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10 practical, evidence-based recommendations for improving maternal outcomes of cesarean delivery

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7. Keep the risk of adhesions in mind

Closing the peritoneum may reduce long-term adhesion formation

The CAESAR study collaborative group. Caesarean section surgical techniques: a randomised factorial trial (CAESAR). BJOG. 2010;117(11):1366–1376. doi: 10.1111/j.1471-0528.2010.02686.x.

According to the findings of this large, multicenter, randomized trial, the rate of maternal infectious morbidity did not change whether or not a drain was used or the peritoneum was closed. The study evaluated only maternal infectious morbidity related to peritoneal closure—not long-term adhesion formation. Nevertheless, it appears that closure of the peritoneum at the time of cesarean delivery is associated with a lower rate of long-term adhesion formation.

8. Forget adhesion barriers

Their use to prevent intra-abdominal adhesions is ill-advised

Albright CM, Rouse DJ. Adhesion barriers at cesarean delivery: advertising compared with the evidence. Obstet Gynecol. 2011;118(1):157–160.

After cesarean delivery, there is a potential for intra-abdominal adhesions to form, which can lead to pain, small bowel obstruction, and injury during repeat surgery. A review of the literature suggests that the use of adhesion barriers at cesarean delivery is not cost-effective. Randomized trials are needed.

9. Be vigilant for bladder and ureteral injuries

Know the risk factors and preventive strategies for these injuries

Gungorduk K, Asicioglu O, Celikkol O, et al. Iatrogenic bladder injuries during caesarean delivery: a case control study. J Obstet Gynaecol. 2010;30(7):667–670.

Karram M. Avoiding and managing lower urinary tract injury during vaginal and abdominal deliveries. In: Sibai BM, ed. Management of Acute Obstetric Emergencies. Philadelphia, Pa: Elsevier-Saunders; 2011:179–187.

The reported incidence of bladder injury at the time of cesarean delivery ranges from 0.13% to 0.31% during primary cesarean and reaches 0.6% during repeat cesarean. During primary cesarean, bladder injury usually occurs during entry into the peritoneal cavity and involves the high extraperitoneal aspect of the bladder. In repeat cesarean, it usually occurs during dissection of the bladder flap and involves the intraperitoneal aspect of the bladder (dependent portion).

Bladder and ureteral injuries are more likely to occur in the presence of one or more of the following risk factors:

  • emergency or crash cesarean delivery
  • cesarean delivery after prolonged pushing
  • history of uterine or abdominal surgery
  • central placenta previa or accreta
  • lateral or downward extension of the uterine incision
  • uterine rupture
  • need for hysterectomy.

Inadvertent bladder injury during entrance into the peritoneum should be managed with layered closure of the cystotomy. Because such injury occurs high in the bladder, it requires only a short period of postoperative drainage. In contrast, injury to the base of the bladder requires appropriate mobilization of the bladder off any adherent structures to allow tension-free closure of the injury. Since this type of injury lies in the dependent portion of the bladder, it requires postoperative drainage for 10 to 14 days. Close the injury in two layers, using fine, delayed, absorbable suture in interrupted or running fashion, with the first layer approximating the mucosa and the second layer imbricating the muscularis.

Ureteral injury is rare during cesarean delivery. When it does occur, it usually occurs during repair of lacerations from the uterine incision or control of excessive bleeding from the lower segment or broad ligament (FIGURE). The most common site of injury from uterine lacerations is at the level of the uterine vessels, whereas the most common site of injury at cesarean hysterectomy is the lower portion of the ureter near the uterosacral ligaments.

If you suspect injury, confirm ureteral patency by making a cystotomy in the bladder dome to visualize the orifices, and attempt to pass a ureteral catheter or pediatric feeding tube through the orifice into the ureter until you reach a point above the area of concern. If there is an obstruction, kinking, or transection, consult a urogynecologist or urologist.

Risks of lateral and downward extension


Avoid lateral and downward extension of the uterine incision, which may injure the blood vessels or ureter.
Source: Sibai BM, ed. Management of Acute Obstetric Emergencies. Philadelphia, Pa: Elsevier-Saunders; 2011.

10. Close the skin with subcuticular suture

This approach is associated with lower risk of wound separation and infection than is closure with staples

Tuuli MG, Rampersad RM, Carbone JF, Stamilio D, et al. Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol. 2011;117(3):682–690.

Wound complications following cesarean can include hematoma, seroma, complete separation, or infection (superficial or deep). Wound complications may be more likely with staple closure of a transverse skin incision than with subcuticular suture. Other issues to consider when choosing a type of skin closure include postoperative pain, cosmesis, and how long it takes to deliver the infant.

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