Cesarean Section Technique: What’s New in the Evidence Base?
Marya G. Zlatnik, MD, MMS
Maternal Fetal Medicine
UCSF
Hamano, Teisuke. 1880. Kainin no kokoroe (Information on pregnancy). Japanese Woodblock Print Collection, Archives & Special Collections, UCSF Library & Center for Knowledge Management.
No Disclosures
Learning Objectives
• Review new techniques & literature re: C/S
– “Gentle” cesarean
– ERAS
– Infection prevention
– (Pain control)
– Hemorrhage
– Sutures
• Evidence‐base (according to me)
Cesarean Rates Continue to Rise
Low‐risk cesarean delivery is defined as a cesarean delivery among term (37 or more completed weeks), singleton, vertex births to women giving birth for the first time. (NTSV)
Osterman MJK, Martin JA. Trends inlow‐risk cesarean delivery in the United States, 1990–2013. NationalVital statistics reports; vol 63 no 6. Hyattsville, MD: National Center for Health Statistics. 2014
Cesarean Section Technique• Family‐friendly
• ERAS
• Prophylactic Atbx
• Prep
• Remove FSE
• Abdominal Incision
• Bladder flap
• Uterine incision
• Placental delivery
• Exteriorization of uterus
• Uterine incision closure
• Peritoneal closure
• Irrigation
• Fascial closure
• Subcutaneous closure
• Staples/skin
• Special dressings
Family‐Centered or “Gentle” Cesarean
UCSF Family‐Centered Cesarean
• Buy in from OB, Peds, Nursing, Anesthesia
• Clear double drapes
• Staffing (extra RN)
• UCSF Protocol created by Dr. Robyn Lamar
UCSF Family‐Centered Cesarean
• Mother may choose music to be played in OR
• Double drape (with clear window) used
• Anesthesia places ECG leads away from mother’s chest
• Mother’s chest warmed prior to skin‐to‐skin with instant hot pack
• Elevate head of bed, to facilitate viewing the birth & skin‐to‐skin
• After delivery of head, OB delivers body slowly
• After delivery of head, drape dropped if mother desires to see birth
• Consider delayed cord clamping for 30‐60 seconds
• Pediatricians receive the baby as usual; 1 min APGAR on warmer; goal to be
back to mom by 5 minutes for skin‐to‐skin
• After close, while drapes are removed & mother is cleaned, partner may help
with weighing baby & observe other routine care
• Once mother is on recovery bed, baby placed skin‐to‐skin again & the dyad
transported together to recovery
+Ev
+Ev
+Ev
Music Therapy for C/S
• RCT in Taiwan: music to decrease anxiety – 64 pts, planned C/S, nl babies
– Headphones, low volume of classical, new age or Chinese religious music
– Decreased anxiety scores
– More satisfied with C/S experience
– No difference in physiologic measures of anxiety
Chang 2005
Family‐Centered or “Gentle” Cesarean
Contraindications:• Prematurity• Emergency cesarean• Anticipated resuscitation (ex: anomalies, nonreassuringFHR)
Protocol inappropriate in some situations & clinical judgment always takes precedent•Ex: with vasa previa, slow delivery of body inadvisable•Ex: increased BMI, elevating the head of the bed may impact surgical visualization •Ex: insufficient nursing staff to remain with baby in OR
Enhanced Recovery After Surgery (ERAS)
• Emphasis on evidence‐based care
• Pre‐op preparation
– Nutrition
– Expectations
• Intra‐op
– Multimodal pain Rx
• Post‐op care
– Bowel recovery
Enhanced Recovery After Surgery (ERAS)
• Retro cohort
• Prepost, n= 531
• Decreased post‐op LOS by 7.8% or 4.86 hrs overall (P<.001)
• Decreased post‐op direct costs by 8.4% or $642.85 per pt (P<.001)
• No difference readmissions
Fay AJOG 2019
Enhanced Recovery After Surgery
• No cesarean guidelines yet on ERAS Society site
• AJOG published guidelines 2018‐2019
ERAS at UCSF• In the clinic: antepartum
– Confirm eligibility
– Mostly education
– Treat anemia
ERAS at UCSF• In the clinic: pre‐op visit
– Education re: anesthesia
– Carb drink (Boost Breeze): drink at home (2 hrsbefore)
– CHG wash: night before
ERAS at UCSF• Day of: pre‐op
– Acetaminophen 1000 mg PO x1
– CHG wash, clipping
ERAS at UCSFIntra‐op
• Zofran, Reglan
• Toradol IV x1
• Duramorph or TAP blocks
ERAS at UCSFPACU
• Pain control
• Nausea control
• Incentive spirometry
ERAS at UCSF
Post‐op
• Day 0:
– Scheduled acetaminophen & ketorolac
– Hydromorphone PCA if inadequate
– Aggressive bowel regimen
– Regular diet
– Ambulate
– Foley out at 8 hours if ambulating ok
• Day 1:
– Ibuprofen scheduled, d/c PCA PO opioids
ERAS at UCSFPost‐op
• Day 0‐1
ERAS at UCSF
Post‐op
• Day 2:
– Scheduled acetaminophen & ibuprofen
– Prn opioids
– Prep for d/c home
• Day 3:
– d/c home
Prophylactic Antibiotics
• Decrease infection?
• Side effects
• Single or multiple doses
• Which generation?
• When?
Prophylactic Antibiotics
• Cochrane Review
– 4700 pts
– RR 0.42 (95%CI 0.28‐0.65) morbidity/death
– Effect bigger if labor
• Decreased fever, SSI, endometritis, UTI, LOS (RR ~0.4)
• No benefit to multi‐dosesSmaill Cochrane 2010
Prophylactic Antibiotics Single vs Multiple Doses
Hopkins & Smaill Cochrane Database of Systematic Reviews 1999, 2010
Prophylactic Atbx—Fever 1st Generation vs. 2nd or 3rd
Alfirevic Cochrnae 2010Hopkins Cochrane 1999
Same result with Ampicillin vs. Ceph
Pre‐incision Atbx: Decreased SSI vs After Cord Clamp
26
p= 0.002
p= 0.014
p= 0.020
Kaimal SMFM 2008
0
2
4
6
8
Overall Endometritis Cellulitis
SS
I (%
)
2005-2006n= 800
After 2006n= 516
2013 Clinical Practice Guidelines: Antimicrobial Prophylaxis in Surgery
• American Society Health‐System Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, Society for Healthcare Epidemiology of America
• Based on pharmacokinetic dosing studies, 1g cefazolin is often not enough but no RCT
• At UCSF we use cefazolin 2g (3g if BMI >120kg)
• Re‐dose if 4> hrs from 1st dose or EBL >1500 cc
Bratzler 2013
Prophylactic Atbx—Extended Spectrum Regimens
• RCT adding metronidazole vag gel– 224 pts; vaginal gel vs placebo gel
– Less endometritis (7 vs 17%), trend towards less fever; no difference in wound infxn, LOS
• Ureasplasma increases risk for C/S SSI
– Cephalosporin doesn’t cover
– Post‐cord‐clamp cefotetan plus placebo or doxy+azithro
Andrews 2003
Pitt 2001
Extended spectrum Prophylaxis
• UAB studies over 14 years– In 2000, IV cefotetan or cefazolin & IV azithro at cord clamp
– Decreased endometritis
– Decreased wound infections
29
Tita ObGyn 2009Tita AJOG 2008
Extended spectrum Prophylaxis
• Multicenter RCT: C/SOAP Trial– 2013 pts, C/S in labor or ROM (chorio excluded)– Ave BMI 35 (>60% had BMI >30)– Std atbx + Azithro prior to incision– Fewer SSIs, fevers, PP readmits
30 Tita NEJM 2016
Extended spectrum Prophylaxis
• Multicenter RCT: C/SOAP Trial
31
Tita NEJM 2016
Extended spectrum Prophylaxis?
• UCSF baseline rate much lower (<1%)
• Hesitant to extend atbx spectrum for all C/S pts
– Concerns re: atbx resistance, messing up microbiome
• Selectively extend atbx spectrum– eg, pt w/ DM/obesity
– Cefazolin 2‐3g IV preop + azithro 500mg IV after cord clamp (mix in 250mL/give over 1 hr )
32
Abdominal Prep
• Several small RCTs: different solutions
– No clear winner
– Magann 1993, Brown 1984, Weed 2011
• CHG better than povidone‐iodine in G. Surg (has persistence)
– Darioche 2010
• Bundled CHG cleanse + OR prep + other interventions decreased SSI rate
– Rauk 2010
Vaginal Prep prior to C/S
• Povidone‐iodine prep ‐> decreased endometritis, esp w/ ROM
• No difference in fever or wound complications
• ? benefit if already chorio
• Possible effect on neonatal thyroid studies
• Risk of vaginal lac (case at ZSFG)
• Dahlke gives a “B”
• Done at ZSFG
– Cochrane 2014, Reid 2001, Rouse 1997, Starr 2005
ZMG2
Vaginal Cleansing prior to C/S
• Meta‐analysis Sept 2017
• Povidone‐iodine prep ‐> decreased endometritis, fever, esp w/ labor/ROM
• No difference in wound complications
• Only 6 of 16 specified pre‐incision atbx
• ? benefit if already chorio
– Caissutti ObGYN 2017
ZMG2
Bladder Flap
• 2 RCTs: Total 360 pts• 1 & RC/S: Bladder BladFlap vs Not
• No bladder flap:– Shorter incis del time by 1 min in 1C/S
– +/‐ Shorter op time, Less Hgb drop, Microhematuria, Pain
• Not powered for bladder injury (would need 40K pts)
Hohlagschwandtner 2001Tuuli 2012
Uterine Incision—Blunt vs. Sharp Extension
RCTs: Blood loss greater with sharp– More transfusions
– Rodriguez 1994, Magann 2002, Cochrane 2008
• Cephalad to caudadextension
– Less blood loss, fewerextensions
– Cromi 2008, Sekhavat 2010
Uterine Incision: BABE
• B: Breathe. Pause before making the hysterotomy
• A: Allis clamps. Use Allis clamps, if needed, to help elevate the hysterotomy
• B: Blunt. Use a single digit to sweep over hysterotomy bluntly between each scalpel pass
• E: Extend. Extend hysterotomy bluntly (stretch laterally or vertically)
Betsy Encarnacion O’Donnell 2012
Placenta: Manual Removal
• Manual extraction: bigger Hct drop, more endometritis (vs spontaneous)
Cochrane 1995
Anorlu Cochrane 2008
Exteriorization of Uterus
• Easier repair? (easier to teach)
• ? Infection, bleeding risk
• Anesthesiologist blames you for emesis
• No real differences in complications, including emesis
Cochrane 2006, 2009
Management of Hemorrhage
• CMQCC hemorrhage toolkit V2.0 (revised March 2015)https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit
Photo courtesy of CMQCC and David Lagrew, MD
Every hospital will need to customize the protocol—but the point is every hospital
needs one
CMQCC OB Hemorrhage Emergency Management Plan
Copyright California Department of Public Health, 2014; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Hemorrhage Taskforce Visit: www.CMQCC.org for details
Obstetric Hemorrhage Emergency Management Plan: Table Chart Format version 2.0
Assessments Meds/Procedures Blood Bank
Stage 0 Every woman in labor/giving birth Stage 0 focuses on risk assessment and active management of the third stage.
Assess every woman for risk factors for hemorrhage
Measure cumulative quantitative blood loss on every birth
Active Management 3rd Stage:
Oxytocin IV infusion or 10u IM
Fundal Massage-vigorous, 15 seconds min.
If Medium Risk: T & Scr If High Risk: T&C 2 U If Positive Antibody
Screen (prenatal or current, exclude low level anti-D from RhoGam):T&C 2 U
Stage 1 Blood loss: > 500ml vaginal or >1000 ml Cesarean, or VS changes (by >15% or HR 110, BP 85/45, O2 sat <95%)
Stage 1 is short: activate hemorrhage protocol, initiate preparations and give Methergine IM.
Activate OB Hemorrhage Protocol and Checklist
Notify Charge nurse, OB/CNM, Anesthesia
VS, O2 Sat q5’ Record cumulative
blood loss q5-15’ Weigh bloody materials Careful inspection with
good exposure of vaginal walls, cervix, uterine cavity, placenta
IV Access: at least 18gauge Increase IV fluid (LR) and
Oxytocin rate, and repeat fundal massage
Methergine 0.2mg IM (if not hypertensive) May repeat if good response to first dose, BUT otherwise move on to 2nd level uterotonic drug (see below)
Empty bladder: straight cath or place foley with urimeter
T&C 2 Units PRBCs (if not already done)
Stage 2 Continued bleeding with total blood loss under 1500ml
Stage 2 is focused on sequentially advancing through medications and procedures, mobilizing help and Blood Bank support, and keeping ahead with volume and blood products.
OB back to bedside (if not already there) Extra help: 2nd OB,
Rapid Response Team (per hospital), assign roles
VS & cumulative blood loss q 5-10 min
Weigh bloody materials Complete evaluation
of vaginal wall, cervix, placenta, uterine cavity
Send additional labs, including DIC panel
If in Postpartum: Move to L&D/OR
Evaluate for special cases: -Uterine Inversion -Amn. Fluid Embolism
2nd Level Uterotonic Drugs: Hemabate 250 mcg IM or Misoprostol 800 mcg SL
2nd IV Access (at least 18gauge)
Bimanual massage Vaginal Birth: (typical order) Move to OR Repair any tears D&C: r/o retained placenta Place intrauterine balloon Selective Embolization
(Interventional Radiology) Cesarean Birth: (still intra-op) (typical order) Inspect broad lig, posterior
uterus and retained placenta
B-Lynch Suture Place intrauterine balloon
Notify Blood Bank of OB Hemorrhage
Bring 2 Units PRBCs to bedside, transfuse per clinical signs – do not wait for lab values
Use blood warmer for transfusion
Consider thawing 2 FFP (takes 35+min), use if transfusing > 2u PRBCs
Determine availability of additional RBCs and other Coag products
Stage 3 Total blood loss over 1500ml, or >2 units PRBCs given or VS unstable or suspicion of DIC
Stage 3 is focused on the Massive Transfusion protocol and invasive surgical approaches for control of bleeding.
Mobilize team -Advanced GYN surgeon -2nd Anesthesia Provider -OR staff -Adult Intensivist Repeat labs including
coags and ABG’s Central line Social Worker/ family
support
Activate Massive Hemorrhage Protocol Laparotomy: -B-Lynch Suture -Uterine Artery Ligation -Hysterectomy Patient support -Fluid warmer -Upper body warming device -Sequential compression stockings
Transfuse Aggressively Massive Hemorrhage Pack Near 1:1 PRBC:FFP 1 PLT apheresis pack per 4-6 units PRBCs
Unresponsive Coagulopathy: After 8-10 units PRBCs and full coagulation factor replacement: may consult re rFactor VIIa risk/benefit
Blood Loss:1000-1500 ml
Stage 2
SequentiallyAdvance through
Medications &Procedures
Pre-Admission
Time of admission
Identify patients with special consideration:Placenta previa/accreta, Bleeding disorder, or those who decline blood products
Follow appropriate workups, planning, preparing of resources, counseling and notification
Screen All Admissions for hemorrhage risk:Low Risk, Medium Risk and High Risk
Low Risk: Draw blood and hold specimenMedium Risk: Type & Screen, Review Hemorrhage ProtocolHigh Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol
All women receive active management of 3rd stageOxytocin IV infusion or 10 Units IM, 10-40 U infusion
Standard Postpartum Management
Fundal Massage
Vaginal Birth:Bimanual Fundal MassageRetained POC: Dilation and CurettageLower segment/Implantation site/Atony: Intrauterine BalloonLaceration/Hematoma: Packing, Repair as RequiredConsider IR (if available & adequate experience)
Cesarean Birth:Continued Atony: B-Lynch Suture/Intrauterine BalloonContinued Hemorrhage: Uterine Artery Ligation
To OR (if not there); Activate Massive Hemorrhage Protocol
Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts 6:4:1 or 4:4:1
IncreasedPostpartum Surveillance
Definitive SurgeryHysterectomy
Conservative SurgeryB-Lynch Suture/Intrauterine BalloonUterine Artery LigationHypogastric Ligation (experienced surgeon only)Consider IR (if available & adequate experience)
Fertility Strongly Desired
Consider ICUCare; Increased
Postpartum Surveillance
Verify Type & Screen on prenatal record;
if positive antibody screen on prenatal or current labs (except low level anti-D from Rhogam), Type & Crossmatch 2
Units PBRCs
CALL FOR EXTRA HELPGive Meds: Hemabate 250 mcg IM -or-
Misoprostol 600-800 SL or PO
Cumulative Blood Loss>500 ml Vag; >1000 ml CS>15% Vital Sign change -or-
HR ≥ 110, BP ≤ 85/45 O2 Sat <95%, Clinical Sx
Ongoing Evaluation:
Quantification of blood loss and
vital signs
Unresponsive Coagulopathy:After 10 Units PBRCs and full
coagulation factor replacement,may consider rFactor VIIa
HEMORRHAGE CONTINUES
Blood Loss:>1500 ml
Stage 3
Activate Massive
Hemorrhage Protocol
Blood Loss: >500 ml Vaginal
>1000 ml CS
Stage 1Activate
Hemorrhage Protocol
NO
Stage 0All Births
Transfuse 2 Units PRBCs per clinical signs
Do not wait for lab valuesConsider thawing 2 Units FFP
YES
YES NO
On
goin
g C
um
ula
tive
Blo
od L
oss
Eva
lua
tion
Cumulative Blood Loss>1500 ml, 2 Units Given,
Vital Signs Unstable
YESIncrease IV Oxytocin RateMethergine 0.2 mg IM (if not hypertensive)Vigorous Fundal massage; Empty Bladder; Keep WarmAdminister O2 to maintain Sat >95%Rule out retained POC, laceration or hematomaOrder Type & Crossmatch 2 Units PRBCs if not already done
Activate Hemorrhage ProtocolCALL FOR EXTRA HELP
Continued heavy bleeding
Increased Postpartum Surveillance
NO
NO
CONTROLLED
INCREASED BLEEDING
California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for detailsThis project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division
Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014
Management of HemorrhageNPR.org
Management of Hemorrhage: TXA
• Tranexemic Acid
Pacheco ObGyn 2017
TPA
Fibrin degradation
Management of PPH: TXA
WOMAN Trial Lancet 2017
• WOMAN trial: 20,060 women with PPH after VD or CS
• RCT: 1g IV TXA or placebo
• Outcomes: death from hemorrhage, death from all causes, or hysterectomy
• Funding: London School of Hygiene & Tropical Medicine, Pfizer, UK Dept Health, Wellcome Trust, Bill & Melinda Gates Foundation
Management of PPH: TXA
WOMAN Trial Lancet 2017
Maternal Death
Management of PPH: TXA
WOMAN Trial Lancet 2017
Laparotomy for bleeding by subgroup
Management of PPH: TXA
WOMAN Trial Lancet 2017
Management of Hemorrhage
Tranexamic Acid (TXA) Protocol
Management of Hemorrhage
Topical recombinant activated Factor VII Case series, 5 pts with previa, 5 controls, Denmark
“swab” soaked in saline containing recombinant activated Factor VII (1 mg in 246 ml) applied to placental bed, repeated x1 prn
Median EBL 490 ml (300-800 ml)
No changes in thrombin, fibrinogen, PTT, INR, plts
Schjoldager AJOG 2017
CORONIS Trial Lancet 2016
• International, pragmatic trial 2x2x2x2x2
• 19 sites in S. America, Africa, India, Pakistan
• 1st or 2nd C/S, follow up at 3 yrs
• 15,633 women studied:– Blunt vs. sharp abdominal entry
– Repair of uterus in or out
– 1 vs. 2 layer closure of uterus
– Closure vs. non‐closure of peritoneum
– Chromic vs. polyglactin‐910 for uterus
• Outcomes of subsequent pregnancies, pain
Incision Type, Uterine Repair, Etc.
– CORONIS Trial 2016
Incision Type, Uterine Repair, Etc.
• No differences
CORONIS Trial 2016
Incision Type, Uterine Repair, Etc.
• No differences
CORONIS Trial 2016
Closure of Uterine Incision: 1 vs. 2 Layers
• Short term:
– OR time
– Hemostasis/Blood loss
– Endometritis
• Long term:
– Scar strength/VBAC risk
Short Term Outcomes: 1 vs. 2 Layer Closure
• Hauth’s RCT, UAB + 9 other studies
• No difference in use of extra hemostatic stitches
• Less blood loss
• Less post‐op pain
• 5‐7 min shorter OR timeHauth 1992, Cochrane 2008
1 vs. 2 Layer Closure:Scar Strength
• Follow‐up from Hauth’s RCT
• 906 pts in RCT164 preg again
• 83 previous 1‐layer, 81 previous 2‐layer
• 56/70 vs 64/75 successful VBACs
• No difference in PPH, infxn, LOS
• One dehiscence in 1‐layer group, no ruptures (power only .07)
Chapman 1997
1 vs. 2 Layer Closure: Scar Strength TOLAC
• Retrospective data conflicting whether rupture risk increased or not
• Risk of uterine rupture after 1‐layer closure notsignificantly different from 2‐layer closure overall (OR 1.34; 95% CI 0.24–4.82) Sardo 2017– risk increased after locked 1‐layer closure (OR 4.96) but not after unlocked 1‐layer closure (OR 0.49) compared w/ 2‐layer closure Robwerge 2011
– 2‐layer closure thicker scar Sardo 2017
• Need RCT Bujold 2002, Dumwald 2003, Roberge 2011, Sardo 2017 (ISUOG metanalysis)
Knot Slips/Types of Knots
• Square
• Surgeon’s square (least likely to slide undone, but can’t tighten after 2nd throw)
• Square slip (can slip, even after 5 throws; inadvertently tied by one‐handed technique)
• Granny (not a bad knot, but easy to accidentally make granny slip knot)
• Granny slip (not secure)
Loop‐to‐Strand Knots (e.g.when tying fascia suture in midline)• 0 & 2‐0 Monocryl, 6 throws , stretched until failure
(breakage or slippage)• Loop‐to‐single strand, sliding knot
– 55‐85% untied– 112 newtons to break knot
• Loop‐to‐single strand, flat square knot– 5‐15% untied– 117 newtons to break knot
• Strand‐to‐single strand, flat square knot– NONE untied– 132 newtons to break knot
Hurt 2004
Failure of WoundType of Suture Material
• Metaanalysis from General Surgery lit.
• Nonabsorbable vs. absorbable
– NNT = 50 for incisional hernia
• Risk of hernia not increased with PDS, is increased with Vicryl
Hodgson 2000
• Monocryl & Chromic no good for sheep C/SGreenberg 2011
Wound Irrigation
• RCT in cattle
– C/S for macrosomia
– Wounds irrigated with betadine vs nothing
– No difference in wound infections
• Only a few RCTs in humans
– Study design flaws
– Saline vs nothing
– No difference in wound complications, more nausea with irrigation
de Kruif 1987
Bamigboye, Harrigill 2003Cochrane 2006, Viney 2010
Peritoneal Closure vs. Not
• Short term outcomes vs. long term outcomes
• Short‐term: Non‐closure better
– Shorter OR time
– Less fever
– Shorter LOS
– Trend less analgesia need & wound infection
Bamigboye, Cochrane 2010,2014
Long Term Outcomes: Non‐Closure of Peritoneum
• Cohort & retrospective studies mixed on what causes fewer adhesions
• 2 pseudo RCT suggest nonclosure better
• 1 RCT non‐closure fewer adhesions
Lyell 2005, Stark 1995, Lyell 2012
Weerawetwat 2004, Komoto 2006
Kapustian 2012
Failure of Wound: Fascial Suturing Technique• No RCT data in human C/S
• Suture tears through fascia = most common cause
• Fascia tears—less likely with 1 cm wide suture bites based on lab data, general surgery literature
– Stitches 1 cm back from edge (SL/WL ratio)
– Not strangulating
– Mass closure
Adamsons 1966, Hogstrom 1985
Skin Closure: Re‐approximation of subQ
• A few meta‐analyses– Some included all pt, others included those with > 2cm subQ fat
– 3‐0 plain gut, 2‐0 polyglactin, 3–0 polyglycolic mostly running stitches
– Decreased wound complications, NNT = 16
Pergialiotis BJOG 2017, Chelmow2004, Cochrane 2006
Skin Staples, Suture, or Glue? Staples vs. SubQ Suture
• A few RCTs, 2 meta‐analyses
• Staples quicker (by ~5‐9 min)
• Pts often prefer suture
• Sutures fewer wound infections/ breakdowns
– NNT 16
• Sew if there is time
Frishman 1997, Tuuli 2011, Clay 2011Mackeen 2014
Suture vs. Suture
• Comparison of Subcuticular Suture Type for Skin Closure After Cesarean Delivery: A Randomized Controlled Trial
• RCT: Monocryl vs Vicryl
• Composite wound measure: 8.8% vs 14.4%
• No difference when analyzed by actual suture used
Buresch, AM et al. Obstetrics & Gynecology130(3):521-526, September 2017.doi: 10.1097/AOG.0000000000002200
SubQ Suture vs Skin Glue
• A few small studies, 1 RCT (107 pts)
• No difference:
– OR time
– wound disruption (?)
– scar scores
– NOT POWERED
Daykan AJOG 2017
Silver‐Impregnated Dressing
Connery AJOG 2019
• RCT, n=657
• Silver nylon vs gauze dressings
• Primary outcome similar – 4.6% silver nylon group
– 4.2% gauze group, P = 0.96
• Similar rates of superficial SSI <1 wk (1.2% vs 0.9%) & <6 wks (4.6% vs 4.2%) after delivery (P >.99)
• Adjusting for confounding variables, current smoking (aOR 4.9; 95% CI 1.8−13.4) body mass index ≥40 kg/m2 (aOR 3.08; 95% CI 1.3−6.8), & surgery length (minutes) (aOR 1.02; 95% CI 1.002−1.04), but not use of gauze dressing, were associated with superficial SSI
Negative Pressure Wound Therapy (prophylactic, in obese women)
• Systematic review/meta‐analysis 2017
– n= 1,830, incl retrosp.; n= 230 ( 5 RCTs)
• No difference:
– Wound complications or infections
Smid Obs Gyn 2017
Negative Pressure Wound Therapy (prophylactic, in obese women)
• Systematic review/meta‐analysis 2018
– 9 studies, included cohort studies in meta‐analysis, n= 1,702, incl retrosp.; 6 RCTs
• Yes difference:
– Wound complications RR 0.68 (0.49‐0.94), but including RCTs only RR 0.82 (0.57‐1.18)
– SSI RR 0.55 (0.35‐0.87)
– Senior author with $120K research funding from KCI
Yu Ajog 2018
Conclusions
• Yes:– Prophylactic Atbx (pre‐incision, add azithro if risk mod‐high)
– Blunt or sharp abdominal entry
– Repair of uterus in or out
– 1 or 2 layer closure of uterus
– TXA for PPH
– Monocryl for skin
• Maybe:– ERAS
– Family‐friendly
– Add azithro
– Prep vagina
– Wound vac
• No: – Not ready for aF7
– Gluing, stapling skin
– Silver dressing
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