Cesarean delivery remains one of the most common and oldest ob-gyn procedures, but new evidence should change the way C-sections are performed.
“Evidence can inform practice, but it cannot replace expertise,” said Eric Strand, MD, FACOG, associate professor of obstetrics and gynecology, Washington University, St. Louis. “Evidence-based medicine is recognition that data can inform practice in important ways.”
Dr. Strand explored some of the recent data on C-section techniques during the Monday morning clinical seminar “Evidence-Based Cesarean Delivery: A Step-by-Step Guide.” Some evidence-based recommendations are already standard procedure. An audience poll showed that nearly all administer prophylactic antibiotics before the skin incision. Ob-gyns traditionally waited until the cord was clamped to give antibiotics.
Incision choices are less current. Most practitioners use the traditional Pfannenstiel incision. Recent data suggests lower rates of complication with the Joel-Cohen incision, a straight lateral incision about two centimeters above the Pfannenstiel location.
“There are good data suggesting that there are benefits from using the Joel-Cohen, including shorter length of maternal stay, less febrile morbidity, less pain medication use, shorter time to delivery and less OR time overall,” Dr. Strand said. “It is designed for less tissue dissection and disruption.”
There are fewer recommendations on patient positioning and skin preparation.
Women are typically positioned to the left to avoid vena cava compression and improve blood flow to the uterus and the placenta, Dr. Strand noted. A Cochrane Review in 2013 found no apparent benefit to a 20 degree left lateral table tilt compared to a supine position. The data were too weak to produce any recommendations.
All ob-gyns recognize the need for skin preparation. There are multiple options available, including aqueous or alcohol-based iodine and alcohol-based chlorhexidine solutions. Efficacy data are conflicting.
“We all know that the skin should be prepped,” Dr. Strand said, “but how you prep is up to you.”
The bladder flap helped minimize infection before antibiotics but no longer serves a useful purpose. Cesarean delivery without a bladder flap appears not to add additional risks, Dr. Strand said, but significantly shortens operative time.
Recent data strongly supports the use of blunt dissection using the fingers instead of scissors or other sharp instruments.
Manual extraction of the placenta is another traditional technique that’s changing. Recent trials show lower rates of endometritis compared to spontaneous extraction.
The data are less clear for exteriorizing the uterus. There are advantages both ways, Dr. Strand said. Surgeon preference and technical issues such as adhesions are the deciding factors.
The data on uterine incision repair and subsequent uterine rupture are unclear. Some data suggest that single layer repair is associated with a greater risk of rupture. Other studies suggest that a locked stitch is more likely to result in future uterine rupture than an unlocked stitch.
Peritoneal closure is similarly mixed. Closing the parietal peritoneum is associated with fewer adhesions of fascia to the uterus, omentum to uterus, and omentum to fascia. And there are benefits to not closing the visceral peritoneum, including decreased inflammation, urge incontinence, and urinary frequency.
Adhesion barriers generally provide no benefit, Dr. Strand said, while subcutaneous tissue management changes with depth. There are no advantages to closing subcutaneous tissues less than two centimeters deep and advantages to closing tissues deeper than two centimeters.
The data are clear when it comes to skin closure. Sutures have fewer complications than staples, and subcuticular sutures have the lowest rates of wound separation.
“This is a procedure we all do every day,” Dr. Strand said. “For many aspects of the C-section, there are no right answers. But there are some good recommendations to follow.”