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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