) published between 2004–2024 involving 628 RCTs with a total of 190,349 participants. Table 1 summarises the main characteristics of the included SRs (see Annex 4 for details).…”

“…RTC/No. participants) Certainty of evidence Category Preparation Use of retractors 35 O'ring retractor Standard care Need for uterine exteriorization 0.48 [0.33, 0.69] (4/1301) Moderate Adequate visualization 1.01 [1.04, 1.16] (2/352) Moderate SSI 0.76 [0.34, 1.79] (5/1515) Low Use of aspiration device Use of surgical swabs Bladder flap 36 Bladder flap formation Non formation Skin incision to delivery (min) 1.27 [0.63, 1.92] (3/466) Very Low Blood loss (ml) 42.40 [−32.30, 117.0] (3/479) Very Low Bladder injury 0.96 [0.19, 4.84] (3/479) Very Low Total surgical time (min) 3.50 [−0.19, 7.16] (4/581) Very Low Duration of hospitalization (days) 0.07 [−0.50, 0.64] (2/364) Very Low Uterine incision Hysterotomy technique (location/length) Hysterotomy expansion 37 , 38 , 39 Blunt dissection/expansion Sharp dissection/expansion Operative time (min) −2.06 [−2.11, −2.01] (2/1276) High Mean blood loss (ml) −55.00 [−79.48, −30.52] (2/1145) Moderate Blood transfusion 0.24 [0.09, 0.62] (2/1345) Low …”

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

“…In a meta-analysis of randomized trials, cephalad-caudad blunt extension reduced the risk of unintended incision extension (RR 0.62; 95% CI, 0.45-0.86) and uterine vessel injury (RR 0.55; 95% CI 0.41-0.73). 45 In general, the uterine incision should be ≥10 cmthe mean biparietal and suboccipito-bregmatic diameters at term are about 9.5 cm-to avoid a difficult delivery and uncontrolled extensions. Avoid attempts to deliver the fetus through a uterine opening that is too small.…”

“…Compared with the blunt group, the incidence of postpartum hemorrhage (13% vs. 9%; RR 1.23, 95% CI, 1.03–1.46) and need for a transfusion (2% vs. 0.4%; RR 1.65; 95% CI, 1.25–2.21) was significantly greater in the sharp group. In a meta‐analysis of randomized trials, cephalad‐caudad blunt extension reduced the risk of unintended incision extension (RR 0.62; 95% CI, 0.45–0.86) and uterine vessel injury (RR 0.55; 95% CI 0.41–0.73) 45 . In general, the uterine incision should be ≥10 cm—the mean biparietal and suboccipito‐bregmatic diameters at term are about 9.5 cm—to avoid a difficult delivery and uncontrolled extensions.…”