LSCS

OPTIMIZING PATIENT OUTCOMES in
PROCEDURAL ASPECTS of
CAESAREAN SECTIONS
SoTM
CLINICAL DISCUSSION
Led by Dr. __________________

designation and hospital_______
SoTM_OBGY:JJMI-MA-ET/1403084
OUR MISSION
• Science of Tissue Management (SoTM) - an initiative taken by

Ethicon.
• Goal - Improve patient outcomes in Caesarean section
• Objective - Initiate an evidence – based dialogue on proper

closure methods and techniques in Caesarean section
• Endeavor – Arrive at a consensus and formulate

recommendations.
INCREASED CAESAREAN RATE
• Increasing patient demand (49)

• Fear of pain
• Convenience to schedule the delivery ELECTIVELY
• Perception of C-Section being less traumatic for
the baby and mother.
• Legal reasons – defensive practice
• Medical reasons - increasing age with co-morbidity • (2) Xing Lin Feng et
• Surgeons and hospitals willing to recommend C- al. Bulletin of the
section (2) World Health
Organisation 2012
Need to inform mothers of the risks involved • (49) Torloni et al.,
BMC Pregnancy and
Childbirth 2013,
13:78
TODAY’S OBJECTIVE
Evidence-based overview of
the various procedural aspects of caeserean section
to minimize the risk of complications
Goal to:
• Reduce complications
• Improve cosmetic result
REDUCING
COMPLICATIONS
RISK FACTOR - IDENTIFICATION
Health of
patient History Urgency (3)
Crash-
emergency
Repeat
Higher risk Compromised
C-Section
Emergency
X X
1st • (3) Pallasmaa et
Lower risk Healthy Elective
C-Section al., Acta
Obstetricia et
Gynecologica.
2010; 89: 896–
902
OUTCOME IS MULTIFACTORIAL
Patient Adhesion formation

Factors
Infection
Surgeon
Surgical Wound disruption
Factors (uterus / fascia / skin)
Pain
Cosmesis
Tissue
Factors
INTERVENTIONS TO BE DICUSSED
INCISIONS
TISSUE
HANDLING
LAYER
CLOSURE
UTERUS
PERITONEUM
SHEATH
SKIN
DISCUSSION 1
INCISIONS
SKIN INCISIONS
 Vertical versus Transverse incision
 Transverse incision is the most preferred incision as it

gives best clinical outcome
 Pfannenstiel vs Joel Cohen vs Misgav-Ladach
 Recommendation is to place the skin incision atleast 2

cm above pubic symphysis ( to reduce risk of bleeding)
 Less blood loss and faster healing is seen with Joel

Cohen’s incision
 Longitudinal Incision – may be needed in certain

specific situations
 Appropriate length – aim to stay within lateral margin

of rectus muscle to avoid bleeding from superficial
epigastric vessels
Discussion on case to case modifications
UTERINE INCISION
 Curvilinear – marking or scoring

with scalpel .
 Incision in lower uterine segment
 Incision in the centre followed by

blunt extension of uterine incision
 Correct dextro-rotation before

incision
DISCUSSION 2
TISSUE HANDLING
PLACENTAL DELIVERY
 Avoid manual removal of the placenta
 Wait for placental separation
 Control cord traction is preferred - reduces risk of endometritis
 Discussion on using mops in the uterine cavity after the removal of placenta
EXTERIORIZATION FOR
UTERINE CLOSURE
Points for consideration
 Isolation of wound area
 Blood loss due to angulation of uterine vessel
 Febrile morbidity
 Suturing time
 Tissue handling
 Risk of infection and need for post-op analgesia
Discussion on experience and clinical evidence
CLOSURE –
DIFFERENT LAYERS
DISCUSSION 3
UTERINE CLOSURE
CONSIDERATION POINTS
CONSIDERATIONS ASPECTS THAT MAY

SHORT-TERM INFLUENCE
CLINICAL OUTCOME
• Blood loss
• Operating time 1. Number of layers
• Infection
2. Locking or non-locking
suture technique
LONG-TERM
3. Inclusion or exclusion of
• Adhesion formation the decidua
• Scar defect
4. Continuous or
• Placenta accreta / interrupted
praevia
5. Type of suture material
• Ectopic scar pregnancy
• Uterine rupture
# LAYERS:EVIDENCE FOR SHORT TERM
Evidence Outcomes Favors
Single layer closure enables

Cochrane • Smaller blood loss (70 ml) Single-layer
review 2008 • Shorter operation time by 7,4 min
(9) • No significant differences in other short-term closure
complications
Single layer closure enables

CAESAR trial • Shorter operation time by 2,1 min
with 3033 • No significant differences in other short-term Neutral
women (10) complications (including blood loss)
(9) Dodd JM et al. Cochrane

Database of Systematic
In short-term, single layer closure is clinically Reviews 2008, Issue 3.
equivalent to double-layer closure apart from a (10) CAESAR study

Slightly shorter operating time collaborative group, BJOG. 2010
Oct;117(11):1366-76
# LAYERS:EVIDENCE FOR LONG TERM
Blumenfeld; • Single-layer closure was associated with 7-fold

study with Double-layer
increase in the risk of developing bladder
127 women closure
(15) adhesions compared to double-layer closure
Double-layer improves the quality of the scar:

• Significantly higher myometrial thickness (13) Double-layer
Glavind (13)
• Shorter scar defect(13) closure
(15) Blumenfeld YJ et al,

BJOG. 2010 May;117(6):690-4
In the long term, double-layer closure may (13) Glavind J et al.,

decrease the risk of adhesions and scar defects Ultrasound Obstet Gynecol.
2013 Aug;42(2):207-12
CONTINUOUS OR INTERRUPTED?
• Continuous suturing saves operating time and may reduce
blood loss (18)
• (18)
Hohlagschwandtner
et al., Arch Gynecol
Obstet. 2003 Apr;26
8(1):26-8. Epub
2002 May 7
LOCKING Vs NON LOCKING SUTURES
• Single-layer closure and double-layer closure carry the same

risk of uterine rupture in subsequent pregnancy(11)
• However, a LOCKED single-layer closure is associated with an
increased risk of uterine rupture (compared to double-layer
closure) (11)
• Locking sutures can cause increased tissue damage and
weaker scars (12)
(11) Roberge et al.,

International Journal of
Gynecology and
Obstetrics 115 (2011) 5–
10
(12) Jelsema et al., J
Reprod Med. 1993
May;38(5):393-6.
Locking the suture increases the risk of uterine rupture, however,

locking in the first layer to be discussed on the basis of experience
SECURING UTERINE ANGLES
• Secure uterine angles
• Discuss options
• Green-Armytage to acheive hemostasis
INCLUSION OF DECIDUA
• Including the full thickness of the uterine wall may
bring decidua into the scar
•
Decidua Included Decidua Excluded

• Decidual inclusion resulted in defective uterine healing in 78%
of cases. (16)
• (16) Poidevin,
• When decidua was excluded from the suture, all cases
L.;Obstet
resulted in perfect healing. (16)
Gynaecol Br Emp
1961
Operative aspects of excluding decidua to be Dec;68:1025-9.
discussed
TYPE OF SUTURE MATERIAL
• Use of catgut was associated with:
• A higher rate of uterine rupture (19)
• Thinner myometrium (20)
• Increased inflammation in natural absorbable suture may leads to

increased fibrosis / impaired healing rendering difficulty in subsequent
pregnancy & delivery
• (19) Sestanovic et al., Lijec Vjesn.

2003 Sep-Oct;125(9-10):245-51
A catgut suture in tissue A synthetic suture in tissue • (20) Bérubé L et al, J Obstet
Gynaecol Can. 2011 Jun;33(6):581-
7.
Synthetic suture is prefered over catgut
CONCLUSION ON UTERINE CLOSURE
The uterus should be closed preferably in two

layers, excluding decidua with a continuous non
locking, absorbable synthetic suture.
DISCUSSION 4
PERITONEAL CLOSURE

CLINICAL OUTCOME
• Postoperative fever
• Infection • Closure or non-closure
• Postoperative pain of the visceral
peritoneum
• Operating time
• Closure or non-closure
LONG-TERM of the parietal
peritoneum
• Adhesion formation
• Chronic pain • (21). Awonuga et al.,
Reprod Sci. 2011
• Infertility Dec;18(12):1166-85.
• Delayed delivery doi:
(21) 10.1177/19337191114
14206. Epub 2011 Jul
20.
CREATION OF BLADDER FLAP
Originally:
• Creation of bladder flap to minimize bladder injury during
access
• Closure to protect the peritoneal cavity from intra-uterine
infection (before antibiotics were used) (22)
However:
• Bladder injuries are usually caused by surgical difficulty
encountered WHILE developing the bladder flap (22)
• Hence, creation of bladder flap is not recommended • (22) Malvasi et al.,

Chir Vol. 32 - n.
11/12 - pp. 498-503
November-
December 2011
PERITONEAL CLOSURE-SHORT TERM
• Operating time was reduced by 6 minutes (29)

Cochrane
• Significantly less post-operative fever (29) Non-closure
review 2010
• Long-term results ”not adequately assessed”
• Incision-to-delivery time was shorter with

Tuuli RCT
with 258 omission of bladder flap (25)
women • No differences in bladder injuries or other Non-closure
(2012)
intraoperative or postoperative complications
(25)
• (29) Bamigboye et
al.;Cochrane Database S
Short-term outcomes favor non-closure of the yst
visceral peritoneum Rev. 2003;(4):CD000163
.
• (25) Tuuli et al., Obstet
Gynecol 2012;119:815–
21
PERITONEAL CLOSURE-LONG TERM
• Closure of the VP creates an inflammatory
Malvasi RCT reaction, which leads to adhesion formation.
with 112 • In the closure group, 57.4% of women had Non-closure
women (26) adhesions compared with 20.6% in the non-
closure group.
• Visceral peritoneum closure is associated with
Shahin RCT transient urinary problems (more postpartum
with 620 frequency of urination and/or incontinence) Non-closure
women (27) • Closure of the visceral peritoneum changes
the angles of the bladder and the uretha
• (26) Malvasi et al. /
Long-term outcomes favor non-closure of the International Journal of
visceral peritoneum Gynecology and
Obstetrics 105 (2009)
131–135
• (27) Shahin et al., Int
SoTM_OBGY:JJMI-MA-ET/1403084 Urogynecol J (2010)
21:33–41
CONCLUSION
• There is no convincing evidence for creation of the bladder

flap.
• If bladder flap is created, non-closure of the visceral

peritoneum minimizes the risk of short-term and long-term
complications.
The clinical data suggest, that the visceral

peritoneum at the bladder flap should not be
closed
PARIETAL PERITONEUM CLOSURE
Ellis et al., Br J • Closing the peritoneum does not reduce

Surg (1977) Non-closure
RCT (28) hernias or dehiscence (28)
Short-term:
Bamigboye et
• No significant differences in endometritis, Non-closure
al., Cochrane
fever, wound infection or hospital stay Long-term implications
Database
are not certain
Systematic
• Reduction of operative time
Review
(2003) (29)
Long-term: Closure
Cheong • Non-closure associated with more adhesion Note: based on limited
Systematic formation (30) # of studies (3) and #
review (2009) of patients (249)
DISCUSSION
• Limited data suggests, that closing the parietal peritoneum

seems to decrease the rate of adhesions
• The parietal peritoneum may be closed separately or

approximated when suturing the rectus muscles
• Closure leads to higher suture material mass, increased

operating time, more chances of adhesions
• Closure of visceral peritoneum leads to Higher rate of

adherent bladder in subsequent surgery
No convincing evidence to support the closure of either

visceral or pariteal peritoneum.
Recommendation to be based on tempering with
operator experience
DISCUSSION 5
SHEATH CLOSURE

CLINICAL OUTCOME
• Wound dehiscence
• Suturing technique
LONG-TERM
• Bite size
• Incisional hernia
• Tension
• Chronic pain
• Suture material
AIM: Avoid wound rupture and incisional hernia

and minimize the risk of long-term pain
TRANVERSE INCISONS AND
COMPLICATION RATES
Incisional hernia rates lower in Pfannenstiel (0-2%) (31) than in
midline incisions (up to 26%) (33) probably due to:
• Contraction (coughing etc.) of the abdominal wall

muscles does not increase tension on the transverse
wound (32)
• Incision is situated in richly vascularized muscular tissue,

• (31) Kisielinski et al.,
which may benefit wound healing (32) Hernia (2004) 8: 177–
181
• (32) Burger et al.,
• The force required to approximate the edges of a vertical Scandinavian Journal of
incision is approximately 30 times greater than the force Surgery 91: 315–321,
required to approximate a transverse incision (31) 2002
• (33) Millbourn et al.,
Arch Surg.
2009;144(11):1056-
1059
DOES IT MATTER HOW THE SHEATH IS
CLOSED?
• Yes, as long as we have no studies comparing different

closure techniques.
Should we adopt the best practice from midline

closure?
EVIDENCE-BASED CLOSURE OF THE
FASCIA IN THE MIDLINE (1/2)
Continuous, non- • Is faster than interrupted technique
locking technique • Increases the collagen content and the
wound strength
Use small bites at close • Increases the tensile strength of the wound
intervals, including only • Better tensile distribution, enabling closure
aponeurosis into the stitch with less tension
• Include only tissue with suture holding
capacity (=aponeurosis), which also helps
to avoid soft tissue necrosis
• The stitches should be placed 5-8 mm from
the edge of fascia, about 5 mm apart
• TR 114 Pure Progress
Module 1: 8 Strategies for
optimising outcomes by
addressing complications
in abdominal midline
closure.
EVIDENCE-BASED CLOSURE OF THE
FASCIA IN THE MIDLINE (2/2)
Avoid tension • Approximate, do not strangulate!
• Excessive tension decreases
collagen content and thereby also
the tensile strength of the wound
• Suture Length :Wound length ratio >
4:1
• TR 114 Pure
• Provides a safety margin in case a Progress Module 1:
Use slowly absorbable, complication delays the wound 8 Strategies for
monofilament suture healing optimising
outcomes by
• Slowly absorbable sutures are addressing
associated with decreased rates of complications in
incisional hernia in abdominal wall abdominal midline
closure closure.
RISK OF NERVE ENTRAPMENT
• Up to 33% have chronic pain after Pfannenstiel incision (35)

• 7% experienced moderate or severe pain
• 8,9% had pain which impaired daily activities
• Nerve entrapment found in ≈50% of patients with

moderate or severe pain (35)
• Up to 25% experience numbness (34)

• (34) Luijedijk et al.,
ANNALS OF SURGERY
1997 Vol. 225, No. 4,
365-369
Nerve entrapment may lead to chronic pain • (35) Loos et al. Obstet
Gynecol. 2008 Apr;111(
4):839-46. doi:
10.1097/AOG.0b013e3
1816a4efa.
RISK OF NERVE DAMAGE
• Injury to the iliohypogastric and

ilioinguinal nerves by the Pfannenstiel
incision is more likely to occur
because of the superficial course of
the nerves.
Nerve damage can result from:

• Incision of the nerve followed by
neuroma formation
• Incorporation of the nerve by a
suture in the closure of the fascia
• The tethering or constriction of the
nerve
(34)
in the surrounding scar tissue
Extension of the incision beyond lateral border of • (34) Luijedijk et al.,

rectus muscle may lead to nerve damage ANNALS OF SURGERY
1997 Vol. 225, No. 4,
365-369
SHEATH CLOSURE TECHNIQUE
• Identify angle and edges of sheath incision prior to suturing.
• Continuous non-locking
• Delayed absorbable suture material
• Avoid non – absorbable, as it leads to suture sinus formation.
• Polyglactin tensile strength is not maintained until stage of

collagen maturation
CONCLUSION
• Close the fascia with continuous suture, using small bites at

close intervals, avoiding tension
• Angle and edges to be clearly identified
• Begin with surgeon knot, end with an Aberdeen knot
• Identify & spare iliohypogastric and ilioinguinal nerves

when the incision is extended beyond the lateral edge of
the rectus muscles
Close the fascia with a running, delayed

absorbable suture. Use small stitches at close
interval, with minimal tension
DISCUSSION 6
SKIN & SUBCUTANEOUS

CLOSURE
SSI PREVENTION
• Antibacterial bath same day morning – use of antibacterial soap
• No shaving --- clipping preferred
• Skin preparation – Chlorhexidine Vs Povidone-iodine
• Ideal to use chlorhexidine.
• Antibiotics – prophylactic single dose before skin incision. First generation

cephalosporins are drugs of choice.(Discussion on timing)
• COMORBIDITIES
– Risk factors for Surgical Site Infection - Increased BMI,
diabetes complicating pregnancy.
NICE guidelines on Prevention of SSI
SUBCUTANEOUS CLOSURE

SHORT-TERM INFLUENCE CLINICAL
OUTCOME
• Wound disruption
• Infection • Eliminating dead space
• Haemaoma formation
• Relieving tension on the
• Seroma formation skin
LONG-TERM
• Cosmesis
Objective: Reduce the rate of complications

and improve cosmesis
WHY TO CLOSE THE SUBCUTANEOUS
LAYER ?
Naumann, • Non-closure of the subcutaneous layer has

Obstet been associated with wound disruption
Closure
Gynecol. 1995 (gaping wound above the fascia, seroma,
(36)
hematoma) in up to 26% of patients (36)
• Fat closure reduces the risk of

Anderson, The haematoma, seroma and wound
Cochrane Closure
Library 2008 (37) complications (infections and wound
ruptures) (37)
Chelmow, • Closure of the fat resulted in 34% decrease

Obstet in the risk of wound disruption with fat Closure
Gynecol. 2004
(38) thickness >2 cm (38)
ANATOMY OF SUBCUTANEOUS LAYER
• Subcutaneous layer can be divided into (42):
• Superficial (Adipose) fatty layer
• Superficial fascia (Scarpa’s fascia)
• Deep (Adipose) fatty layer skin
superficial fatty
layer
• Fat has the lowest suture pull-out superficial fascia
force (39) deep fatty
layer
• Fat 0,2 kg
muscle fascia
• Muscle 1,27 kg muscle layer
• Fascia 3,77 kg
• Fat can be closed to eliminate dead-space (39) Westaby S ed. Wound Care 1985
but the closure contributes minimally to • (42) Lancerotte;Surg Radiol Anat
wound strength
(2011) 33:835–842
SUTURE PLACEMENT
• Closing the superficial fascia (SF) removes tension from the skin (40)
• Tension on skin leads to widening of the scar and worse cosmetic result
• Repair of SF layer significantly increases the strength of the wound repair(41)

• May decrease wound dehiscence (41)
• Closure of the SF creates a surface which does not allow the scar on skin to
attach to the muscle fascia (42)
• (40) Chopra et al., Surg

Radiol Anat (2011)
33:843–849
• (41) Song AY Aesthet Surg
J 2006
• (42) Lancerotte;Surg
Radiol Anat (2011)
33:835–842
Discussion on the merits of placing the suture in
the superficial fascia
CONCLUSION
• The superficial fascia should be identified, and the

subcutaneous stitches should be placed in this fascia, not
in the fat.
• Closure of the superficial fascia (Scarpa´s fascia) will

decrease wound disruption, increase wound strength and
improve the cosmetic result.
Place the subcutaneous stitch into the superficial

fascia
SKIN

SHORT-TERM INFLUENCE CLINICAL
OUTCOME
• Rupture
• Infections • Suturing technique
• Skin closure technology

LONG-TERM
• Cosmetic result
Objective: Mimimize scarring, maximizing patient • (43) Opoien et al., Acta

comfort . Provide good cosmesis Obstetricia et
Gynecologica. 2007; 86:
1097-1102
COSMETIC RESULTS
Cosmetic result is influenced by:

• Infections
• Closure technique
• Choice of material / device
• Time of removal of non-absorbable materials
• Patient factors
SIGNIFICANCE OF INCISION
IN COSMESIS
• Transverse incision is the most preferred incision as it gives best clinical outcome
• Incision width depends upon the size of baby
• Pfannenstiel Incision– Curvilinear incision – has to be 2 cms above pubis
• Joel -Cohen incision – straight incision - has to be 3 cms above the pubis.
• Less blood loss and faster healing is seen with Cohen’s incision
• Longitudinal Incision – made in certain specific situation – eg – Placenta increta,

etc.
OPTIONS FOR SKIN CLOSURE (1/2)
Dermabond
-Not effective in CS
-Wound cannot be dry always
-Apposition of skin edges may be compromised due to tension
Interrupted sutures -
-Preferred only in case of longitudinal incisions

-In bleeding diathesis, mattress interrupted sutures preferred (as Hemostasis is a
concern in such a case)
Disadvantages - Low cosmesis, More no. of knots
OPTIONS FOR SKIN CLOSURE (2/2)
Subcuticular
Advantages -Better post operative healing
-No need to remove stiches (in case of absorbable suture)
-Better cosmesis
-Lesser post operative pain
Staplers
Advantages -Quicker, easy
Disadvantage -Costlier,
-Removal is painful and cumbersome,
-Studies show no superiority in cosmesis and healing
SUTURES V/s STAPLERS
Cochrane 2012 (44):
• Absorbable subcuticular sutures and non-absorbable

staples are associated with similar incidence of wound
infection
• However, staples are associated with an increased risk of

skin separation if removed on day 3 (at time of hospital
discharge)
Can a later removal of staples decrease the risk

of disruption? – need to evaluate this
• (44) Mackeen et al., Cochrane
Database of Systematic Reviews
2012, Issue 11. Art. No.: CD003577
SUTURES
• Absorbable vs. Non-absorbable

• Subcuticular closure with absorbable vs. non-
absorbable suture results in similar short-term
outcomes except for itching at 4 weeks (45)
• Subcuticular vs. Percutaneous

• The use of absorbable subcuticular suture may be
associated with less pain and better cosmesis
compared to both staples (46) and to percutaneous
sutures (47)
• (45) Tan et al.; (45) Tan et
al.;Int J Gynaecol Obstet.
2008 Nov;103(2):179-81.
doi:
10.1016/j.ijgo.2008.05.02
3. Epub 2008 Jul 18.
• (46) Frishman et al.;J
Reprod Med. 1997
Oct;42(10):627-30.
• (47) Naskar et al.;J Indian
Med Assoc. 2012
Sep;110(9):644-5, 648.-5,
SoTM_OBGY:JJMI-MA-ET/1403084 648.
SURGICAL SITE INFECTION (SSI)
• Reported rates 1.8% before discharge, 8.9% within 30 days (43)
• Most of the infections are superficial (43)
• Risk factors include operating time > 38 minutes and

BMI >30 (43)
• Wound infection may cause

• Delayed healing
• Wound separation
• Suboptimal cosmetic result
• Antibiotic regimen (per NICE guidelines)
• (43) Opoien et al., Acta

Obstetricia et
Gynecologica. 2007; 86:
1097-1102
META-ANALYSIS:
Antibacterial sutures reduce infection risk with 30% (p<0.001) (52)
Both in vitro and in vivo animal experiments have

shown that triclosan-coated sutures (TCS)
attenuate bacterial colonization SoTM_OBGY:JJMI-MA-
ET/1403084
DEMONSTRATION
Closure technique
• The skin edges should be apposed with no tension
• Ensure good hemostasis – there should no hematoma under the skin closure
• With Absorbable – at least one end secured with knot

• With non absorbable – both ends secured with knot
• If knots are outside the wound, trimming is required at time of discharge
• Tie knot over gauze piece, to prevent suture going deep in nonabsorbable
sutures
• In bleeding diathesis, mattress interrupted sutures preferred (as hemostasis is a

concern in such a case)
CONCLUSION ON SKIN CLOSURE
• Closure with staples or with non-absorbable suture may

cause a need for an additional visit for removal, therefore
closure with an absorbable subcuticular suture is to be
preferred.
• If staples are used and are removed before discharge

(postop day 3-4), the wound should be supported by skin
strips or topical skin adhesive.
Close the skin with a delayed absorbable,

antibacterial suture material
CLOSURE AS PER INCISION
Transverse Incision
Preference
Subcuticular Continuous
Absorbable monofilament (Monocryl)/Braided
Antibacterial sutures preferred if available
Longitudinal incision
Preference
Mattress interrupted
Non Absorbable mono filament (Prolene/ Ethilon)
Discussion on the significance of needle size and

suture length
CONCLUSIONS &
DISCUSSION
CONCLUSIONS & DISCUSSION
• The uterus should be closed with unlocked
1 continuous suture, in double layer (avoiding
decidua) closure.
• The visceral peritoneum should be left

unsutured.
2
• There seems to be some evidence, although

not conclusive, for the closure of the parietal
3 peritoneum.
CONCLUSIONS & DISCUSSION
• The fascia should be closed with a non-locking
4 continuous delayed non-absorbable
monofilament suture, using small bites at close
interval. Tension should be avoided, and if the
incision in extended laterally beyond the borders
of the rectus muscles, the nerves should be
identified and spared.
5 • The superficial fascia (Scarpa´s fascia) should be

identified, and the subcutaneous stitches should
be placed in this fascia, not in the fat.
6 • Skin should be closed with absorbable,

subcuticular, preferably antibacterial suture.
THANK YOU!
REFERENCES
REF# Author Title Reference
1 WHO World Health Report 2010
Factors influencing rising caesarean section rates in China between 1988 Bulletin of the World Health Organization, Volume 90, Number 1, January
2 Xing Lin Feng et al.
and 2008 2012, 1-74
Cesarean delivery in Finland: maternal complications and obstetric risk

3 Pallasmaa et al. Acta Obstetricia et Gynecologica. 2010; 89: 896–902
factors
Surgical techniques used during caesarean section operations: results of a European Journal of Obstetrics & Gynecology and Reproductive Biology
4 Tully et al.
national survey of practice in the UK 102 (2002) 120–126
Serious maternal morbidity after childbirth: prolonged hospital stays

5 Hebert et al. Obstet Gynecol. 1999 Dec;94(6):942-7.
and readmissions.
6 Phipps et al. Risk factors for bladder injury during cesarean delivery. Obstet Gynecol. 2005 Jan;105(1):156-60.
7 Pallasmaa et al. Severe maternal morbidity and the mode of delivery Acta Obstetricia et Gynecologica. 2008; 87: 662-668
8 Clark et al. Placenta previa/accreta and prior cesarean section. Obstet Gynecol. 1985 Jul;66(1):89-92
Surgical techniques for uterine incision and uterine closure at the time of
9 Dodd et al. The Cochrane Library 2012, Issue 8
caesarean section
The CAESAR study Caesarean section surgical techniques: a randomised factorial trial
10 BJOG. 2010 Oct;117(11):1366-76.
collaborative group (CAESAR)
Single- versus double-layer closure of the hysterotomy incision during

11 Roberge et al. International Journal of Gynecology and Obstetrics 115 (2011) 5–10
cesarean delivery and risk of uterine rupture
Continuous, nonlocking, single-layer repair of the low transverse

12 Jelsema et al. J Reprod Med. 1993 May;38(5):393-6.
uterine incision.
Ultrasound evaluation of the caesarean scar after single- and double-

13 Glavind et al. Ultrasound Obstet Gynecol. 2013 Jan 3.
layer uterotomy closure: a cohort study
Impact of methods for uterine incision closure on repeat caesarean

14 Yasmin et al. J Coll Physicians Surg Pak. 2011 Sep;21(9):522-6.
section scar of lower uterine segment
Single- versus double-layer hysterotomy closure at primary caesarean

15 Blumenfeld et al. BJOG. 2010 May;117(6):690-4.
delivery and bladder adhesions
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OPTIMIZING PATIENT OUTCOMES in

Led by Dr. __________________

• Science of Tissue Management (SoTM) - an initiative taken by

• Goal - Improve patient outcomes in Caesarean section

• Objective - Initiate an evidence – based dialogue on proper

• Endeavor – Arrive at a consensus and formulate

• Increasing patient demand (49)

Patient Adhesion formation

 Transverse incision is the most preferred incision as it

 Pfannenstiel vs Joel Cohen vs Misgav-Ladach

 Recommendation is to place the skin incision atleast 2

 Less blood loss and faster healing is seen with Joel

 Longitudinal Incision – may be needed in certain

 Appropriate length – aim to stay within lateral margin

 Curvilinear – marking or scoring

 Incision in lower uterine segment

 Incision in the centre followed by

 Correct dextro-rotation before

 Avoid manual removal of the placenta

 Wait for placental separation

 Control cord traction is preferred - reduces risk of endometritis

Points for consideration

 Isolation of wound area

 Blood loss due to angulation of uterine vessel

 Risk of infection and need for post-op analgesia

Discussion on experience and clinical evidence

CONSIDERATIONS ASPECTS THAT MAY

Single layer closure enables

Single layer closure enables

(9) Dodd JM et al. Cochrane

equivalent to double-layer closure apart from a (10) CAESAR study

Blumenfeld; • Single-layer closure was associated with 7-fold

Double-layer improves the quality of the scar:

(15) Blumenfeld YJ et al,

In the long term, double-layer closure may (13) Glavind J et al.,

• Single-layer closure and double-layer closure carry the same

(11) Roberge et al.,

Locking the suture increases the risk of uterine rupture, however,

• Green-Armytage to acheive hemostasis

Decidua Included Decidua Excluded

• Increased inflammation in natural absorbable suture may leads to

• (19) Sestanovic et al., Lijec Vjesn.

Synthetic suture is prefered over catgut

The uterus should be closed preferably in two

CONSIDERATIONS ASPECTS THAT MAY

• Hence, creation of bladder flap is not recommended • (22) Malvasi et al.,

Evidence Outcomes Favors

• Operating time was reduced by 6 minutes (29)

• Incision-to-delivery time was shorter with

• There is no convincing evidence for creation of the bladder

• If bladder flap is created, non-closure of the visceral

The clinical data suggest, that the visceral

Ellis et al., Br J • Closing the peritoneum does not reduce

• Limited data suggests, that closing the parietal peritoneum

• The parietal peritoneum may be closed separately or

• Closure leads to higher suture material mass, increased

• Closure of visceral peritoneum leads to Higher rate of

No convincing evidence to support the closure of either

CONSIDERATIONS ASPECTS THAT MAY

AIM: Avoid wound rupture and incisional hernia

• Contraction (coughing etc.) of the abdominal wall

• Incision is situated in richly vascularized muscular tissue,

• Yes, as long as we have no studies comparing different

Should we adopt the best practice from midline