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Grand Rounds

Meta-analysis: Cephalad-Caudad or Transverse Blunt Expansion During Cesarean?

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BACKGROUND AND PURPOSE:

  • Blunt vs sharp uterine incision appears to be associated with decreased blood loss
  • There is some evidence that suggests cephalad-caudad expansion of the uterine incision may also be associated with fewer maternal morbidities than traditional transverse blunt expansion
  • Pergialiotis et al. (AJOG, 2021) evaluated adverse maternal outcomes associated with cephalad-caudad vs transverse blunt expansion

METHODS:

  • Systematic review and meta-analysis
  • Study inclusion criteria
    • RCTs
    • Studies that assessed the impact of the cephalad-caudad blunt expansion of the low transverse uterine incision during cesarean delivery verse transverse blunt expansion
  • Study design
    • Effect sizes were calculated using random-effects model
  • Primary outcomes
    • Risk for incision extension
    • Need for additional sutures
    • Need for transfusion
  • Secondary outcomes
    • Difference in intraoperative blood loss
    • Risk of uterine vessel injury
    • Risk of uterine atony
    • Need for additional uterotonics
    • Need for incision extension (e.g., inverted T)

RESULTS:

  • 6 trials | 2818 total women
  • Cephalad-caudad blunt expansion of the uterine incision was associated with a lower prevalence of
    • Unintended incision extension
      • Relative risk (RR) 0.62 (95% CI, 0.45 to 0.86)
    • Uterine vessel injury
      • RR 0.55 (95% CI, 0.41 to 0.73)
  • In addition, with cephalad-caudad blunt expansion, there was no increase in need for
    • Additional suture placement
      • RR 0.62 (95% CI, 0.31 to 4.12)
    • Increased transfusion rates
      • RR 0.75 (95% CI, 0.28 to 2.03)
  • The intraoperative duration was comparable with transverse blunt expansion cases
    • Mean difference −0.45 minutes (95% CI, −2.12 to 1.21)
  • The risk of intentional incision extension in the form of an inverted T was also comparable with transverse blunt expansion
    • RR 0.38 (5% CI, 0.09 to 1.52)
  • Required sample size was reached in the unintended incision extension and uterine vessel injury outcomes

CONCLUSION:

  • When performing cesarean delivery, cephalad-caudad blunt expansion resulted in fewer maternal adverse events compared to transverse expansion
  • The authors conclude

The findings of our study suggested that cephalad-caudad blunt expansion of the uterine incision is superior to transverse expansion in terms of reducing unintended incision extension and uterine vessel injury 

Learn More – Primary Sources:

Cephalad-caudad versus transverse blunt expansion of the low transverse hysterotomy during cesarean delivery decreases maternal morbidity: a meta-analysis

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Related ObG Topics:

Classical vs Transverse Uterine Incision for Preterm Birth
What is the Best Practices Prevention Bundle for Post Cesarean Infection?
Can Evidence-Based Interventions Reduce C-section Complications?
Classical Cesarean Incision: Delivery at 36 vs 37 Weeks

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