Unintended Extension of the Lower Segment Uterine Incision at Cesarean Delivery: A Randomized Comparison of Sharp versus Blunt Techniques

Aşıcıoğlu, Osman; Güngördük, Kemal; Aşıcıoğlu, Berhan Besimoğlu; Yıldırım, Gökhan; Güngördük, Özgü; Ark, Cemal

doi:10.1055/s-0033-1361934

Cited by 7 publications

(3 citation statements)

References 8 publications

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“… 4 Two RCTs and four systematic reviews have since been published supporting this technique as it is associated with fewer unintended extensions. 31 – 36 …”

Section: Standardized Cesarean Delivery Surgical Techniquementioning

confidence: 99%

The Case for Standardizing Cesarean Delivery Technique

Dahlke

Mendez‐Figueroa

Maggio

et al. 2020

Obstetrics &Amp; Gynecology

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“… 4 Two RCTs and four systematic reviews have since been published supporting this technique as it is associated with fewer unintended extensions. 31 – 36 …”

Section: Standardized Cesarean Delivery Surgical Techniquementioning

confidence: 99%

The Case for Standardizing Cesarean Delivery Technique

Dahlke

Mendez‐Figueroa

Maggio

et al. 2020

Obstetrics &Amp; Gynecology

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“…In an evaluation of CDs performed following labour, the hysterotomy extensions were significantly more common after a prolonged second stage of labour (Sung et al 2007). Variations in surgical technique including blunt versus sharp creation of the hysterotomy have also been assessed (Rodriguez et al 1994; Magann et al 2002; Cromi et al 2008; Sekhavat et al 2010; Xu et al 2013; Asicioglu et al 2014b; Xodo et al 2016). While there is a trend towards a reduced incidence of hysterotomy extensions after blunt creation, this has not been statistically significant in meta-analysis (RR 0.57; 95%CI 0.28–1.17) (Xu et al 2013).…”

Section: Introductionmentioning

confidence: 99%

Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity

Giugale

Sakamoto

Yabes

et al. 2018

Journal of Obstetrics and Gynaecology

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We conducted an observational retrospective cohort study to evaluate the risk factors and the maternal morbidity associated with unintended extensions of the hysterotomy during caesarean delivery. We evaluated 2707 women who underwent low-transverse caesarean deliveries in 2011 at an academic, tertiary-care hospital. Hysterotomy extensions were identified through operative reports. Of the 2707 caesarean deliveries, 392 (14.5%) had an unintended hysterotomy extension. On the multivariable regression modelling, neonatal weight (OR 1.42; 95%CI 1.17-1.73), the arrest of labour [first-stage arrest (2.42; 1.73-3.38); second-stage arrest (5.54; 3.88-7.90)] and a non-reassuring foetal status (1.65; 1.20-2.25) were significantly associated with hysterotomy extensions. Hysterotomy extensions were significantly associated with an increased morbidity including an estimated blood loss >1200 millilitres (2.06; 1.41-3.02), a decline in postoperative haemoglobin ≥3.7 g/dL (2.07; 1.35-3.17), an evaluation for lower urinary tract injury (5.58; 3.17-9.81), and a longer operative time (8.11; 6.33-9.88). Based on these results, we conclude that unintended hysterotomy extensions significantly increase the maternal morbidity of caesarean deliveries. Impact statement What is already known on this subject? Maternal morbidity associated with caesarean delivery (CD) is significantly greater than that in vaginal delivery. Unintended extensions of the hysterotomy occur in approximately 4-8% of CDs and are more common after a prolonged second stage of labour. The morbidity associated with hysterotomy extensions has been incompletely evaluated. What do the results of this study add? We demonstrate a rate of hysterotomy extension in a general obstetric population of approximately 15%, which is higher than previously reported estimates, and represents a potential doubling of the rate of the unintended hysterotomy extensions in recent years. The most significant risk factor for a hysterotomy extension was a second-stage labour arrest with a fourfold increase in the frequency of extensions. A hysterotomy extension is a significant independent risk factor for an intraoperative haemorrhage, a drop in postoperative haemoglobin, an intraoperative evaluation for lower urinary tract injury, and longer CD operative times. What are the implications of these findings for clinical practice and/or further research? A second-stage arrest is a strong independent risk factor for a hysterotomy extension. Recent re-evaluations of the labour curve that extend the second stage of labour will likely increase the frequency of CDs performed after a prolonged second stage. In these scenarios, obstetricians should be prepared for an unintended hysterotomy extension and for the possibility of a longer procedure with the increased risks of blood loss and the need for evaluation of the lower urinary tract.

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“…7 Our study support the results of Xu LL et al and postulate that blunt type of uterine incision is associated with less blood loss when the bias of arrest disorder is excluded because if myometrial planes are used bluntly for cutting they are associated with less oozing from myometrial edges and sharp expansion is associated with increased bleeding because of increased bleeding from the incised edges itself, from muscle ooze, traumatized vasculature or secondary to a greater forward extension of distal incision. 15,16 Further studies are needed for evaluation of type of uterine incision in patient with repeat cesarean section as there is increased risk of inadvertent uterine extension when blunt uterine incision is used. 17,18…”

Section: A H E a D O F P R I N Tmentioning

confidence: 99%

Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section

Faiza

Sadaf²,

Ameena³

et al. 2021

Pak J Med Sci

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Objectives: To compare the effect of blunt and sharp incision of uterus at cesarean section on intra-operative haemorrhage. Methods: This trial was conducted at the Department of Obstetrics and Gynaecology, Pakistan Ordinance Factory Hospital, Wah Cantt from 14th January to 13th July 2012. Total 80 women planned for lower segment cesarean section through Pfannensteil incision were randomized to either blunt uterine incision (Group-A, n=40) or sharp uterine incision (Group-B, n=40). The fall in Haemoglobin and HCT was compared in two groups and analyzed with help of SPSS version 10. Results: Both groups were similar in terms of demographic features like age, parity, gestational age and indication for cesarean section. The participants in Group-A reveled significantly less drop of mean Hb concentration as compared to Group-B (1.47±1.08 and 1.95±0.85 respectively, P value 0.031). Similarly, the fall in mean HCT was significantly less in Group-A in comparison to Group-B (3.21±1.3 and 4.21±2.17 respectively, P-value 0.015) Conclusion: Blunt expansion of uterine incision during caesarean section is associated with less fall in Haemoglobin and HCT as compared to sharp expansion. doi: https://doi.org/10.12669/pjms.37.7.4159 How to cite this:Faiza, Sadaf F, Ameena B, Khan NR. Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4159 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Unintended Extension of the Lower Segment Uterine Incision at Cesarean Delivery: A Randomized Comparison of Sharp versus Blunt Techniques

Abstract: Sharp expansion of the uterine incision was related to a higher risk of unintended extension and maternal blood loss. Because blunt expansion is associated with a lower risk for unintended extension and maternal blood loss, it should be the first option during elective cesarean delivery.

Cited by 7 publications

References 8 publications

The Case for Standardizing Cesarean Delivery Technique

The Case for Standardizing Cesarean Delivery Technique

Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity

Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section

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