Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis

Purpose Hypotension is common after spinal anesthesia for cesarean delivery. It is associated with nausea, vomiting and fetal acidosis. Previous research on phenylephrine excluded obese subjects. We compared the incidence of intraoperative nausea and vomiting (IONV) in obese patients who received a prophylactic phenylephrine infusion versus those who received phenylephrine boluses for the treatment of spinal-induced hypotension. Methods In this multi-centre, double-blinded randomized controlled trial, 160 obese women undergoing elective cesarean delivery under spinal anesthesia were randomized to receive a prophylactic phenylephrine infusion initiated at 50 μg/min and titrated according to a predefined algorithm or 100 μg phenylephrine boluses to treat hypotension. Maternal systolic blood pressure was maintained within 20% of baseline. The primary study outcome was the incidence of IONV. Results IONV was significantly reduced in the infusion group compared to the bolus group, 46% vs 75%; relative risk 0.61 (95% CI 0.47 to 0.80); P < 0.001. This was associated with significantly reduced need for intraoperative rescue antiemetics, 26% vs 42%; relative risk 0.62 (95% CI 0.40 to 0.97); P = 0.04, but no difference in the incidence of vomiting. Postoperative vomiting at 2h was reduced in the infusion group, 11% vs 25%; relative risk 0.44 (95% CI 0.21 to 0.90); P = 0.02, however there were no differences in the incidence or severity of postoperative nausea, need for rescue antiemetics at 2h and 24h or the incidence of postoperative vomiting at 24h. The infusion group had a significantly lower incidence of hypotension but greater incidence of reactive hypertension. Conclusion In obese women undergoing cesarean delivery with spinal anesthesia, prophylactic phenylephrine infusion was associated with less intraoperative nausea, less need for rescue antiemetics and reduced early postoperative vomiting. Trial Registry Number NCT01481740 https://clinicaltrials.gov/ct2/show/NCT01481740?term=NCT01481740&rank=1

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“…A recent systematic review has found there is no significant difference in IONV when exteriorized vs. in-situ CD is performed. 26 …”

Section: Discussionmentioning

confidence: 99%

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

George

McKeen

Dominguez

et al. 2017

Can J Anesth/J Can Anesth

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“… 4 , 13 , 47 – 49 Similar to prior studies, there may be benefit to either exteriorization or in situ repair depending on the outcome of interest. In the most recent systematic review by Zaphiratos et al, 48 exteriorization appeared to reduce blood loss. Previous RCTs and reviews demonstrated benefit of in situ repair with regard to patient nausea, vomiting and resumption of bowel motility postoperatively.…”

Section: Standardized Cesarean Delivery Surgical Techniquementioning

confidence: 97%

The Case for Standardizing Cesarean Delivery Technique

Dahlke

Mendez‐Figueroa

Maggio

et al. 2020

Obstetrics &Amp; Gynecology

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“…9 There was statistically no significant difference between the two groups as far as intra-operative nausea, vomiting is concerned. 5,7 Blood loss is significantly more in the non-eventrated group; uterine eventration at caesarean section is not to be condemned. 10 For active management of the 3 rd stage of labour WHO recommended uterotonics before placental delivery in all cases to prevent PPH.…”

Section: Review Of Literaturementioning

confidence: 96%

“…There is no statistically significant difference regarding intra-operative nausea, vomiting. 5 Surgical time is also shorter in extra-abdominal repair. 6 Post-operative febrile morbidity was lower with relative risk of 0.41 in patients undergoing eventration of uterus.…”

Section: Review Of Literaturementioning

confidence: 99%

Exteriorization of uterus before placental expulsion and intra-myometrial oxytocin versus in situ repair and IV oxytocin during LSCS â€“ A comparative study

2020

IJOGR

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Introduction: A suitable modification of any step of caesarean section to reduce blood-loss should be considered as the morbidity and mortality of CS is mostly associated with excessive hemorrhage. Aim: This is a comparative study of uterine exteriorization and intra-myometrial (IMM) oxytocin 5 IU before placental expulsion with conventional method of intra-abdominal repair with 10 IU IV oxytocin with primary objective to compare the blood-loss. Materials and Methods: A prospective study of 2 groups, 100 women in each group (Primis & 2 nd gravidas between 19-34 years of age) having hemoglobin above 10 gm% in cephalic presentation with almost identical indications for CS excluding prematurity, APH, IUGR, bleeding disorders, fibroids etc. Standard caesarean procedure followed except exteriorization of uterus before placenta delivery and IMM oxytocin 5 IU in Gr1; and intra-abdominal repair and slow IV 10 IU oxytocin in Gr2. Preoperative, Postoperative and difference of Hb, duration of surgery from baby birth to starting of abdominal closure, blood-loss by volumetric method noted and compared after mean calculation by student t and chi-square test. Intra-operative and post-operative complications compared by relative risk calculation. Results: The values of postoperative Hb level 99.2 against 89.2g/l, Hb difference between pre-and postoperative level 12.7 against 23.2g/l, blood loss 394.8 ml against 461.6 ml, duration of surgery 11 min 10 sec against 19 min 53 sec were highly significant (p < 0.0001 by student t and chi square test). The hospital stay with relative risk calculation shows significant difference between 2 groups. Conclusion: Exteriorization of uterus before placental separation and IMM oxytocin reduces not only blood loss and time taken in caesarean sections, also the hospital stay.

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Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis

Cited by 29 publications

References 34 publications

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

The Case for Standardizing Cesarean Delivery Technique

Exteriorization of uterus before placental expulsion and intra-myometrial oxytocin versus in situ repair and IV oxytocin during LSCS â€“ A comparative study

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