BACKGROUND AND PURPOSE:

• A frequently cited reason to avoid exteriorization for uterine repair following cesarean delivery relates to potential for nausea and vomiting
  • Phenylephrine infusion with spinal anesthesia decreases the risk of hypotension and nausea
• Mireault et al. compared exteriorization vs in situ repair using a standardized anesthetic protocol with the goal of assessing impact on patient nausea and vomiting

METHODS:

• Randomized double-blind controlled trial (RCT)
• Participants
  • Women undergoing elective cesarean delivery
  • Exclusion: Risk factors for uterine atony and PPH | Preoperative nausea and vomiting | BMI >35 kg/m2
• Standardized anesthetic protocol used for all patients
  • 1,000 mL of Lactated Ringer’s (over 5 to 10 minutes) then 300 mL/hour infusion
  • Spinal placed with patient in sitting position (hyperbaric bupivacaine, fentanyl and morphine)
  • Patient then placed in supine position with left uterine displacement
  • Phenylephrine perfusion: 0.5 micrograms/kg of lean body weight/min
• Interventions
  • Exteriorization
  • In situ uterine repair
• Statistical analysis
  • Power: 80 patients per group was needed to demonstrate a 50% reduction in intraoperative nausea and vomiting with in situ repair
• Primary outcome
  • Postdelivery intraoperative nausea and vomiting using a 4-point scale (0 to 3)
  • Patients asked to rate nausea at time of skin incision, hysterotomy, placental delivery, beginning of uterine repair, beginning of fascia repair (last 2 time points used to assess nausea related to repair)
  • Patient and data collector were blinded
• Additional data collected included
  • Hypotensive episodes | Tachycardia | Antiemetics | Vasopressor boluses | Length of surgery | Blood loss

RESULTS:

• 180 women randomized
  • Exteriorization: 90 women
  • In situ repair: 90 women
• Nausea and vomiting were more common in the exteriorization group (p=0.01)
  • Exteriorization: 39%
  • In situ repair: 22%
• The exteriorization group more commonly experienced
  • Hypotension (p<0.001)
    • Exteriorization: 80%
    • In situ repair: 50%
  • Tachycardia (p=0.02)
    • Exteriorization: 33%
    • In situ repair: 17%
• More phenylephrine boluses were administered to the exteriorization group (p<0.001)
  • Exteriorization: median 4 boluses
  • In situ repair: median 2 boluses
• No differences were found for the following
  • Duration of surgery
  • Blood loss
  • Postoperative hemoglobin decline

CONCLUSION:

• When using standard anesthesia protocols that includes phenylephrine, in situ uterine repair is associated with less postoperative nausea and vomiting, compared to exteriorization
• There was no difference in blood loss or surgery duration

Learn More – Primary Sources:

Uterine Exteriorization Compared With In Situ Repair of Hysterotomy After Cesarean Delivery: A Randomized Controlled Trial

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