The other day I attended a session entitled “Myths and Truths of Cesarean Delivery Technique” presented by Dr. Aviva Lee-Parritz from Boston Medical Center. The discussion critically evaluated the surgical techniques commonly employed to accomplish cesarean deliveries. C/sections are one of the most common procedures performed in this country (and probably the most common in women) and becoming more common every day. The bottom line is that we all do them, but the best approach to the operation has never been defined! When I trained (too many years ago), the operative approach had been accepted for many years and simply passed down from resident-to-resident. No one ever questioned the legitimacy of that approach. After all, it was described in Williams’ Obstetrics and wasn’t that written by divine inspiration?!?
To be fair, the technique was based in good surgical principles designed to minimize risks for bleeding and infection at a time when these were major concerns, prior to both blood transfusion and antibiotics. Indeed, the procedure most commonly used today (the low-transverse cesarean section – referring to a cross-wise incision in the uterus, regardless of the skin incision) has not changed much since it was first described by Kerr in 1926. Over the years, we developed specific guidelines for the type of skin incision (transverse, lower abdominal vs. vertical) that was made under specific circumstances; we usually ‘developed the bladder flap’ (incised the thin layer of peritoneum over the lower uterine segment and pushed the bladder down before incising the uterus) except in dire emergencies; we knew the type of uterine incision that was preferred (transverse or vertical) under specific circumstances; we reached into the uterus to remove the placenta after the baby was delivered and then wiped the uterine cavity clean; we closed the uterine incision in two layers; and, then reapproximated ‘like-to-like’ (closed the bladder flap, closed the peritoneum, closed the fascia, closed the subcutaneous layer of fat, and then closed the skin) to complete the operation. And, despite all those steps, most of us could perform the procedure in a woman having her first one in less than 30 minutes ‘skin-to-skin’.
About 15 years ago, a paper was authored by Dr. John Hauth that suggested closing the uterus in a single layer was just as good as closing in two, thereby reducing operative time and the ‘perinatal morbidity’ associated with prolonged procedures, mainly, blood loss, infection, and risk for deep venous thrombosis and pulmonary embolism. In other words, there did not appear to be any short-term risks to this approach and there might even be some benefits. Around the same time, other papers challenged the necessity of closing the peritoneum (the thin layer of ‘skin’ that lines the inner abdomen and covers the internal organs (i.e., the ‘bladder flap’ over the uterine incision as well as the peritoneum of the abdominal wall). Without critically evaluating the individual risks and benefits of omitting these steps, many practitioners jumped on the bandwagon of the ‘simplified cesarean section’ and began closing the uterus in one big layer, leaving the raw surfaces of the ‘bladder flap’ and uterine incision exposed, and stopped closing the peritoneum lining the inner abdominal wall. Although I was rather skeptical at the time that this was really the right thing to do (raw surfaces tend to increase the risk for adhesions (scar) formation), especially because we had no long term follow-up on these women with regard to subsequent deliveries, our residents loved it because there were fewer steps (although they never seemed to do the operation any faster than us old fogies did in our heyday when ALL the steps were performed), so we just sort of went along for the ride.
Well, in recent years, as the cesarean delivery rate has skyrocketed, vaginal births after cesarean section have diminished (significantly), and we are performing more and more repeat cesarean procedures (and threepeats, and fourpeats, and fivepeats,….). We are also encountering more and more complications secondary to the previous procedures (occult and overt uterine ruptures, dense adhesions, placenta previas, placenta accretas, cesarean hysterectomies…). It is becoming clear that revisiting what, why, and how we are doing cesareans, and systematically ascertaining the best approach to the entire operation is necessary. It is also likely that the approach I was taught, based on what was considered to be ‘good surgical technique’ (but no data) and passed on by tradition, and the current ‘minimalist’ procedure, also based on a limited amount of data compared to the total number of procedures done, are at opposite extremes and the ‘truth’ probably lies somewhere in between.
As Dr. Lee-Parritz pointed out, if we look at the information already available from various sources both in OB and other surgical specialties, we are well on our way to defining a better approach to cesarean section. Without going into details of the hows and whys, herein, her analysis of the literature supports the fact that we should continue to use prophylactic antibiotics perioperatively (probably best given prior to the skin incision); we can probably perform most cesareans through a transverse abdominal incision; we probably do not routinely need to develop extensively the bladder flap; the uterine incision can safely be widened by blunt dissection; the placenta should be removed by traction rather than by ‘manual extraction’ (to minimize blood loss and infectious morbidity); the uterus should probably be closed in two layers (at least for all women planning another pregnancy, although how that is best accomplished and even what suture should be used is yet to be decided; if no ‘bladder flap’ is developed, we probably do not need to close either the visceral or parietal peritoneum; we should reapproximate the subcutaneous tissues, especially in obese patients; and, we can close the skin anyway we want to, although most patients would prefer not to see sutures or have staples that need to be removed at a later time and, actually, seem to have less postoperative pain when the skin is closed in a running subcuticular (under the skin) stitch.
If these steps were routinely employed, we should be able to minimize short-term risks of infection, bleeding, length of procedure, and perioperative pain and perhaps put a dent in the long-term complications of uterine scar dehiscence and pelvic adhesions that increase the morbidity of a subsequent pregnancy for both mother and baby. Who knows, an improved technique might also reduce the subsequent risk of placenta accreta and cesarean hysterectomy (allowing women to have more and more cesarean sections!). Unanswered questions could be readily addressed by a few well-organized multicenter research studies (in view of the huge total number of cases being performed each year, both first time and repeat procedures). We should be able to decide upon the best technique for closure of the uterus, the best suture to use under specific circumstances, and the best approach to employ with regard to closure of all the other body layers we went through to get the baby delivered.