Grand Rounds

RCT Results: In Situ vs Uterine Exteriorization for Cesarean Repair

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

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

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

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

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